Digital Replantation
Section snippets
Classification
For purposes of outcome assessments, amputations are classified according to:
- 1.
Complete or incomplete, devascularized or vascularized.
- 2.
Mechanisms of injury
- -
guillotine
- -
crush
- -
avulsion
- -
- 3.
Level
- -
Tamai 1 to 4 for finger amputation, and 1 to 2 for tip amputation [23]
- -
- 4.
Age
- -
children
- -
adults
- -
Indications for replantation
Current consensus generally accepts that replantation is indicated for the thumb, single digits distal to superficialis insertion (mid middle phalanx), multiple digits, and all amputations in children [24], [25]. Looked at another way, the only nonreplantable indication is for single digits at or proximal to the proximal interphalangeal joint in adults. Even this is relative because now patients' demands will override wisdom and explanation. The results of replantation obviously depend on the
Contraindications to replantation
Replantation may be contraindicated for reasons involving the patient or the digit.
Technique
Replantation, especially of multiple digits, is a time and motion study, a disciplined routine that requires leadership from the outset to prevent it from degenerating into rudderless Brownian movement by wide-eyed residents each demanding “give me a go at this.” Direction includes communication with anesthetists regarding the likely duration and potential requirement for dextran therapy, antibiotics and anticoagulation, and the awareness of its risks if a brachial plexus block or indwelling
Operative sequence
Several excellent articles, reviews, and chapters have been written on this subject [23], [24], [25], [27], [28] and only some of the more important issues that we identify are discussed here.
Prolonged ischemia and the “no reflow” phenomenon
After prolonged ischemia, arterial inflow may be established, but little or no venous outflow is seen. This no reflow phenomenon is the consequence of the ischemia-reperfusion injury, a multifaceted insult comprising anoxic cell death, edema, spasm, thrombosis, and inflammation leading to occlusion of the microvasculature. Despite the energy and expenditure invested into experimental research in this field, beyond the use of thrombolytics, such as urokinase or tissue plasminogen activator
Survival
Survival rates for replantation are directly proportional to the chosen indication and surgeon's experience, and skill. Clearly, because of the nature of the replantation injury, the overall success rate would be expected to be less than for elective microsurgical free flaps, although in one of the largest prospective series ever reported of 1,018 digits Waikakul and colleagues [38] reported a survival rate of 92%, reflecting the acknowledged technical mastery of the Asian microvascular
Summary
The reattachment of the amputated digit still holds sway in the pantheon of “great operations.” That sense of awe as the death pallor drains from the face of the finger and the vital succulence of youth smiles back. The miracle of Lazarus more than 2000 years ago is still talked about today, so too will Tamai's first replantation remain an historic milestone. But while it is awesome for the resident and a necessary chore for the surgeon, it has always been a desperate bore for the anesthetist
References (65)
Definitions and classifications in replantation surgery
Br J Plast Surg
(1980)Replacement of the amputated digit
Br J Plast Surg
(1973)- et al.
Evaluation of digital replantation–a review of 100 cases
Orthop Clin North Am
(1977) - et al.
Digital replantation and revascularisation. A long term review of one hundred cases
Hand
(1978) Twenty years' experience of limb replantation–review of 293 upper extremity replants
J Hand Surg [Am]
(1982)- et al.
Digital replantations including fingertip and ring avulsion
Hand Clin
(2001) Indications and selection for digital amputation and replantation
J Hand Surg [Br]
(2001)Microvascular hand surgery-transplants and replants-over the past 25 years
J Hand Surg [Am]
(2000)- et al.
Arterial system of the fingers
J Hand Surg [Am]
(1990) Microsurgical revascularisation of the thumb pulp with a discussion of the venous drainage of the thumb
J Hand Surg [Br]
(1985)