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Emergency Medicine > TRAUMA AND ORTHOPEDICS
Replantation
Article Last Updated: Sep 4, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Ziad N Kazzi, MD, Assistant Professor, Director of Medical Toxicology, Department of Emergency Medicine, University of Alabama in Birmingham; Assistant Medical Director, Alabama Poison Center; Medical Toxicologist, Regional Poison Center of Birmingham
Ziad N Kazzi is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, and American College of Medical Toxicology
Coauthor(s):
Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS, Professor of Clinical Emergency Medicine, Department Chair, Associate Residency Director, Department of Emergency Medicine, University of California at Irvine
Editors: Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
replantation, amputated digits, amputated finger, amputated toe, amputation injury, amputation, amputated, digital replantation, severed finger, severed limb, severed toe, red-line sign, ribbon sign, avulsion, crush avulsion, toe-to-thumb transfer
Background
In the past 200 years, successful replantation of amputated digits has gradually moved from fantasy to reality. William Balfour performed the first successful fingertip reattachment in 1814; Thomas Hunter is credited with the first thumb replantation performed in the following year. Little progress was made until the pioneering work of William Steward Halstead and Alexis Carrel, who performed replantation experiments with dog limbs in the 1880s. Dr Carrel won the Nobel Prize in 1912 for his work on vascular anastomoses and for pioneering renal transplantation. In 1962, Ronald A. Malt performed the first successful replantation of an entire limb in a 12-year-old boy whose arm had been severed in a train accident. With the development of the operating microscope by Julius Jacobson and Ernesto Suarez in the early 1960s, replantation became easier, and its use began to spread throughout the Western world. With the advent of microvascular reanastomosis, digit replantation became tenable. In 1965, Shigeo Kmatsu and Susumu Tamai were the first to perform such a procedure. Modern replantation is now available in most large hospitals.
Pathophysiology
Amputation replantation is the reattachment of a completely severed part. This is distinguished from incomplete nonviable amputations, which require revascularization. Revascularization is the reconstruction of the blood supply of an incompletely amputated part.
In general, revascularization usually provides better functional results than replantation itself. Experienced hand surgeons can successfully replant most amputations. However, viability alone is an inadequate measure of success. The goal in replantation is the restoration or reconstruction of a functional limb, not merely the restoration of adequate tissue perfusion.
Degloving injuries are those in which the soft tissue is torn from the underlying bone, as when a glove is removed from the hand. These often are a result of jewelry getting caught in machinery.
History
An adequate history of the injury is important and should include the mechanism, time, and place of injury; condition of the injured part; hand dominance; and general condition of the patient.
- The mechanism of amputation is important; injuries due to sharp mechanisms have a much better chance of successful replantation than those caused by blunt crushing forces.
- If a narrow zone of crush injury is present, replantation may be possible by excising the crush zone and replanting with clean margins.
- Avulsion amputations caused by rollers offer a markedly reduced chance of successful, functional replantation, although such repairs are not impossible.
- The time elapsed since injury affects the amount of local and systemic hemorrhage and, hence, the degree of ischemia in the tissue and amputated part.
- Wound contamination progresses with time because bacteria proliferate on the wound surface.
- The source of contamination may influence the choice of antibiotic, method and duration of irrigation, and degree of debridement prior to replantation.
- Determine the patient's dominant hand, although this information is of only relative importance.
- Ask about allergies, immunizations, and chronic active disease processes.
- Ask if any old injury is present. Negative prognostic factors include old age, peripheral vascular disease, congestive heart failure, and diabetes mellitus with complications. In the surgeon's judgment, these factors may make replantation inadvisable.
- Assess the patient's psychiatric history. If the amputation was self-inflicted, a psychiatric evaluation is recommended.
Physical
- Perform a detailed examination of the hand, and describe the injury and neurovascular status.
- In cases of amputated digits, determine whether the amputation is within zone II of the hand (proximal to the flexor digitorum superficialis tendon insertion). Injuries in this zone are associated with poor postoperative functional outcome.
- A red-line sign may be seen in avulsion injuries with associated traction on the neurovascular bundle. These are small subcutaneous hematomas caused by intimal tears along the bundle. This sign is usually a negative prognostic sign.
- A ribbon sign is seen in patients where the blood vessel was subjected to stretch and torsion. The vessel will resemble a gift-wrap ribbon. This sign is also of negative prognostic value.
- Perform a general physical examination, concentrating on cardiovascular disease.
- Perform a rectal examination to ensure that anticoagulation can be accomplished during or after surgery, if necessary, without placing the patient at risk for GI bleeding.
Causes
The 6 mechanisms of amputation injury are the following:
- Sharp cut, as from a knife or meat slicer
- Dull cut, as from a saw or dull edge (eg, fan blade)
- Cut with a narrow segment of crush injury, as from a punch press
- Cut and avulsion, as from a machine that causes partial amputation and subsequent reflexive withdrawal of the hand that completes the amputation
- Avulsion, as from a finger or hand caught in an anchor rope or horse reins
- Crush avulsion, as from a machine (eg, rollers) that crushes the limb then pulls the digits off
Lab Studies
- Assess the patient's hemoglobin and/or hematocrit level at baseline, and follow up with serial determinations if significant blood loss is suspected.
- Assess coagulopathy by determining the prothrombin time and platelet count if the patient's history suggests a bleeding disorder or liver disease.
- Type and cross-match 2-4 units of packed RBCs if the patient's history suggests significant blood loss.
- Obtain an ECG in patients older than 45 years and in those with a history of cardiac ischemia or arrhythmia.
- A case report suggests that pulse oximetry can be used to document arterial flow to a part that is incompletely amputated when clinical findings of arterial flow with Doppler ultrasonography suggest an absence of arterial perfusion.1
Imaging Studies
- Radiographs of the injured part
- Obtain posteroanterior, lateral, and oblique radiographs of the amputated part and stump.
- Carefully assess for radiopaque foreign bodies.
- Comminution of the fracture implies a crush injury mechanism and is associated with soft-tissue trauma.
- If the joint is destroyed at the level of amputation, perform arthrodesis (fusion); this results in loss of joint function.
- If a crush injury is severe, a mosaic of fragments may preclude attempts at replantation.
- Obtain a chest radiograph if it is indicated by the patient's age or underlying lung or heart disease or if blunt or penetrating chest injury is suspected.
Prehospital Care
- At the scene, collect and preserve all amputated parts, even those crushed and not thought to be useful. Parts not suitable for replantation can provide tendons or bone.
- Cool the amputated part to 4°C to preserve it; 1 hour of warm ischemia is equivalent to approximately 6 hours of cold ischemia. Hence, cooling can markedly prolong the window of opportunity for replantation or revascularization.
- Wrap the part in saline-soaked gauze, and place it in a dry plastic bag. Place this bag on ice as soon as possible. This 2-layer approach avoids submersion of the part in ice water, which causes freezing of the tissues and cell destruction. Dry ice is too cold and causes tissue freezing and cell destruction.
- Estimate the blood lost at the scene; this information is useful regarding resuscitation prior to surgery. Control bleeding from the amputated stump.
Emergency Department Care
- Uncontrolled arterial bleeding is the only immediately life-threatening complication likely to be encountered in the ED after injury to the upper extremity. Normal hemostasis involves circumferential constriction of affected arteries and their retraction into the amputated stump. The addition of a pressure dressing usually suffices to control bleeding. With partial arterial lacerations, retraction is prevented, and bleeding control can be more difficult.
- Control hemorrhage in the upper extremities with local direct pressure or a pressure dressing. Use of a proximal tourniquet is acceptable, although not preferred, if direct pressure is not effective. The surgeon can clamp and ligate a bleeding vessel, but this can complicate later repair. In the ED, point control with localized pressure over the bleeding vessel or use of a pressure dressing is preferred.
- Elevate the arm. Ensure that a poorly applied pressure dressing does not become a tourniquet and cause ischemia in the amputated stump. If a tourniquet is used, use if for as briefly as possible, perhaps only during resuscitation for acute hypovolemia. Use of a tourniquet for more than 3 hours may lead to irreversible loss of function. Do not use a tourniquet during an interhospital transfer. A consultant may appropriately use a temporary tourniquet to better identify important structures such as nerves and vessels.
- Blind ligation or clamping of bleeding vessels could lead to greater damage because neurovascular bundles place ischemia-sensitive nerves near bleeding vessels. Careless clamping also can lead to vessel thrombosis, which requires shortening of a vessel and/or interposition of a vessel graft.
- Do not allow the patient to smoke prior to making the decision to replant or repair the amputation; smoking can cause vasospasm and complicate the procedure.
- For partial amputations, splint the involved extremity to prevent further damage. Reduce any malrotation to limit ischemia. Avoid tension on the tissue bridge, which can damage nerves or vessels. Cooling of a partially amputated part is controversial. If no demonstrable perfusion of the part exists, cool it as if it were completely amputated. If a pulse or bleeding from the capillary bed is present, avoid cooling.
- Bone, tendon, and skin can tolerate approximately 8-12 hours of warm ischemia and as long as 24 hours of cold ischemia. However, muscle necroses after 6 hours of warm ischemia or 12 hours of cold ischemia. In general, amputated digits may tolerate 12 hours of warm ischemia and 24 hours of cold ischemia. Other major amputations tolerate 6 hours of warm ischemia and 12 hours of cold ischemia because of their larger muscle content. Excessive ischemia time reduces muscle function and can result in myoglobinuria on reperfusion, placing renal function at risk. More proximal amputations involving more muscles must, therefore, be treated quickly.
- Amputations are tetanus-prone wounds. Therefore, 0.5 mL of tetanus toxoid (adsorbed) must be administered intramuscularly if the last booster was received more than 5 years earlier. If the patient was not previously immunized or if the immunization status is unclear, administer tetanus toxoid and tetanus immune globulin (500 U intramuscularly).
- A digital or regional nerve block is not recommended before a hand or plastic surgeon evaluates the patient because documentation of nerve function prior to surgery is important. Use systemic analgesics with intravascularly administered narcotics.
Consultations
Consult a hand surgeon.
Prophylactic antibiotics are indicated with amputation, crush, or degloving injuries. Devitalized tissue is a good culture medium for bacterial contaminants. Common pathogens are Staphylococcus aureus (most likely organism) and group A streptococci, whereas clostridia species and organisms from the Enterobacteriaceae family are less common. Gram-negative and anaerobic bacteria are more commonly found with extensive tissue damage or with wounds grossly contaminated with soil, saliva, or feces. In these cases, perform Gram staining and cultures before initiating antibiotic therapy.
If the amputation is from a human bite, antibiotic coverage should include streptococci, Eikenella corrodens, anaerobic bacteria, and staphylococci. Use oral amoxicillin and clavulanate for human bites without amputation. Use intravenous ampicillin and sulbactam or ticarcillin and clavulanate for amputations or established infections caused by human bites. A combination of penicillin G and an antistaphylococcal antibiotic also is acceptable for minor bite wounds.
Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens.
| Drug Name | Cefazolin (Ancef, Kefzol) |
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| Description | First-generation semisynthetic cephalosporin; binds 1 or more penicillin-binding proteins; arrests bacterial cell-wall synthesis and inhibits bacterial growth; primarily active against skin flora, including S aureus. |
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| Adult Dose | 250-1000 mg IV/IM q6-8h |
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| Pediatric Dose | 25-50 mg/kg/d IV/IM divided tid/qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid decreases renal clearance and prolongs effect; concurrent use with aminoglycosides may increase renal toxicity; may yield a false-positive result for glucose with urine dipstick testing |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in patients with renal impairment |
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| Drug Name | Ampicillin and sulbactam (Unasyn) |
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| Description | Drug combination that involves a beta-lactamase inhibitor with ampicillin; covers skin organisms, enteric flora, and anaerobes; not ideal for nosocomial pathogens. |
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| Adult Dose | 1.5 g (1 g ampicillin with 0.5 g sulbactam) to 3 g (2 g ampicillin with 1 g sulbactam) IV/IM q6h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin |
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| Pediatric Dose | <3 months: Not established
3 months to 12 years: ampicillin 100-200 mg/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram decrease renal excretion of ampicillin and sulbactam and increase levels of the antibiotics; allopurinol increases ampicillin excretion; may potentiate ampicillin rash and decrease the effect of oral contraceptives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in patients with renal failure; evaluate rash and differentiate from hypersensitivity reaction |
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| Drug Name | Ticarcillin and clavulanic acid (Timentin) |
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| Description | Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth; antipseudomonal penicillin and a beta-lactamase inhibitor covers most gram-positive and gram-negative organisms, as well as anaerobes. |
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| Adult Dose | 3.1 g IV q4-6h |
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| Pediatric Dose | 100 mg/kg/dose IV q8h |
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| Contraindications | Documented hypersensitivity; do not treat severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with oral penicillin during the acute stage |
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| Interactions | Tetracyclines may decrease the effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if they are administered in same IV line; effects when administered with aminoglycosides are synergistic; probenecid may increase penicillin levels |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Obtain CBCs before therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and determine BUN and creatinine levels during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions |
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Drug Category: Analgesics
Pain control is essential to quality patient care, ensuring patient comfort and promoting pulmonary toilet. Most analgesics have sedating properties, which are beneficial for patients with painful skin lesions.
| Drug Name | Meperidine (Demerol) |
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| Description | Analgesic with multiple actions similar to those of morphine; may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. |
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| Adult Dose | 25-50 mg IV q2-3h prn |
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| Pediatric Dose | 0.25-0.50 mg/kg IV q2-3h prn; not to exceed adult dose |
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| Contraindications | Documented hypersensitivity; upper airway obstruction; significant respiratory depression; during labor when premature delivery is anticipated; use of MAOIs |
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| Interactions | Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid use with protease inhibitors |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in patients with head injuries because meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution with postoperative use and in patients with a history of pulmonary disease (suppresses cough reflex); because of tolerance, use of substantially increased doses may aggravate or cause seizures even if no history of convulsive disorders exists; closely monitor the patient for morphine-induced seizure activity if a history of seizure exists |
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| Drug Name | Fentanyl (Duragesic) |
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| Description | More potent narcotic analgesic with a much shorter half-life than morphine sulfate; DOC for conscious sedation analgesia; ideal for analgesic action of short duration during anesthesia and in immediate postoperative period. After initial dose, do not titrate subsequent doses more frequently than q3h or q6h. Pain in most patients is controlled with 72-h dosing intervals; some patients require dosing intervals of 48 h. |
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| Adult Dose | 1 mcg (0.001 mg)/kg IV/IM q30min to q2h prn |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; respiratory depression; constipation; nausea; emesis; urinary retention; hypotension; potentially compromised airway that would make it difficult to establish airway control rapidly |
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| Interactions | Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects when both drugs are used concurrently |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in hypotension, respiratory depression, constipation, nausea, emesis, or urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation |
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| Drug Name | Morphine (Astramorph, MS Contin, Duramorph, Oramorph) |
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| Description | DOC for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used and are commonly titrated until desired effect is obtained. |
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| Adult Dose | 4-10 mg bolus slow IV; may repeat to maximum of 30 mg for severe pain |
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| Pediatric Dose | 0.1-0.2 mg/kg slow IV/IM |
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| Contraindications | Documented hypersensitivity; respiratory depression; nausea; emesis; constipation; urinary retention; hypotension; potentially compromised airway that would make it difficult establish airway control rapidly |
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| Interactions | Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in atrial flutter and other supraventricular tachycardias; vagolytic action may increase the ventricular response rate |
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Further Inpatient Care
- Repair may be performed with an axillary nerve block with bupivacaine, which provides anesthesia lasting 12-16 hours. However, children must have general anesthesia because they do not tolerate axillary block well.
- The surgical sequence for replantation varies slightly with amputations distal and those proximal to the wrist and with the mechanism of injury (clean cut, crush, avulsion). Since injury distal to the wrist is more common, the following surgical sequence is delineated:
- Surgeons must be skilled at microvascular reanastomosis and be able to achieve a 90% patency rate in a 1-mm-diameter vessel in laboratory animals. Viability of the replanted limb is no longer the sole determinant of success; functional recovery, preoperative and postoperative risks, and duration of treatment are vital factors in making the decision to replant. The duration of treatment, including rehabilitation, should not exceed 2 years; if it does, the replantation is not thought to be worthwhile. Amputation with early fitting of a prosthesis is a viable alternative in these cases.
- With tourniquet-induced ischemia and use of a microscope, the stump is debrided of all crushed tissue, foreign bodies are removed, and the vessels and nerves are identified and tagged. The amputated part then is similarly debrided, with irrigation of the cut end, while maintaining cooling. Vessels and nerves are identified and tagged.
- If indicated, an intramedullary K wire is inserted into the bone of the amputated part. If needed, the bone is shortened to eliminate tension on repaired arteries, veins, and nerves. Alternatively, a vein graft may be performed to reduce tension on vessels. Bones are fixed with K wires, intramedullary screws or pegs, or small plates with screws.
- The extensor tendon is repaired by using horizontal mattress 4-0 polyester sutures. A tendon graft also may be necessary if a sufficient length of tendon is not available. Finally, if extension is deemed expendable, arthrodesis (joint fusion) may be performed. Then, the flexor tendon is repaired with sutures.
- Arterial repair is performed next. Brisk blood flow from the proximal vessel should be confirmed prior to vascular anastomosis. Restoration of proximal blood flow may require relief of vascular compression, warming of the patient, administration of adequate blood volume, elevation of the patient's blood pressure, irrigation of the proximal part with warmed lactated Ringer solution, intraluminal flushing with papaverine solution, and correction of systemic metabolic acidosis.
- To avoid thrombosis, reconnect only normal intima visualized under the microscope. A vein graft may be necessary. Tourniquet-induced ischemia may be continued until the anastomosis is complete, although bolus injection of heparin is recommended to prevent thrombosis.
- Ideally, 2 veins should be repaired for each artery. No tension should be present on the vessels. Perform nerve repair next, with fascicular or bundle repair. A nerve graft may be necessary.
- Skin coverage is the final step. Skin grafts or flaps may be required.
- Postoperative anticoagulation with heparin, aspirin, and occasionally dextrans is commonly used to prevent thrombosis. A survey of surgeons in the United Kingdom showed that the use of dextran is not uniform and not necessarily beneficial in terms of outcome. Because of their adverse effects profile, dextrans are less commonly used than aspirin.2
- Patients are encouraged to avoid smoking and caffeine for a month because these may enhance vasoconstriction.
In/Out Patient Meds
- Postoperative anticoagulation with aspirin and dextrans is recommended to prevent thrombosis. Patients are encouraged to avoid smoking and caffeine for a month because these may enhance vasoconstriction.
Transfer
- The prevalence of severe associated injuries is 0.8%. Prior to considering transfer, ensure that the patient has no life-threatening conditions other than the amputation, if applicable. Transfer is indicated in the following cases:
- Amputations of thumbs and/or multiple digits
- Amputations in children
- Amputations of individual digits distal to the superficialis insertion
- Complete amputations that might benefit from acute microsurgical reconstruction (eg, revascularization, coverage of free flap)
- Clean amputations at the palm, wrist, or forearm
- Use of the Internet to transmit high-resolution images, including photographs and radiographs, of potential cases for replantation and use of a digital camera in the ED to facilitate replantation consultation might prevent unnecessary transfer of patients.
- Contraindications to transfer include the following:
- Significant associated injuries
- Coexisting medical problems (eg, recent stroke, myocardial infarction) that prohibit surgery
- Prolonged warm ischemia time (>12 h), especially with limb amputations
- Relative contraindications to transfer include the following:
- Amputation of single digits in adults through or proximal to the proximal interphalangeal joint
- Multilevel injuries
- Injuries caused by a severe crush-avulsion mechanism
- Severe contamination
- Wide segmental tissue injury
- Use of bulky dressings should be avoided during transport because these can conceal bleeding. Bleeding should be controlled before applying the dressing or before cooling the distal extremity without perfusion.
Complications
- Arterial insufficiency is one of the most common causes for replantation failure. Other causes include venous congestion and thrombosis.
- Infection may occur.
- Systemically, myonecrosis leading to rhabdomyolysis and renal insufficiency may occur if significant muscle mass that was transiently ischemic is replanted. These occur with forearm or lower leg replantations but not with finger replantations.
- Osteomyelitis may occur.
- Function may be limited after replantation.
- Cold intolerance of the replanted limb is a universal problem. Similarly, cold-induced vasospasm occurs in essentially all patients.
- Sensitivity to light touch and 2-point discrimination frequently is impaired, while limitations in the flexion of joints distal to the replantation vary.
- Cosmetic deformity may occur.
Prognosis
- Success rates as high as 90% have been reported for complete and incomplete amputations.
- Multivariate analysis of factors that favor functional recovery after finger replantation or revascularization showed better recovery for patients younger than 40 years compared with older patients. Injuries caused by a sharp mechanism have a better prognosis than those caused by a crush mechanism; injuries caused by a crush mechanism have a better prognosis than those caused by avulsion; and injuries at the middle phalangeal level have a better prognosis than those a the proximal level.
- A meta-analysis showed that smoking, diabetes, and avulsion or crush injury are poor prognostic factors in replantation of amputated digits.3
| Media file 2:
Radiologic appearance of a hand with 2-digit amputation. |
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Media type: X-RAY
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| Media file 5:
Radiologic appearance of a complete thumb amputation. |
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Media type: X-RAY
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Replantation excerpt Article Last Updated: Sep 4, 2007
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