Free tissue transfer and Replantation post operative managment

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Ronald Malt performed the first replantation on May 23, 1962 at Massachusetts General Hospital on a 12-year-old boy who had his right arm amputated in a train acciden.

Since Malt's first replant, technological advances and the use of the microscope have made possible the replantation of other parts, including thumbs, fingers, ears, scalps, facial parts, and genitalia.

PREOPERATIVE MANAGEMENT

Evaluation for replantation

Life before limb. Assessment of injury (Level, mechanism, dominant

hand ,age ,smoking,full medical history And previous injury to same limb ).

Obtaining x-rays for both severd and stumb parts. Obtain Length of ischemia of the severed part, digits can tolerate about

12 hours of warm ischemia and more than 24 hours cold ishemia ,muscles can tolerate about 6 hours warm ishemia, so the more proximal the amputation the faster surgery it needs.

Sharp amputations do better than crushed,avulsion or blunt cuts .

Amputated part should be warned in saline moistens gaues then in sealed bag then to bag of ice to prevent cold injury to tissue

Postoperative

Postoperative managment is extremely important in achieving a high success rate in replantation.

vascular insufficiency may develop postoperatively but can frequently be corrected if detected early.

Eighty percent of vascular occlusions occur within the first 48 hours after surgery. The salvage rate in a failing replantation explored early ranges from 66% to 80%.

Arterial thrombi usually result from platelet aggregation and present on day 1, whereas venous thrombi result from fibrin clotting and usually present by day 2 or 3.

Patients are restricted from eating for the first 24 hours in case they need to be taken back to the operating room.

bulky dressing. Hand should be elevated , If arterial inflow is diminished, the hand

may be lowered. If venous outflow is slow, the hand needs additional elevation.

The room is kept warm, limb should be warmed by lamp and the patient well hydrated.

Appropriate analgesics are used to control pain and anxiety because they can lead to an adrenergic response and vasoconstriction, especially in children.dressing change should also done under good analgesia or even sedation.

Smoking is prohibited because it leads to hypoxia, reduction of peripheral blood flow, and increases the risk of thrombosis, also advise patients to avoid caffinated drinks.

Color, pulp turgor, capillary refill, and warmth should be monitored every 1 hour for the first 48 hours, then every 4 hours till 5th day postoprtive.

Leeches therapy can be used if congestion present.

Postoperative Postoperative

Postoperative New technology could also be used for flap monitoring including :

pulse oximetry Doppler and duplex Digital thermometry Laser Doppler

Digital thermometry

Laser Doppler showing blood flow fingers

Postoperative medications The commonly used anticoagulants can be divided into agents that :

1. Decrease platelet function e.g. aspirin and could be used for 3 weeks.2. Increase blood flow or decrease blood viscosity e.g. dextran , The antithrombotic effect

of dextran is thought to be due to binding to erythrocytes, platelets, and the vascular endothelium. It is mostly thought to interfere with the formation of fibrin clot and to prevent the aggregation of red thrombi. This effect is thought to be significantly greater than any effect on platelets.

3. Counteract the effect of thrombin on platelets and fibrinogen e.g., heparin. Antibiotics Cover with pointing to Aeromonas hydrophila infection if leesh therapy

was used. Proper hydration,and good analgesics.

Postopertavie therapy Hand therapy can be started about a week after replantation, once

anticoagulation is stopped. Therapy protocols depend on the level of the replant and the stability of skeletal fixation. A dorsal splint is provided and the patient started on gentle active range of motion exercises.

Postoperative Secondary surgery

Secondary surgery like tenolysis, nerve grafting, tendon transfer, bone, grafting, intrinsic muscle release, and arthrodesis are frequently required in replants to enhance function. these procedures brefered to be done approximately 3 months after replantation.

EXPECTED OUTCOMES OF DIGITAL REPLANTATION

15-50% replant failure rate. 50% of patients require a blood transfusion. 10 days average hospital stay. Cost of replantatioo is 1 ~ 15 times that of reception amputation. 36-77% chance of only protective sensation. Motion in replanted is averages 50% of normal . 60% of patients needs additional surgery (average 2.5 procedures). 7 mo average time off work.

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