replantation grand rounds

8/11/2019 Replantation Grand Rounds

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Replantation:

Hey Doc, can you putmy finger back on ?

Amy F Kells MD PhD

Division of Plastic & Reconstructive

Surgery

Washington University, St Louis

October 3, 2014
http://brand.wustl.edu/download-artwork/official/Official_WUSTL-2line-centered/


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Goals of

Replantation Presentation

History of Replantation

Pre & Post Operative Management

Surgical Technique and Relevant AnatomyResults of Digital Replantation

Costs to Society

Indications & ContraindicationsThumb Replantations: a special case

Replantations: the Horizon


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Replantation History

First replantation performed onMay 23, 1962 byDr Ronald Malt at MGH

12 year boy who amputated hisarm in train accident

The amputation level was thehumeral neck

A steel rod was used for boney

fixationBrachial artery and 2 veins andthe median, ulnar and radialnerves were repaired


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Replantation History

Dr Malt performed anotherreplant in 1964 andpublished his resultstogether with Dr McKhann in

the September 7th1964issue of Journal of the

American MedicalAssociation.

Later, Dr Malt reported hisfirst patient had somerecovery of function afterwrist arthrodesis and tendontransfers.


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Replantation History: First Digital Replant

The first successful digitalreplantation was performedon July 27, 1965 by

Drs Komatsu and Tamai.Department ofOrthopedic SurgeryNara Medical CollegeNara, Japan

Published 1968 in Plasticand ReconstructiveMicrosurgery, 42: 374-77


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First Digital Replantation

28 y/o male cut off leftthumb working w/ steelcutting machine

Sent to hospital 30 minafter injury

Severed thumb dropped

on ground once in route

Relatively clean cutthrough MCP joint w/minimal tissue damage


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Brachial plexus block usedfor left arm

Wounds washed and

debridedVolar digital arterycannulated w/ 0.5mm diam.Canula and flushed w/heparin diluted in low

molecular weight dextranCartilage of MCP removedand joint fused w/ 2 K-wiresin position of abduction


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Using 10x-16x magnification,2 volar arteries and 2 dorsalveins were sutured end toend w/ 7-0 braided silk and8-0 monofilament nylon

Nerve repair postponed toavoid trauma to newanastamosis

Extensor tendon repaired

Flexor tendon postponeddue to zone II injury level

The thumb became pinkimmediately, and veins filled


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Complete OR time: 41/2hrs

Ischemic time: 3 hrs

Sl edema developed POD

#2, but resolved in 7 daysSympathetic block wasperformed daily for 18 days

Heparin 200mg/dayintramuscularly and lowmolecular weight dextran

500cc/day were given for 9days

Pt d/cd POD # 40

Returned to work after 4 mos


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POD #200: slight atrophyand loss of sensation buthas pinch

At 2 yrs and 5 mos s/preplantation pt has regainedsome ulnar sided sensation

A moderate flexioncontracture is present inthe IP joint, but thisposition is very useful tohim.

Little has changed in the technique from this first description of a digital replant


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Digital Replantation: Indications

Initial tendency to replant every severedfingerResults of studies published in 1980srevealed about 50% return of function in

replanted digits, worse w/ zone II injuriesToday the emphasis is not how to replant adigit, but how to make it functionalSurgical success previously judged on

viability alone, now focuses on functionaloutcomeThis has led to a refinement of indications fordigital replantation


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Replantation: IndicationsGreens Operative Hand Surgery

Thumb

Multiple digits

Single digit distalto FDS insertion

Partial hand-palm

Almost any part in

childWrist or forearm

Elbow & above w/sharp amputation


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Replantation: ContraindicationsGreens Operative Hand Surgery

Severely crushed or mangled

parts

Multiple level

Single digits proximal to FDSinsertion-especiallyindex& little fingers

Prolonged warm ischemia > 12 hrs

Associated serious

injuries/diseasesArteriosclerotic disease

Mental instability


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Initial ER Management

Do not clamp or tie off any bleedingvessels

Direct pressure with a bulky dressing

will control any digital bleeding duringtransport

Hydrate patient with IV Fluids, keep

NPOTetanus, Antibiotic prophylaxis & ASA


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Initial ER Management: Replant ????

STEP 1: Assess medical status for lengthyreplantation procedure

Other injuries

Cardiac status

Step 2: Examine amputated part

Step 3: Have frank discussion with patient

need for blood, possible anticoag, ICU stay

commitment to rehab

length of time out of work

potential outcome.stiff, painful finger

NEED TO QUIT SMOKING !!!


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Aesthetic Plastic Surgery 2002;26:477-482

Smoking detrimental via 2 pathways: Nicotine causes vasoconstriction

Relative hypoxia of carboxy-hemoglobin causes increasedfibrinogen & RBC aggregationleads to increased bloodviscosity

2 patients, 3 replanted digits, smoked POD#4..

Both patients lost digits on POD #7 & #9


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Initial ER Management :

Preservation of Digit

Management should begin with appropriate handling ofthe amputated digit

Place in moistened gauze in plastic bag on ice

Do not place directly on ice or directly into liquid

X-ray the digit and hand


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Digital Replantation Technique:

Operative Sequence

Locate and tag vessels and nerves

Debride

Shorten and fix the bone

Repair tendons

Anastomose Arteries

Repair NervesAnastomose Veins

Obtain skin coverage


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Debridement & Tagging

2 teams are optimal

The first step is debridement andtagging of vessels and nerves with9-0 nylon

Longitudinal midlateral incisionsprovide the best exposure to neuro-vascular bundles

Assessment of status of digital

arteries is made at this timeRibbon Sign-walldamageRed Line Sign-distal thrombosis

Tag dorsal veins if you see Ribbon Sign Red Line Sign


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Bone Shortening & Fixation

Bone shortening to avoid need forinterposition grafts

5-10mm of bone shortening should beperformed on the amputated part (not on

thumb)

Multiple methods of bone fixation

Most common method is double or single

axial K-wires for middle or distal phalanx

Crossed K-wires for proximal phalanx 1) Simple & Quick2) Less bone exposure

3) Less skeletal mass

4) Easy correction of rotational deformity

Amputation thru joint will require fusion in functional position


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Tendon Repair


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Arterial Assessment

Drop tourniquet andassess inflow

Assess for need ofinterposition vein graftor vessel shift

Freshen ends ofvessels back to pristineintima


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Arterial Anastomosis

Use double micro vessel clip

9-0 nylon sharp point

Place sutures at 10:00 oclock, 12:00

oclock & 2:00 oclock

Flip vessel 1800

Complete front wall

5000u hep bolus prior to clamp release

Remove clips: assess w/ milk test


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Arterial Anastomosis Assessment

If flow seems sluggish.. confirm adequate Pt BP Pt volume status complete tourniquet deflation

Allow at least 10 minutes forvasospasm to resolve Papaverine Lidocaine Warm irrigation

Development of petechiae

or measles sign orballooning of the inflowlimb of the anastomosis,the sausage sign, shouldbe red flag forthrombosis..

revise anastomosis


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Nerve Repair

Can be performed withtourniquet deflated

Freshen ends so that fascicles

are flush with epineurium

Use epineurial repair

Coapt nerves w/ 3 sutures

Autograft can be used for defects


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Venous Anastomosis

Pronate hand

Look for back bleeding

Very helpful to tag at start

of procedure (rememberits hour 6+ under themicroscope!)

Need 2 veins for 1 artery

Use same anastomotictechnique as artery butneed less sutures.

low pressure system


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Getting Out Of The OR

Loose skin closure

Double check vessel positioning to avoidkinking or compression

Full thickness skin graftsVery loose dressing w/ strict elevation

Pulse oximetry monitoring of replanted digit

Dont forget basics!! Maintain blood pressure MAP>70, UOP >70

FLUIDS NEVER PRESSORS


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Digital Replantation:

Postoperative Management

Continuous plexus blockade.3 to 5 days

Continuous pulse oximetry monitoring

Adequate IV hydration.UOP > 50cc/hrWarming blanket

Aspirin, Avoid caffeine, smoking for 5 weeks

Heparin Use full dose drip after anastomotic revision

Strongly consider in crush or avulsion injuries


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Digital Replantation: Results

1983 to 1995 with 2 yrs or > F/U

1018 digital replantations in 552 pts

Successful outcome 92.9% of digits

Type of injury was the most important predictor of outcome

Regular Cigarette smoking resulted in poor immediate survival

Prolonged ischemia ( >9hrs) led to increased poor functional outcome

Injury in the proximal phalanx region resulted in poor ROM

Repairing the FDP distal stump to the FDS proximal stump improved resultscompared to 2 tendon repair and FDP to FDP

Replantation should be carried out even if only one digit is involved.

Injury 2000;31:33-40


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50% Failure Rate with Smokers


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Digital Replantation: Costs to Society

National sampling data basebased on 20% of USHospitals

304 cases of fingerreplantation in U.S. in 1996

Mean LOS 5.5 days

Total charges $20,330

Extrapolated data:

1,153 replantations in US $ 24 million

Journal of Hand Surgery 2000;25A:1038-42


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Digital Replantation: Costs to Society

30 pts w/ amputations of thumb or 2 or more digits proximal to PIPjoint

24 pts successful replantation, 3 failed, 3 primary amputations

Calculable cost greatest for sick leave (46%), operation (26%),ward cost (20%)

Sick leave mean 8.8 mos (replant), 5.3 mos (failed), 4.8 mos (amp)

Replant cost 1.6 times mean annual salary, amputation 0.8 times

Subjective evaluation of 23 parameters of function, cosmesis andquality of life did not disclose any differences between groups

The Question of whether replantation is economically feasible to society remains

Journal of Hand Surgery (British) 1996;21B:576-80


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Thumb Replantation: A Special Case

Thumb provides more than 40% of entire handfunction and replantation should be considered inmost cases

Even avulsion injuries should be considered

Injuries requiring MP fusion can yield good function

Ulnar artery is dominant

Use vein graft to radial artery in snuff boxGive priority in multi digit amputations: usetransposition technique and replant least damageddigit in place of thumb if it is non-replantable


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Hand Fellowship Thanksgiving Replant Feast

4:00 pm Thursday: thumb replant tobe transferred to Bellevue..Patient

arrives 8:00pmOut of OR 5:00 am Friday

10:00 pm Saturday multidigit replantarrives ER.3:00 am out of

OR.no finger suitable

11: 00 pm SundayAhin the clear

11:15 pm.pager goes off

hey Amy, theres a guy who cut

off his thumb and he really wants

us to try to put it back on


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12:00 am Monday Morning in OR

What I thoughtwhat are you

thinking Rob?What I said.. Hmm

looks like a pretty badinjury, you sure about

this Rob?OK then.Hope you have music ?

54 y/o male drinking while using circular saw


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Amputated Thumb


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Venous Graft for Arterial Anastomosis


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8:00 am Monday Morning

th f ll


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one month follow-up


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My favorite Replant


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My Favorite Replant


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After the Hospital

Chapel Wedding POD#4


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Back to work Full Duty


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Thumb Amputation Options: Toe Transfer

16 pts s/p transfer vs 5 amputations

at MCP levelMean f/u ( 3-13 yr )

Functional testing showed minimaldifference compared to normal side

No significant lower extremitymorbidity from donor site

Transfer pts also showed improvedvitality and emotional domainscompared to amputation pts

Journal of Hand Surgery 2000; 25A:651-8


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Digital Replantation: The Horizon

24 hands have been transplanted onto 18 recipients

Initial results have been promising

Hand transplantation may be an important procedure forfunctional restoration of upper limbs

However, the ethical aspects of chronic immunosuppression for a

non-life threatening condition is an ongoing debateThe future of hand transplants lies in the development of lesstoxic immunosuppressive drugs and/or safer methods oftolerance induction

Acta Orthopaedica 2005; 76(1): 14-27


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Digital Replantation: Bibliography

Wilhelmi BJ, Lee WP, Pagensteert GI,May JW. Replantation in the mutilatedhand. Hand Clin. 2003;19(1):89-120

Morrison WA and McCombe D. DigitalReplantation. Hand Clin. 2007;23(1):1-12

Green DP, Hotchkiss RN, Pederson WC,

Wolfe SW. Greens Operative HandSurgery 5thEdition.Philadelphia: Elsevier, 2005

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