Replantation Treatment & Management

Updated: Feb 11, 2014
  • Author: L Andrew Koman, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

Medical Therapy

Appropriate antibiotics and wound care are indicated to prevent infection.

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Preoperative Details

Amputated parts should be stored dampened with isotonic sodium chloride solution or Ringer's lactate in a cooled environment (on ice within a cooler or in a refrigerator). Contact with a saline ice bath may produce frostbite and should be avoided.

If possible, bleeding from proximal vessels should be controlled with pressure, and ligature control should be avoided.

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Intraoperative Details

The normal sequence of the operative procedure is as follows [8] :

  1. Debridement
  2. Identification and/or tagging of vital structures
  3. Skeletal stabilization
  4. Extensor tenorrhaphy
  5. Placing sutures within flexor tendon ends
  6. Digital artery repair
  7. Neurorrhaphy of digital nerve
  8. Repair of flexor digitorum profundus
  9. Venous repair [9]
  10. Skin closure
  11. Dressing

Debridement and exposure is a crucial aspect of the procedure and should be performed through an extensile midlateral incision when possible. This allows the wound to heal by secondary intention if excessive swelling is present, provides fasciotomies of the digits, and facilitates optimal exposure.

Following debridement, exposure and identification of nerves, arteries, veins, and tendons is helpful. This is performed under magnification using operating telescopes or the operating microscope.

The amount of bone shortening necessary is dictated by the extent of comminution and should be predicated on the ability to obtain adequate nerve, tendon, and skin approximation. Shortening to facilitate vascular repairs is not necessary because vein grafting is adequate. However, poor skin coverage, nerve grafts, and the inability to primarily repair tendons have a negative impact on long-term outcome.

Following appropriate shortening, the bone may be stabilized with longitudinal or crossed interosseous wires, interosseous wire and pin, or miniplates and/or miniscrews. [10] Joint damage may be managed with prosthetic joints, resection arthroplasty, or fusion.

Following bone and/or joint stabilization, the extensor tendon mechanism is repaired. This improves stability. Flexor tendons may be repaired prior to or following arterial and nerve anastomosis. If the flexor tendons are to be repaired following arterial repair and neurorrhaphy, the placement of sutures prior to microprocedures will simplify the process and minimize iatrogenic injury. In general, arteries are repaired first using an operating microscope and appropriate microneedles and microsutures. The most common needle is 50-100 microns in diameter and controls a 10-0 or 11-0 suture. At the surgeon's discretion, a bolus of heparin may be given prior to clamp release or tourniquet release.

For logistical reasons, the digital nerve adjacent to the artery is repaired next. If not repaired previously, the tendon is approximated. The hand is then turned, and the veins are mobilized, trimmed to normal, and repaired under the operating microscope.

The skin is closed if it can be approximated without tension. If concern about skin tension exists, the midlateral incisions are left open or skin grafts are applied.

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Postoperative Details

The involved extremity is placed in a bulky dressing; compression of the dorsal veins is avoided. Avoid constricting circular dressings because both flexor and extensor tendons have been repaired. Immobilization generally is with the wrist in a neutral position.

The timing of rehabilitation depends on the stability of the bone fixation, the adequacy of the tendon repair, and the tension on repaired neurovascular structures. Prior to wound closure, make an intraoperative assessment of the amount of safe active or passive motion so that it may be incorporated at the appropriate time during rehabilitation. Monitoring is clinical and often includes temperature probes or laser Doppler probes. [11]

In the perioperative period, tobacco and smoking products are avoided, [12] caffeine and other stimulants are withheld, and the patient is asked not to use over-the-counter drugs. Thorazine often is used for its calming effect and because it maximizes subdermal plexus recovery. In addition, anticoagulants such as aspirin, Dextran 40, low-molecular-weight heparin, or heparin may be used. In general, Dextran 40, aspirin, and ibuprofen are used for clean cuts in which repairs were achieved without difficulty. If a significant crush or avulsion component is present and concern exists regarding vessel integrity distal or proximal to the anastomosis, heparinization may be considered.

Patients generally are kept in a warm, quiet room for 3-7 days and then are sent home on oral medications (eg, 1 aspirin a day or ibuprofen 200 mg tid).

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Follow-up

Rehabilitation is performed under the supervision of a hand therapist and depends, in part, on the factors listed above.

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Complications

The major complications of replantation include venous or arterial rethrombosis and infection. Infection frequently is the precipitating event in thrombosis.

In the first 24-36 hours, acute arterial injuries generally are handled by reexploration and additional arterial reconstruction. Similarly, early venous insufficiency may be handled with surgical exploration, heparinization, the use of leeches, or removal of the nail bed and the use of heparin-soaked pledgets to allow controlled bleeding.

Late complications include loss of motion from joint stiffness and tendon adhesions. Fusions, tenolysis, or both may be required. In addition, nonunions are common because distal fragments may be avascular.

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Outcome and Prognosis

The outcome and prognosis are variable. [13, 14] Thumbs have the best prognosis, [15] as do digits amputated distal to the insertion of the flexor digitorum superficialis. [16, 17, 18, 19]

Survival of digits was 80-90% for clean or sharp lacerations in the 1980s and 1990s; however, the rate of success of digit replantation was 57%, significantly lower than previous rates, at 2 academic level-I trauma hospitals from 1997-2010. [20] Survivorship after avulsion injury may drop to 50-60%. Sensitivity, except in children, rarely is normal, but 2-point discrimination often is present. Cold sensitivity is a common problem, although it generally decreases over time. [21, 22] The function of replanted digits is never normal. Sensation is protective in more than 90% of patients, but measurable 2-point discrimination is present in only 50% of patients.

In crush or avulsion injuries, protective sensation may drop to 80%, with 2-point discrimination in only 30% of patients. Pain persists after 3% of sharp injuries and 5% of crush avulsions. Occasionally, late amputations are required. Replantation distal to the insertion of the flexor digitorum superficialis results in an average of 85° of proximal interphalangeal (PIP) joint motion and excellent metacarpophalangeal (MP) joint motion. However, proximal to the flexor digitorum superficialis, PIP motion averages only 35°.

Historically, the prognosis for ring avulsion injuries is poor. [23] Urbaniak divided ring injuries into the following 3 types, as follows [24] :

  • Class 1 injuries have adequate circulation and are treated by standard bone and soft-tissue methods.
  • Class 2 avulsions have incomplete revascularization and are treated depending on the clinical circumstances.
  • Class 3 injuries are complete amputations with extensive degloving and are best treated with revision of the residual digit.

However, a recent systematic review by Sears Davis and Chung suggests that functional outcomes after replantation of avulsion injuries are better than historically cited and the routine practice of revision amputation should be reconsidered. [25]

Kay identified the following 4 classes of ring avulsion injury: [26]

  • Class 1 is similar to Urbaniak's.
  • Class 2 ring avulsions show inadequate circulation without skeletal injuries and are divided into arterial or venous. In general, these are reconstructed.
  • Class 3 injuries have inadequate circulation, either arterial or venous, and skeletal injury. They are managed after obtaining bony stability.
  • Class 4 ring injuries are complete and generally treated with revision of the residual digit.

The Sears Davis and Chung review suggests that the above criteria may be too rigid. [25]

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Future and Controversies

In the future, transplantation of digits may be possible and would be feasible in a small percentage of patients.

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