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Abstract
Author Asser Abdelhay Ahmed Sallam
Title Role of Digital Replantation after Traumatic Finger Amputation
Faculty Medicine
Department Orthopedic Surgery
Location Ismailia
Degree Master of Science
Date 2008
Language English
Supervision committee Prof. Dr. Adel Abd El-Hameid Ghoneim
Dr. Tarek Abd El-Aziz Mahmoud
Dr. Mohamed Ahmed Radwan
English Abstract
Digital replantation has attracted a great deal of attension in recent years especially after development of operating microscope and advances in microsutures and micro-instruments. The goal of replantation is successful restoration of function. In this essay, a review of the value of digital replantation after traumatic finger amputation during the last 35 years was done. Requisities for replantation surgery, transportation of patient & amputated parts and microsurgical equipment and instrumentation for replantation have been illustrated. Indications for replantation apply to amputations of the thumb, more than one finger, and part of the hand. There are many steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are shortened and rejoined. Muscles, tendons, arteries, nerves and veins are then repaired. The outcome is variable. Thumbs have the best prognosis, as do digits distal to the flexor digitorum superficialis. Success rates of 90% have been reported. Hand therapy and temporary bracing are important to the recovery process. Mutilating hand injuries can be associated with psychological disturbances. So, Promotion of a healthy adjustment should begin as soon after the injury as possible. Patients in whom alternatives to replantation are considered are those in whom replantation cannot be performed because of severe mangling or complete loss of the amputated parts. These include phalangization, distraction lengthening, toe-to-hand transfer and pollicization. A comparison of data regarding procedure and outcome of replantation has been discussed leading to a conclusion that microsurgical digital replantation is the best solution for traumatically amputated fingers for better function and appearance.
Key Words Re-implantation, amputation, digital replantation, severed finger, severed toe, crush avulsion, toe-to-thumb transfer, pollicization, replantation alternatives
ACKNOWLEDGEMENT
Praise to Allah, the master of the universe, and most merciful.
I would thank Prof Dr. Adel A. Ghoneim, professor of orthopedic surgery, Suez Canal University, for his determination that I must do this work, teaching me a lot about microsurgery, as well as his guidance during all its stages.
I am very greatfull to Dr. Tarek Abdel-Aziz, lecturer of orthopedic surgery, Suez Canal University, for his great encouragement and kind help.
I also like to express my appreciation to Dr. Mohamed A. Radwan, lecturer of orthopedic surgery, Suez Canal University, for his support, his patience and removing obstacles, which met me.
LIST OF ABBREVIATIONS
2 PD: two point discrimination
ADL: activity of daily living
AO: Arbeitsgemeinschauft fur Osteosynthesefragen
ASD: acute stress disorder
ASIF: Association for the Study of Internal Fixation
A-V: arterio-venous
cc: cubic centimeter
CMC: carpo-metacarpo
DIP: distal inter-phalangeal
ECG: electrocardiography
EPM: early protective motion
Fb: the objective tube focal length
FDP: flexor digitorum profundus
FDS: flexor digitorum superficialis
Fo: the objective lens focal length
FPL: flexor pollicis longus
IM: intra-muscular
IP: interphalangeal
IV: intra-venous
K-wire: Kirschner wire
MCP: metacarpo-phalangeal
Me: the eyepiece magnification
mg: milligram
MGH: Massachusetts General Hospital
mm: millimeter
Mt: total magnification
N/S: normal saline
NPO: nothing per oral
PIP: proximal inter-phalangeal
PTSD: post-traumatic stress disorder
ROM: range of motion
TAM: total active motion
VAS: visual analogue scale
LIST OF TABLES
Page
Table (1): Muscles controlling the thumb movements………………………………………………………...
13
Table (2): Nonunion rates for various techniques of osteosynthesis with replantation…………………………………..
65
Table (3): Survival rates for replantation………………………… 139
Table (4): Carlsson VAS scale of the influence of the injury on different hand functions…………………………………………...
144
Table (5): The functional results after replantation as assessed by Chen’s classification……………………………………………….
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LIST OF FIGURES
Page
Figure (1): The ’thumbs up’ gesture is a sign of approval in many cultures, and an obscene gesture in many others…………………………....................................................
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Figure (2): Human hand with index finger extended………….. 15
Figure (3): The ring finger on this hand is extended…………... 16
Figure (4): Human hand with little finger extended…………… 16
Figure (5): Schematic representation of the relationship between the natatory ligament and the three longitudinal layers of the aponeurosis in the palmar digital area……………………
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Figure (6): Palmar digital area and entry point of the vasculonervous pedicle………………………………………….
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Figure (7): Transverse section in the finger…………………… 18
Figure (8): The three systems of fascia in the first web and at the base of the thumb. One should note that the pretendinous fibres directed towards the index finger have an insertion on the radial border of the hand………..................................................
19
Figure (9): Bones of the hand………………………………….. 20
Figure (10): Joints of the hand………………………………… 21
Figure (11): Flexors of digit (anterior view)…………………... 23
Figure (12): Flexor and extensor tendons in finger (dorsal view)……………………………………………………………. 24
Figure (13): Flexor and extensor tendons in finger (extended lateral view)……………………………………………………..
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Figure (14): Flexor and extensor tendons in finger (flexed lateral view)……………………………………………………..
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Figure (15): Dorsal vascular arcade from the dorsal aspect……………………………………………………………
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Figure (16): Dorsal vascular supply to the nail complex and the fingertip…....................................................................................
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Figure (17): Diagram of the arrangement of three dorsal ladder……………………………………………………………
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Figure (18): Volar ladder with dorsal communication and web confluence………………………………………………………
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Figure (19): The venous drainage of the thumb…………………. 31
Figure (20): The dorsal sensory branch angles across the proximal phalanx before reaching the dorsum of the middle phalanx………………………………………………………….
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Figure (21): High Quality Optical Microscope………………...
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Figure (22): Lightweight operating microscope……………….. 41
Figure (23): Light weight loupe……………………………….. 43
Figure (24): Wide field of view loupe…………………………. 43
Figure (25): Field of view by Galilean loupe………………….. 44
Figure (26): Field of view ruler for loupes…………………….. 45
Figure (27): Jeweler’s forceps, straight………………………... 46
Figure (28): Jeweler’s forceps, angled 450 ……………………. 46
Figure (29): Jeweler’s forceps, angled 900…………………….. 46
Figure (30): Vessel dilator……………………………………... 47
Figure (31): Straight needle holder……………………………. 47
Figure (32): Curved needle holder…………………………….. 47
Figure (33): Microscissors…………………………………….. 48
Figure (34): Microvascular clamps……………………………. 48
Figure (35): Levels of replantation…………………………….. 52
Figure (36): (A) The red line and ribbon signs are poor prognostic signs for replantation. (B) This patient degloved a hand in a log crusher splitter, resulting in multilevel neurovascular and bone injuries………………………………...
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Figure (37): (A,B) This patient underwent ectopic implantation of an amputated hand before eventual replantation when he was stable from other injuries………………………...……………...
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Figure (38): The amputated part is wrapped in gauze and placed in a plastic bag. The plastic bag is set on ice…………………………………………………………………..
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Figure (39): Signs of arterial damage should be appreciated, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel……………………………………………………………
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Figure (40): (A,B) Exposure of the neurovascular structures to be labeled on the amputated part………………………………..
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Figure (41): The tourniquet is deflated to assess inflow pressure by the proximal vessel spurt. If the spurt is inadequate, more vessel shortening is required……………………………...
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Figure (42): Once the neurovascular structures of the amputated part have been identified and tagged, they can be carefully retracted for bone shortening………………………….
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Figure (43): In performing the bone fixation, many prefer K-wires, which are quick and safe and can be placed in cross or axial configuration. Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire or as 90-90 wires. Ninety-ninety wires are two intraosseous wires placed perpendicular to each other, which was found to have lower nonunion rates………………………..
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Figure (44): The hand is pronated, and of the dorsal structures, the extensor is repaired first. If the amputation is at the proximal phalanx level it is important to repair the lateral slips to prevent loss of extension at interphalangeal joints…………...
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Figure (45): At least two veins should be repaired in finger replants, especially for replants proximal to the PIP joint. Dorsal veins are preferred because they are larger and don’t interfere with repair of volar structures later……………………
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Figure (46): This is an example of a dorsal vein repair with 10-0 nylon sutures in simple, interrupted fashion over the previously repaired extensor tendon…………………………….
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Figure (47): Schematic illustration of possible sites for harvesting a venous finger flap…………………………………
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Figure (48): A-V fistula as a solution of absent draining veins……………………………………………………………..
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Figure (49): The dorsal skin is loosely approximated. No venous anastomosis was done (right), ulnar arteriorrhaphy (left) was done without soft tissue closure……………………………
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Figure (50): A,B This is a vein graft interposing this arterial defect between the two forceps. Notice the size match with this vein graft harvested from the palmar forearm…………………..
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Figure (51): Diagramatic representation of the Y-shaped vein graft outflow limbs anastomosed end to end to the distal digital arteries……………………………………………………………..
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Figure (52): Diagramatic representation of : A. proximal end to end anastomosis of a vein graft to a common digital artery. B. proximal end to side anastomosis of the vein graft to the superficial palmar arch………………………………………….
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Figure (53): Basic position for holding the instrument………... 81
Figure (54): The grip for each hand is identical. Additional support comes from touching the tips of the small fingers……..
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Figure (55): The suture is lifted until the needle tip just touches the surface below. This enables proper grasping of the needle……………………………………………………………
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Figure (56): Grab the needle just past the halfway point toward the shank………………………………………………………...
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Figure (57): Pass the needle through the far edge and gently evert the near edge as you drive the needle……………………..
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Figure (58): Adjust the suture length until ~5 mm of material extends from the far edge. Pick up the near side at ~10 mm from the edge. Note the position of the suture as it emerges from the top surface of the forceps. Moving the tips of the forceps toward the puncture site will automatically cause the suture to form a loop……………………………………………
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Figure (59): Skin incision (left). Dissection of the subcutaneous tissues (right)…………………….………………
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Figure (60): The fat pad is incised and elevated with exposure of the neurovascular bundle…………………………………….
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Figure (61): Visualization of femoral vessels (left) and ligation of profunda vessels (right)………………………………………
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Figure (62): Clip application (left) and division of the artery (right)……………………………………………………………
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Figure (63): Expansion of the arterial orifice by vessel dilator... 90
Figure (64): Trimming of the adventitia………………………. 90
Figure (65): Making the first knot……………………………... 91
Figure (66): The two stay sutures……………………………… 92
Figure (67): Suturing the back wall……………………………. 92
Figure (68): The completed anastomosis……………………… 93
Figure (69): Empty and Refill test…………………………….. 94
Figure (70): Standard end-to-side technique…………………... 95
Figure (71): An optional end-to-side technique……………….. 96
Figure (72): The back wall first technique……………………….. 97
Figure (73): “Flipping” a mobile vessel……………………….. 98
Figure (74): Skin coverage without tension…………………… 102
Figure (75): First, the vein graft is repaired to the distal ulnar artery. Then the vein graft is pulled through a subcutaneous tunnel to the snuffbox and repaired endto- side to radial artery…………………………………………………………….
103
Figure (76): A technique that has been described to optimize exposure of the ulnar aspect digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis………………………………………..
105
Figure (77): Early protective motion (EPM) I………………… 114
Figure (78): Early protective motion (EPM) II………………... 115
Figure (79): Drawing of a palmar advancement flap for the thumb……………………………………………………………
127
Figure (80): Drawings of the first dorsal metacarpal artery flap. 128
Figure (81): A. A right hand after amputation of the thumb at the midlevel of the proximal phalanx. B. The right hand with the distraction apparatus in place. C. Anteroposterior and lateral radiographs of the first metacarpal, showing the result of distraction lengthening of 2 cm. D. Right and left hands in comparison. Notice that the patient wears a finger prosthesis attached to the previously lengthened thumb remnant………….
129
Figure (82): A. A right hand after traumatic thumb amputation at the middle of the proximal phalanx. B. The design for a trimmed toe transfer. C. The donor site. D. The result after the trimmed toe transfer…………………………………………….
132
Figure (83): A. A left hand showing thumb amputation at the metacarpophalangeal joint level and malrotation of the index finger because of nonunion of the second metacarpal. B. The result after second toe transfer. C. The donor site after second toe harvest……………………………………………………….
132
Figure (84): All finger loss except the thumb…………………. 134
Figure (85): A-K. This patient underwent replantation of the middle and ring fingers after amputation in a log splitter…………………………………………………………...
148
CONTENTS
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1. INTRODUCTION ………………………………………… 1
2. AIM OF THE WORK …………………………………… 5
3. RESEARCH QUESTION ………………………………… 7
4. REVIEW OF LITERATURE …………………………….
4.1. Historical review ……………………………………..
4.2. Finger anatomy ………………………………………
4.2.1. Thumb ………………………………………….
4.2.2. Index finger …………………………………….
4.2.3. Middle finger …………………………………...
4.2.4. Ring finger ……………………………………..
4.2.5. Little finger …………………………………….
4.2.6. The skin of the finger ………………………….
4.2.7. The fascia of the finger ………………………...
4.2.7.1. The palmar digital area ……………………..
4.2.7.2. The finger fascia ……………………………
4.2.8. Bones and joints of the hand ………………….
4.2.9. Digital attachments of the long tendons ………
4.2.9.1. Flexor tendons ……………………………...
4.2.9.2. Extensor tendons and expansions …………..
4.2.9.3. Long tendons of the thumb …………………
4.2.10. Arteries of the palm of the hand …………….
4.2.10.1. The Superficial Palmar Arch ……………...
4.2.10.2. The Deep Palmar Arch ……………………
4.2.10.3. The Posterior Carpal Arch ………………...
4.2.10.4. The Digital Arterial Pattern ……………….
4.2.11. The venous drainage of the digits ……………
4.2.11.1. The Dorsal Side …………………………...
4.2.11.2. The Volar Aspect ………………………….
4.2.11.3. The dorsal venous arch (or network) ……...
4.2.12. The venous drainage of the thumb ………….
4.2.12. Digital nerves ………………………………….
4.2.13.1. The dorsal digital nerves …………………..
4.2.13.2. The palmar digital nerves …………………
4.3. Requisities for replantation surgery ………………..
4.3.1. Emergency Room Staff ……………………….
4.3.2. Surgical Team …………………………………
4.3.3. Anesthesiologists ………………………………
4.3.4. Ward Nursing …………………………………
4.3.5. Equipment …………………………………….
4.3.6. Recovery Room and Intensive Care Unit Nursing ……………………………………………….
4.3.7. Hand Therapists ………………………………
4.4. Transportation of patient and amputated parts …..
4.4.1. The Patient ……………………………………..
4.4.2. Amputated Part ………………………………..
4.4.3. Partial Amputation ……………………………
4.5. Microsurgical equipment and instrumentation for replantation………………………………………………..
4.5.1. Operating Microscope ………………………...
4.5.2. Magnifying Loupes ……………………………
4.5.2.1. Choice of proper magnification ……………
4.5.2.2. Types of magnifying loupes ……………….
4.5.3. Jeweler’s Forceps ……………………………...
4.5.4. Vessel Dilator …………………………………..
4.5.5. Needle holder …………………………………..
4.5.6. Scissors …………………………………………
4.5.7. Microvascular Clamps ………………………..
4.5.8. Instrument Case ……………………………….
4.5.9. Microsuture ……………………………………
4.5.10. Instrument Care ……………………………..
4.6. Indications and contraindications of digital replantation ……………………………………………….
4.7. Surgical technique of digital replantation ………….
4.7.1. Preoperative considerations …………………..
4.7.2. Operative considerations ……………………...
4.7.3. Operative Sequence …………………………...
4.7.3.1. Bone Fixation ……………………………..
4.7.3.2. Extensor Tendon Repair ………………….
4.7.3.3. Dorsal Veins Repair ………………………
4.7.3.4. Dorsal Skin Repair ………………………..
4.7.3.5. Arterial Repair ……………………………
4.7.3.6. Performing Microvascular Anastomosis …
4.7.3.7. Nerve Repair ……………………………...
4.7.3.8. Flexor Tendon Repair …………………….
4.7.3.9. Soft Tissue Repair ………………………...
4.7.3.10. Dressings ………………………………...
4.7.3.11. Special Considerations …………………..
4.7.3.12. Postoperative care ……………………….
4.8. Pharmacologic Agents in Microsurgery…………….
4.8.1. Antiplatelet and anticoagulating agents……...
4.8.2. Vasodilators…………………………………….
4.8.3. Agents affecting blood viscosity……………….
4.8.4. Agents investigated as detrimental to vascular
patency and/or tissue survival………………...
4.8.5. Current drug therapies………………………..
4.9 Hand therapy ………………………………………...
4.9.1. Early phase (protective) ………………………
4.9.2. Intermediate phase (mobilization) …………...
4.9.3. Late phase (strengthening) ……………………
4.10.1. The order and Speed of Sensory Recovery after
Digital Replantation ………………………….......
4.11.2. Cold Sensitivity after Replantation ……………...
4.12. Psycological aspects after mutilating hand injuries
4.12.1. Injury-related issues …………………………
4.12.2. Psychological responses to a mutilating hand injury ………………………………………………….
4.12.3. Promoting healthy adjustment to injury …...
4.12.4. Replantation issues …………………………..
4.13. Alternatives to Thumb Replantation……………...
4.13.1. Patient selection……………………………….
4.13.2. Non-microsurgical techniques……………….
4.13.2.1. Revision Amputation…………………....
4.13.2.2. Phalangization…………………………...
4.13.2.3. Distraction Lengthening………………...
4.13.2.4. Osteoplastic Thumb Reconstruction…….
4.13.2.5. Prosthetic Replacement………………….
4.13.3. Microvascular techniques……………………
4.13.3.1. Pollicization……………………………..
4.13.3.2. Composite Free-Tissue Transfer………...
4.13. Alternatives to Finger Replantation…………….....
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5. MATERIALS AND METHODS ………………………….
5.1. Materials ………………………………………………
5.2. Search strategy ……………………………………….
5.3. Time of the study research …………………………..
5.4. Criteria for selecting those studies ………………….
5.5 Inclusion and exclusion criteria ……………………...
5.6. Study preparation ……………………………………
5.7 Time table ……………………………………………..
5.8.Budget ………………………………………………… 135
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6. DISCUSSION ……………………………………………… 138
7. CONCLUSIONS AND SUMMARY ……………………... 156
8. REFERENCES …………………………………………….. 160
9. ARABIC SUMMARY ……………………………………..
1. INTRODUCTION
The hand plays an immense and integral role in an individual’s vocational and social functioning. The hands, more than any other appendage, provide us with independence, competence, and a sense of autonomy [1].
A hand injury is particularly threatening to an individual who relies upon fine motor skills to perform work-related tasks. Consider the impact of a disabling hand injury for the carpenter, cheif, dentist, or surgeon. There is potential for a hand injury to destroy a career and threaten quality of life [2].
In addition to the functional role of the hands, the hands are vital aspects of the subjective body image. A disfigured hand is easily observed and evaluated by others, resulting in the individual becoming acutely aware of any associated social stigma [3].
Furthermore, increased sensitivity to a disfigured hand may complicate functional recovery. For example, if an individual cannot tolerate the sight of their disfigured hand or tolerate allowing others to view it, they may be at risk for failure to comply with or attend therapy sessions, or they may avoid returning to work [4].
Neumeister & Brown (2003) stated that each finger has its inherent role in the normal function of the hand. Loss of the thumb is equivalent to a 40% loss of function of the hand and a 25% loss of the whole body function. Although the little and ring fingers are not given as high a functional loss, these digits are important in grip strength. The thumb is important for prehensile tasks, whereas the ulnar digits are important for power grasps [5].
Wilhelmi et al. (2003) stated that approximately 100,000 digital amputations occur per year in the USA, approximately 30% of which are suitable for replantation [6].
In 1980, the number of finger amputations in Paris can be estimated at 11,000 (3300 for which were accidents at work) whose overall cost was 89,986,400 Euro, the daily compensations being 2/3 of this figure [7].
Meredith & Koman (1999) demonstrated that amputations of digits occur secondary to laceration, crush, avulsion, and combination injuries [8].
Until 1965 when the first thumb ever was replanted, the treatment of amputated digits had been limited by technical facilities of the medical science. Since 1970s, the development of fine suture materials, microsurgical instruments and the operating microscope has made it possible that replantations have become routine procedures in hand surgery [9].
The goal of replantation (commonly known as re-implantation or re-attachment surgery) after traumatic amputation is successful restoration of function. Simply returning circulation to an amputated part does not in itself define success. Buncke (2002) reported that replantation of a part that will not perform useful activity should be avoided [10].
Generally accepted indications for replantation in the hand apply to amputations involving the thumb, more than one finger, and part of the hand. One of the most controversial issues is the indication for replantation after traumatic amputation of a single finger. O’ Brien et al. (1973) have stated that this should be done only in unusual circumstances [11], while others have recommended that a single finger should not be replanted because of the potential diminution of the over-all function of the hand and prolonged morbidity [12, 13, 14].
Relative contraindications to surgery are complete amputation of a digit proximal to the flexor digitorum superficialis insertion, severe crush or avulsion injuries, segmented injuries, and/or severe bony communication with loss of bone and joint integrity [15, 16].
Chiu (1992) reported that prolonged warm ischemia, crush or avulsion injuries with diffuse arterial damage, and/or the inability to obtain reconstruction that would allow a functional digit are the major contraindications to surgery [17].
O’Brien (1998) found that there are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are shortened and rejoined with pins or plates. Muscles, tendons, arteries, nerves and veins are then repaired [18].
The major complications of replantation include venous or arterial rethrombosis and infection. Infection frequently is the precipitating event in thrombosis [19].
The outcome and prognosis are variable. Thumbs have the best prognosis, as do digits distal to the flexor digitorum superficialis [20].
Chiu et al. (1995) demonstrated that success rates as high as 90% have been reported for complete and incomplete amputations [21].
Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process [22, 23].
In a study done by Hahn & Jung (2006) it was found that when the bandages are removed and the patient see the replanted part for the first time, he may feel shock, grief, anger, disbelief, or disappointment because the replanted part simply does not look like it did before. Worries about the look of a replanted part and how it will work are common. Talking about these feelings with the doctor often helps the patient come to terms with the outcome of the replantation [22].
Wilhelmi et al. (2003) stated that in the future, transplantation of digits may be possible and would be welcome in small percentage of patients [6].
2. AIM OF THE WORK
To review the value of digital replantation after traumatic finger amputation during the last 35 years.
3. RESEARCH QUESTION
In patients with traumatic finger amputation, does digital replantation successfully restore the function?
4. REVIEW OF LITERAURT
4.1. Historical Overview
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 [6].
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. Carrel won the Nobel Prize in 1912 for his work on vascular anastomoses and for pioneering renal transplantation [6]. Carrel performed experimental replantation of a canine hind limb in 1906 [8].
Nylen of Sweden in 1921 was the first to introduce the microscope for clinical use [24]. It was not until 1959 when Douglas realized the first digital Replantation in monkeys [25].
With the development of the operating microscope by Julius Jacobson and Ernesto Suarez in the early 1960s to anastomose vessel 1 mm in diameter, replantation became easier, and its use began to spread throughout the Western world [26].
Kleinert & Kasdan (1963) reported the first thumb revascularization. This was done by repairing a digital artery and a dorsal vein without microscope [27].
Buncke & Schulz (1965) described the technique of microvascular anastomosis in experimental digital Replantation in the rhesus monkeys [28].
In 1964, 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, and Meredith performed replantation after a distal radius/wrist injury in 1965 [8].
Chinese surgeons at the Sixth Peoples Hospital performed successful replantations in the 1960s. However, the first report of a digital replantation occurred in 1968, with Komatstu and Tami’s report of a successful thumb reattachment in a 28 years old male patient whose right thumb was completely amputated at the level of the MP joint [29].
Snyder et al. (1972) published another case of successful replantation of an avulsed thumb. Nervous and tendinous repair were done four months later [30].
In 1973, the American replantation mission to China reported about the great advancement in microsurgery by the team of Tchen who performed more than 220 replantations in the preceding 5 years, with 45% success rate [31].
O’Brien et al. (1973) reported 74% success in 31 digital replantation. The poor prognosis of avulsion is outlined, as they had 100% failure with this mechanism of injury [32].
Hayhurst et al. (1974) defined the rules to be followed in transferring the amputated parts, as well as the delays of revascularization: the upper limit was 6 hours of warm ischemia and up to 24 hours of cold ischemia [33].
Numerous reports of digital replantation appeared in the world’s literature. Patency rates for small vessel anastomosis become predictable and the success rate increased gradually, paralleling the improvements of surgical techniques, microvascular instruments and suture materials [6].
4.2. Finger Anatomy
A finger is a type of digit, an organ of manipulation and sensation found in the hands of humans and other primates. Normally humans have five digits on each hand. The first digit is the thumb. Some English speakers may consider the thumb to be a type of finger, leading to the conclusion that humans have five fingers on each hand. Others may consider the term ’finger’ to apply only to those four digits that are medial to the thumb, leading to the conclusion that humans have four fingers on each hand. Some other languages, such as Russian, use the same generic term for all five digits of a hand [34].
Each finger may flex and extend, abduct and adduct; therefore it may also circumduct. Flexion is by far the strongest movement. In humans, there are two large muscles that produce flexion of each finger, and additional muscles that augment the movement. Each finger may move independently of the others, though the muscle bulks that move each finger may be partly blended, and the tendons may be attached to each other by a net of fibrous tissue, preventing completely free movement. This is particularly noticeable when trying to extend the fourth digit with the others flexed [35].
Fingers are usually moved under conscious control. In humans, they are used for grasping, typing, grooming and writing, and many other activities. They are also used in signaling, as when wearing a wedding ring, finger counting or when communicating in sign language [36].
Fingers do not contain muscles other than errector pili muscles. The muscles that move the finger joints are in the palm and forearm. The long tendons that deliver motion from the forearm muscles may be observed to move underneath the skin at the wrist and on the back of the hand [36].
Each of the fingers has unique cultural and functional significance [37]. from the thumb on the radial side to the ulnar side of the hand, the fingers are in this order:
• Thumb
• Index finger, also called ’pointer finger’, or ’forefinger’
• Middle finger, the longest
• Ring finger
• Little finger, also known as ’pinky’
4.2.1. Thumb:
The thumb consists of 3 bones: distal phalanx (of the first digit), proximal phalanx (of the first digit) and first metacarpal (fig. 1) [36].
Its movements are controlled by eight muscles (each with ”pollicis” in the name) (table 1):
Table (1): Muscles controlling the thumb movements [34].
Name Location Nerve
extensor pollicis longus
abductor pollicis longus
flexor pollicis longus
extensor pollicis brevis
abductor pollicis brevis
flexor pollicis brevis
opponens pollicis
adductor pollicis Forearm
Forearm
Forearm
Forearm
Hand
hand
hand
hand posterior interosseous nerve
posterior interosseous nerve
anterior interosseous nerve
posterior interosseous nerve
median nerve
median nerve
median nerve
ulnar nerve (deep branch)
The thumb shares the following with each of the (other) four fingers [35]:
• Having a skeleton of phalanges, joined by hinge-like joints that provide flexion toward the palm of the hand.
• Having a ”back” surface that features hair and a nail, and a hairless palm-of-the-hand side with fingerprint ridges instead.
The thumb contrasts with each of the (other) four by being the only finger that:
• Is opposable.
• Has two phalanges rather than three.
• Has its inmost phalanx so close to the wrist.
• Has such absolute breadth, and such stubby proportions.
• Is attached to such a mobile metacarpus (which produces most of the opposability) [36].
Typical interdigital grips include the tips of thumb and second finger (forefinger/index finger) holding a pill or other small item, or
thumb and sides of second and third fingers holding a pen or pencil [37].
The opposable thumb has helped the human species develop more accurate fine motor skills. The opposable thumb is also thought to have directly led to the development of tools, not just in humans or their evolutionary ancestors, but other primates as well [38, 39]. The thumb, in conjunction with the other fingers, makes humans and other species with similar hands some of the most dexterous in the world [40].
4.2.2. Index finger:
The second digit of a human hand is also referred to as the index finger, pointer finger, forefinger, digitus secundus, or digitus II (fig. 2) [36].
It is located between the first and third digits - that is, between the thumb and the middle finger. It is usually the most dextrous and sensitive finger of the hand, though not the longest. It may be used to point to things, for hunt and peck typing, to press an elevator button, or to tap on a window. The index finger often is used to represent the number 1, or when held up or moved side to side (finger-wagging), it can be an admonitory gesture. With the hand held palm out, it represents the letter d in the American Sign Language alphabet. In sports, it can also represent victory. Studies have also found that a smaller index finger compared with the ring finger indicates a better athlete. [41]
4.2.3. Middle finger:
The middle finger (or the long finger) is the third digit of the human hand and usually the longest finger, located between the index finger and the ring finger. It is also called the third finger, digitus medius, digitus tertius, or digitus III. In all cultures, extending the middle finger is, more often than not, construed as offensive [37].
4.2.4. Ring finger:
The ring finger is the fourth digit of the human hand, and the second most ulnar finger, located between the middle finger and the little finger (fig. 3) [36]. It is also called digitus medicinalis, the fourth finger, digitus annularis, digitus quartus, or digitus IV.
The medical finger. Some cultures named it after its supposed magic power, especially the healing power. An example of the idea of its healing power is Bhaisajyaguru, the Medicine Buddha, who uses his right ring finger for medicine. The ring finger. Some cultures associated it to magic rings [37].
This is particularly common in European languages. The nameless finger. Many cultures avoided the true name of a powerful entity, and called it indirectly or called it nameless. A wedding ring is traditionally worn on the ring finger. According to tradition in some countries, the wedding ring is worn on the left ring finger because the vein in the left ring finger, referred to as the vena amoris was believed to be directly connected to the heart, a symbol of love [37].
4.2.5. Little finger:
The little finger, often called the pinky, is the most ulnar and usually smallest finger of the human hand, opposite the thumb, next to the ring finger (fig. 4). It is also called the fifth finger, the baby finger, or the fourth finger [37].
There are four muscles that control the little finger [34]:
- Hypothenar eminence:
Opponens digiti minimi muscle
Abductor minimi digiti muscle (adduction from third palmar interossei)
Flexor digiti minimi brevis (the ”longus” is usually absent)
- Extensor digiti minimi muscle
A pinky promise is made when a person wraps one of their pinky fingers around the other person’s pinky and makes a promise. Traditionally, it’s considered binding, and the idea was originally that the person who breaks the promise must cut off his pinky finger [37].
4.2.6. The skin of the finger:
The skin of the dorsum of the fingers is thin, hairy and freely mobile on the underlying tendons and bones [42]. The palmar skin is characterized by flexure creases and the papillary ridges, or “finger prints”, which occupy the whole of the flexor surface [43].
4.2.7. The fascia of the finger:
4.2.7.1. The palmar digital area
The most superficial fibres of the pretendinous bands of the palmar fascia have an insertion in the dermis distal to the distal palmar crease. The intermediate fibres run deep to the neurovascular bundles on either sides of the metacarpophalangeal joints to reach the side of the finger and form the spiral bands. At the same level, the natatory ligament is made up of fibres passing across the distal palm but also of fibres passing down each side of the finger to blend with the spiral band and form the lateral digital sheet (fig. 5) [44]. A three-dimensional chiasm is thus formed through which pass the digital nerves and vessels (fig. 6) [45].
4.2.7.2. The finger fascia
The superficial sheath is more or less cylindrical, fibrofatty on the dorsal and palmar surfaces but thicker laterally (lateral sheet). Deeper, one finds some denser fascial condensations such as the flexor tendon sheaths or Cleland’s and Grayson’s ligaments (figures 7 & 8) [44, 46]. Cleland’s ligaments are rather thick fibrous structures that extend from the sides of the phalanges and are inserted into the skin opposite the interphalangeal joints. They are V shaped with their vertex on the lateral borders of the finger. The neurovascular pedicles are superficial to Cleland’s ligaments which are never diseased in Dupuytren’s contracture [44].
Figure 7: Transverse section in the finger [44]
Graysons’s ligaments are much thinner and delicate than Cleland’s. They run from the flexor tendon sheath to the lateral skin in front of the neurovascular pedicles. These ligaments are in the same plane as the natatory ligaments, they have the same embryological origin and they are also often diseased in Dupuytren’s contracture [47].
4.2.8. Bones and joints of the hand:
The articulated bones of the hand are made up of carpus (eight bones), five metacarpals and phalanges of the five digits (fig. 9). The eight carpal bones articulated together form a semicircle, the convexity of which is proximal and articulated with the forearm. Distally they articulate with the metacarpals. The eight carpal bones lie in two rows. In the proximal row are scaphoid, lunate, triqutral and pisiform. The four bones of the distal row are trapezium, trapezoid, capitate and hamate. The thumb metacarpal is shorter and thicker than the others. Its base has a saddle shaped facet for the trapezium. The convex facet on its head is not prominently rounded as those of the other four metacarpals. The shaft is set at right angles to the plane of the other four. The remaining four metacarpals show expanded bases by which they articulate with the distal row of carpal bones and with each other. The middle metacarpal shows a prominent styloid process that projects distally into the angle between capitate and trapezoid. The heads carry rounded articular facets. The four metacarpal bones form a gentle concavity for the palm. Their heads form the knuckles of the fist [48].
Two phalanges form the thumb and three form each finger. Each of the five proximal phalanges has a concave facet on the base for the head of its own metacarpal. Middle and distal phalanges carry a facet on its base that is divided by a central ridge into two concavities. Each distal phalanx expands distally into a tuberosity for attachment of the digital fibrofatty pad. The joints of the hand include the midcarpal joint, carpometacarpal joint, metacarpophalangeal joint and the proximal and distal interphalangeal joints (fig. 10) [48].
4.2.9. Digital attachments of the long tendons:
4.2.9.1. Flexor tendons:
The tendon of flexor digitorum superficialis enters the fibrous flexor sheath on the palmar surface of the tendon of flexor digitorum profundus. It divides into two halves, which flatten a little and spiral around the profundus tendon and meet in its deep surface in a chiasma (a partial decussation). This form a tendinous bed, in which lies the profundus tendon. Distal to the chiasma the superficialis tendon is attached to the margins of the front of the middle phalanx (figs. 11, 12, 13 and 14) [48].
The profundus tendon enters the fibrous sheath deep to the superficialis tendon, then lies superficial to the partial decussation of the latter before passing distally to reach the base of the distal phalanx. Each tendon receives blood vessels from the palmar surface of the phalanges. The vessels are invested in synovial membrane. The vascular synovial folds are the vincula [48].
4.2.9.2. Extensor tendons and expansions:
Passing across the metacarpophalangeal joint, the tendon blends with the central axis of a triangular fibrous expansion on the dorsum of the proximal phalanx. The base of the triangle is proximal and extends around the metacarpophalangeal joint to link with the deep transverse metacarpal ligament. The margins of the expansion are thickened by the attachments of the tendons of the lumbrical and interosseous muscles. As the extensor tendon approaches the proximal interphalangeal joint, it splits into a middle slip and two collateral slips. The middle slip is attached to the base of middle phalanx. The collateral slips are joined by the thickened margins of the expansion and converge to be inserted together into the base of the distal phalanx (figs. 12, 13 and 14) [48].
4.2.9.3. Long tendons of the thumb:
On the flexor aspect, there is only one tendon that is of flexor pollicis longus invested by its synovial sheath as it passes to the distal phalanx. On the extensor surface, the tendons of extensor pollicis brevis and longus are each inserted separately into a proximal and distal phalanx. The extensor pollicis longus tendon receives a fibrous expansion from both abductor pollicis brevis and adductor pollicis. These expansions serve to hold the long extensor tendon in place on the dorsum of the thumb [48].
Figure (11): Flexors of digits [49]
Figure (13): Flexor and extensor tendons in fingers [49]
4.2.10. Arteries of the palm of the hand:
The ulnar artery enters the hand anterior to the flexor retinaculum on the lateral side of the ulnar nerve and the pisiform bone. The artery gives off a deep branch and then continues into the palm as superficial palmar arch [50, 51].
4.2.10.1. The Superficial Palmar Arch:
This is an arterial arcade that lies in contact with the deep surface of the palmar apponeurosis [43]. The arch is completed on the lateral side by one of the branches of the radial artery, either the superficial palmar branch, the radialis indices, or the principes pollices [42]. The arch lies across the center of the palm, in level with the distal border of the outstretched thumb web [43].
Four digital arteries arise from the convexity of the arch and pass to the fingers. The most medial artery supplies the medial side of the little finger [42]. The remaining three common palmar digital arteries run distally to the webs between the fingers where each vessel divides into proper palmar digital arteries that supply adjacent fingers. The thumb side of the index finger and the thumb itself are not supplied by the superficial palmar arch as they receive branches from the radial artery. The radial artery leaves the lower end of the radius and slopes across the snuff box over the trapezium and so passes into the hand between the two heads of the first dorsal interosseous muscle. Lying now between this muscle and the adductor pollices, it gives off two large branches. The arteria radialis indices passes distally between the two muscles to emerge on the radial side of the index finger, which it supplies. The princeps pollices artery passes distally along the metacarpal bone of the thumb and divides into its two palmar digital branches at the metacarpal head [43].
4.2.10.2. The Deep Palmar Arch:
It is the direct continuation of the radial artery. It curves medially beneath the long flexor tendons and is in contact posteriorly with the metacarpal bones and the interosseous muscles. The arch is completed on the medial side by the deep branch of the ulnar artery. The curve of the arch lies across the upper part of the palm at a level with the proximal border of the extended thumb [42]. The deep branch of the ulnar nerve lies within the concavity of the deep arch. from its convexity three palmar metacarpal arteries pass distally and in the region of the metacarpal heads they anastomose with the common palmar digital branches of the superficial palmar arch [43].
4.2.10.3. The Posterior Carpal Arch:
It is an arterial anastomosis between the radial, ulnar and anterior interosseous arteries. It lies on the back of the carpus and sends dorsal metacarpal arteries distally in the intermetacarpal spaces, deep to the long tendons. These split at the webs to supply the dorsal aspect of the adjacent fingers. They communicate through the interosseous spaces with the palmar metacarpal branches of the deep palmar arch [43].
4.2.10.4. The Digital Arterial Pattern:
It consists of palmar and dorsal parts. The palmar part of the finger consists of both digital arteries that are connected by superficial and deep anastomoses. The deep anastomses proceed deep to the flexor tendons and are of two types: diaphyseal anastomoses that are usually voluminous and two in number except for the thumb; originate from the digital arteries via a common trunk with the dorsal branch of the corresponding phalanx and lie opposite the proximal and middle phalanges, and articular anastomoses that are smaller than the diaphyseal ones, and they lie on the dorsal side of the flexor tendons, opposite the proximal and distal interphalangeal joints. The superficial anastomoses also consist of diaphyseal anastomoses that are very minute, encountered only in the proximal phalangeal level and anastomoses of the pulp formed by the anastomosis of both digital arteries forming an arcade in the distal phalangeal level (figs 15 & 16) [50, 51, 52].
While the dorsal part consists of a well defined longitudinal dorsal arterial network. Proximally this includes the dorsal digital arteries, which are the terminal branches of the dorsal metacarpal arteries, but distally from the middle of the first phalanx, the network contains numerous branches of the volar digital artery [53].
The dorsal digital arteries terminate by further subdividing into smaller branches at the proximal third of the proximal phalanx or less often by being directly anastomosed to the longitudinal dorsal arterial network. This essentially consists of the plexiform anastomoses between the dorsal branches of the volar digital arteries [54].
Figure (15): Dorsal vascular arcade from the dorsal aspect [50]
D.A. : Distal arcade P.A. : Proximal arcade
S.A. : Superficial arcade D : Palmar digital artery
T : Transverse branch of palmar digital artery
M : Dorsal branch of palmar digital artery
P.N.F. : Proximal nail fold
Figure (16): Dorsal vascular supply to the nail complex and the fingertip [51]. The dorsal branch arises from the volar digital artery and ends in the formation of the superficial arcade
D.A. : Dista arcade P.A. : Proximal arcade
S.A. : Superficial arcade D : Palmar digital artery
T : Transverse branch of palmar digital artery
M : Dorsal branch of palmar digital artery
P.N.F. : Proximal nail fold
4.2.11. The venous drainage of the digits:
4.2.11.1. The Dorsal Side:
The dorsal veins of the fingers form an arcade opposite the proximal portion of the proximal phalanx. This arcade drains into the veins on the dorsum of the hand and forearm. Sometimes the proximal phalangeal arcade is double or triple. The number of these arcades is inversely proportion to their caliber. The afferents of this arcade are longitudinal veins from the dorsal side of the fingers and volar veins (fig. 17) [55].
4.2.11.2. The Volar Aspect:
The volar systems of veins drain into the commissural veins (which may form the anterior venous arcade) and into the dorsal system via connecting veins. The commissural veins are found in the depth of each web and they give tributaries to the lateral part of the dorsal arcade. They also give branches which accompany the common volar digital arteries in the palm which in turn form the venae comitantes of the superficial palmar arch (fig. 18) [55].
4.2.11.3. The dorsal venous arch (or network):
The dorsal venous arch lies in the subcutaneous tissue, superficial to the extensor tendons and proximal to the metacarpal heads [43].
It drains on the lateral side into the cephalic vein, and on the medial side, into the basalic vein. The greater part of theblood from the whole hand drains into this arch, which receives digital veins and freely communicates with the deep veins of the palm through the interosseous spaces [42].
4.2.12. The venous drainage of the thumb:
There are multiple volar veins (3 or more) at the distal phalangeal level form an irregular arcade proximal to the interphalangeal crease. On both sides this network drains at the proximal phalangeal level to the dorsal veins, thereby forming an oblique venous system which joins the dorsal system (fig. 19) [56].
In addition to the oblique system, the radial aspect of the volar surface of the thumb drains into the thenar network along the radial border of the hand, which drains into the volar wrist veins or into the snuffbox veins. The dorsal network originates from the distal oblique pulp veins and the paraungual veins. The dorsal venous system at the proximal phalangeal level of the thumb consists of multiple longitudinal parallel vessels which drain into the dorsal network of the hand and wrist [56].
Figure (18): Volar ladder with dorsal communication and web confluence [55]
Figure (19): The venous drainage of the thumb. A Volar aspect, B Radial aspect, C Dorsal aspect [56]
4.2.13. Digital nerves:
Lying immediately deep to the superficial palmar arch are the common palmar digital nerves. They pass distally to the webs, between the slips of the palmar apponeurosis and divide like the arteries into proper palmar digital nerves (figure 20) [43].
The palmar digital arteries and nerves are called “proper” when each is distributed only to one finger. The term “common” indicates that the nerve or artery is distributed to two adjacent fingers through two proper palmar digital branches which arise from it [57].
Figure (20): The dorsal sensory branch angles across the proximal phalanx before reaching the dorsum of the middle phalanx. A similar branch from the opposite side is not shown. The digital nerve trifurcates at the distal interphalangeal joint [43]
4.2.13.1. The dorsal digital nerves:
Five dorsal digital nerves arise from the superfdicial branch of the radial nerve to supply the dorsal surfaces of the thumb and lateral two and half fingers. Two dorsal digital nerves arise from the dorsal branch of the ulnar nerve to supply the dorsal surfaces of the little and medial half of the ring finger [57].
The dorsal digital branches of the radial and ulnar nerves do not extend beyond the PIP joint. The remainder of the dorsum of each finger receives its nerve supply from the palmar digital nerves [42].
A small sensory branch leaves each digital nerve near the base of the proximal phalanx and travels obliquely across the finger to reach the dorsum near the PIP joint. It arborizes to innervate the ipsilateral dorsal skin over the middle phalanx [42].
After giving off this dorsal sensory branch, the proper digital nerve continues down the finger and trifurcates at or just past, the DIP joint. A dorsal branch goes to the nail fold and nail bed area, another to the tip of the finger and a third to a volar pulp [58].
4.2.13.2. The palmar digital nerves:
Two nerves arise from the superficial branch of the ulnar nerve. The medial one is the proper palmar digital nerve to the medial side of the little finger. While the lateral one is the common palmar digital nerve which divides near the cleft between the little and ring fingers to give a proper palmar digital nerve to the contiguous side of each [57].
Five nerves arise from the median nerve in the palm. The medial two are common palmar digital nerves which divide near the clefts on either side of the middle finger to give a proper palmar digital nerve to each side of these clefts. The next is the proper palmar digital nerve to the lateral side of the index finger. The lateral two are proper palmar digital nerves to the opposite sides of the thumb. The most medial common palmar digital nerve communicates with that of the ulnar nerve [57].
4.3. Requisities for Replantation Surgery
Tupper (1987) reported that while it is true that complex microsurgical procedures can be performed by a single surgeon with an experienced operating room crew [59], a microsurgical unit has evolved into a large team.
4.3.1. Emergency Room Staff:
Buncke (2002) stressed on the importance of training of all members of the emergency staff in the details of transmission of incoming calls regarding emergency referrals to the staff surgeon on call. They also relay patient and amputated part care instruction to outlying hospitals and coordinate air and ground transportation. When the patient arrives, the emergency room staff, in conjunction with the staff surgeon, obtains laboratory and x ray studies, undertakes resuscitation, and oversees transport of the patient and amputated parts to the operating room [10].
4.3.2. Surgical Team:
Each 24-hour period must be covered by an emergency surgical team consisting of a staff surgeon and two clinical fellows. This team accepts and manages all emergency referrals. Three surgeons can readily perform a replantation case, including tagging of parts, recipient site dissection, and vein and skin graft harvesting, while rotating operating time in such a way that no one surgeon must work more than 4 hours consecutively. Buncke (1986) showed that three-man coverage permits some overlapping of cases, so that a second replantation case can be started while a first case is in progress. When more than three surgeons are needed for multiple cases, volunteers must be recruited from staff surgeons and fellows not on call [60].
4.3.3. Anesthesiologists:
The anesthesiology group should maintain first-call and second-call schedules that provide an experienced anesthesiologist for cases at all times. The anesthesiologist must be aware with the overall plan including: length of the procedure, use of paralytic agents, positioning of patient, available sites for intravenous lines and monitoring leads, avoidance of vasoconstrictors, importance of maintaining normal body temperature to avoid vasospasm and need for adequate hydration [10, 61].
4.3.4. Ward Nursing:
The overall plan must be outlined to the circulating and scrub nurses as described by Shenaq & Sharma (1997). Within 24 hours, the uncomplicated microsurgical patient is transferred to the microsurgical ward. There, the experienced nursing staff continues to monitor the replanted part and to maintain proper positioning and room temperature [61].
Additionally, they supervise the resumption of diet, maintenance of drains, and postoperative mobilization. A member of the nursing staff joins the physician for morning rounds to clarify plans for medication, mobilization, dressings, and discharge. The nursing staff also should instruct family members in dressing changes and other aspects of home care [10].
4.3.5. Equipment:
Shenaq & Sharma (1997) clarified the importance of presence of proper equipment including: operating microscope, microsurgical instruments, microsutures (9-0 and 10-0 nylon), sterile tourniquets, sterile doppler and dermatome for possible skin grafting [61].
4.3.6. Recovery Room and Intensive Care Unit Nursing:
The nursing personnel of the recovery room and intensive care units (where all microsurgical patients spend at least the first postoperative night) should be specially trained in the positioning of limbs following replantation, room temperature and heating pad adjustments, and monitoring of the replanted part. Monitoring is usually based on quantitative fluorimetry when the part has intact skin [62].
Clinical inspection and surface Doppler monitoring are also performed. With experience, the nursing staff has become adept in the assessment of the vascular status of a replanted part, and any nursing call to the replant physician team gets a prompt response [10].
After injury and prolonged microsurgical procedures, most patients require significant fluid replacement during the first 24 postoperative hours. Additionally, many require sophisticated care for associated injuries (e.g., pulmonary contusion) or medical complications (e.g., delirium tremens) [63].
Sanders (1993) reported that the nursing staff should integrate the special requirements of microsurgical patients into their sophisticated critical care skills to provide optimum management for these patients [64].
4.3.7. Hand Therapists:
The hand therapy unit should be staffed by therapists who are trained in either physical or occupational therapy. They regularly attend rounds, clinics, and surgical procedures and tailor each individual’s therapy to his or her specific needs [10].
While patients are in the hospital, the therapists perform initial splinting and therapy in close consultation with the surgical team [64].
Upon the patient’s discharge, the therapist arranges for follow-up care at either this center or a center closer to the patient’s home. The therapist maintains close contact with the outside therapist to monitor the patient’s progress and deal with problems as they arise. The patient is seen by a therapist during each clinic visit, and the therapist participates in decisions of adjunctive care, secondary surgery, and final disability evaluations. Support garments and prostheses are also coordinated through the hand therapy section [64].
4.4 Transportation of Patient
and Amputated Parts
Successful replantation and return of function of traumatically amputated parts depends on an organized team approach. The replant center must be staffed with enough experienced surgical teams to provide 24-hour service, anticipate concurrent cases, and relieve the operating surgeons during long procedures. A prepared emergency staff must be able to direct the referring emergency room staff and transport team in a safe and expedient transfer to the replant center. Twenty four-hour coverage by anesthesia and operating room personnel must be available. Multiple operating suites must be set up with the proper microscopes, instruments, and sutures [10].
Urbaniak (1982) stated that a carefully trained nursing staff is necessary to render postoperative care and monitoring. Occupational and physical therapists familiar with the unique needs of postreplantation rehabilitation play a major role in the functional recovery of the patient. Social workers and psychologists round out the team and are a necessary adjunct to the nursing staff to help each patient adjust to his or her injury and rehabilitation [65].
The initial responsibilities of the referring emergency room physician and staff as demonstrated by Buncke (2002) are to stabilize the patient, confirm that no coexisting life-threatening injuries exist, and prepare the patient and amputated part for transport to the replant center [10].
Early telephone contact with the microsurgeon by the referring emergency room physician increases the chance for successful replantation. Specific information must be clearly conveyed. The following questions must be answered. What time did the injury occur, and at what point was the part cooled? What type of injury caused the amputation? For example, is it a crush, avulsion, degloving, or guillotine injury? Is the amputation complete? If not, are there signs of circulation or sensation? At what level has the injury occurred? Which hand or limb is injured, and were there any previous injuries to the affected part? Does the patient have any other injuries? Does he or she have any other illnesses? Time is of the essence in these cases, and familiarity with this list of questions and the following protocol can assure rapid, effective primary care [10].
Urbaniak (1982) clarified that if the case is accepted for replantation by the microsurgeon, the next step is to initiate the protocol for transfer [65].
4.4.1. The Patient
The patient’s general condition should be checked to rule out life-threatening injuries as described by Buncke (2002). On arrival at the emergency room, a large-bore intravenous line should be started with lactated Ringer’s solution at a maintenance rate. If there are signs and symptoms of shock, the patient must be stabilized before transportation. Antibiotic coverage should be started immediately. Diphtheria/tetanus toxoid, 0.5 cc IM, is necessary if it has not been administered within the last 5 years. 600 mg aspirin rectal suppository must be inserted (if not contraindicated by history of coagulopathy) for anticoagulation. The patient should be evaluated for pain as needed with IM or IV analgesia of choice. The patient is kept NPO to facilitate later anesthesia, and do not allow him or her to smoke or chew tobacco. X rays should be sent (both part and stump), emergency records, and all laboratory studies (especially hematocrit and urinalysis), including a clot of blood for further miscellaneous tests. An ECG and chest x ray should be sent if the patient is over 35, or if indicated by injury. The patient is transported supine [10].
In injuries of the hand or extremity, Urbaniak (1982) used saline-moistened sponges applied to the wound and covered with a sterile, bulky dressing. If extensive bleeding is noted, pressure dressing rather than a tourniquet is applied. Truly uncontrollable bleeding must be treated surgically before transport. The injured part is splinted and elevated for comfort [65].
4.4.2. Amputated Part
The referring emergency room is instructed to send all parts. Although all tissues may not be replantable, various portions may be used to reconstruct missing elements. Extensive debridement is done in the operating room by the microsurgical team while they examine the part. The parts are rinsed with normal saline to remove gross contamination, then wrapped in dry gauze, placed in dry plastic bag, and placed on ice. (Immersion in ice may cause cold injury to the part. Dry ice is too cold and causes tissue damage) [10].
The gauze and plastic prevent the tissue from coming into direct contact with the ice. This method is preferred to immersion or wrapping in a moist dressing to avoid maceration [65].
4.4.3. Partial Amputation
Urbaniak (1982) applied saline-moistened sponges to wound that is covered with sterile, bulky dressing. Extensive cleansing will be accomplished under anesthesia. The injured part is splinted and elevated for comfort. The site is not injected with local anesthesia as local injection may cause vasoconstriction, vessel compression, or direct vessel injury [10].
4.5 Microsurgical Equipment and Instrumentation for Replantation
4.5.1. Operating Microscope
The operating microscope achieves unique flexibility by incorporating three separate systems as reported by Acland (1977): an objective lens which establishes the working distance, a binocular assembly which is the primary determinant of base magnification and a magnification changer which permits selection of different magnification settings. The objective lens and binocular assembly provide base magnification and essentially fixed at the beginning of operation. The magnification changer can increase or decrease the magnification (figs. 21 & 22) [66].
Figure 22: Lightweight operating microscope [66]
The operating microscope has evolved rapidly to keep pace with developments in the field of microsurgery. Several manufactures now produce top quality instruments designed for extremity microsurgery to include the following essentials:
a. A double headed system allowing the surgeon and the assistant to share the operating field.
b. Foot or voice controlled magnification (zoom) and focusing.
c. Interchangeable eyepiece and objective lenses to match the working distance and magnification range to the clinical situation.
d. A fiber-optic light source updated versions are available to provide constant illumination to the field as magnification changes [67].
Although not essential, Bunke (2002) clarified that motorized X-Y axis control is an extremely helpful and time saving feature, especially during long procedures. This allows the surgeon to move the microscope over the operative field without moving the patient or having to look away from the field. Beam splitters for attachment of a third viewing post and/or photographic equipment are available. Cameras and color video systems can be attached and operated remotely; the latter is especially useful for teaching and for allowing the operating room personnel to observe the procedure [10].
Both ceiling and floor mounts are available; however floor-mounted microscopes are more versatile and have wider applications. The fact that the microscope can be rolled does not mean that it should be frequently moved from place to place, because it is a fragile instrument and is easily damaged. It is best to keep the microscope in the operating room in which it is primarily used or at least close by. A handle (or handles) on the head of the microscope with covers that can be steam sterilized is very valuable to allow the surgeon to move the head of the scope out of the way during the procedure, if necessary. Covers should be available for the knobs controlling the eyepiece adjustments. While some surgeons insist on placing a sterile cover over the microscope, we believe that this is unnecessary if handle covers are available. Placing a drape over the entire microscope takes time and makes use of the microscope cumbersome [67].
Magnification is determined by the combination of objective lens, magnification changer and eyepieces as shown in the following formula:
Mt = Fb/Fo x Me x Mc
where Mt is total magnification, Fb is the objective tube focal length, Fo is the objective lens focal length, Me is the eyepiece magnification and Mc is the magnification factor of the zoom apparatus [68].
Various objective lens focal lengths are available depending on the manufacturer; these range between 125 mm and 450 mm in most instances. We find a 175 to 250 mm objective lens most useful for hand surgery. Eyepieces of 10x or 12.5x are most commonly used, but 20x eyepieces are occasionally needed for repair of small digital vessels in children and for microlymphatic surgery, even though this means a resultant decrease in field size. The size of the field is inversely proportional to magnification and one should use the zoom control freely. Intimal inspection and suture placement are done under maximum magnification, whereas dissection and suture tying require less magnification and a wider field of view [66].
4.5.2. Magnifying Loupes
Loupes are low power telescope designed so small and compact that they can be mounted on sepectacle frames, incorporated into the spectacle lens or attached to a headband. Four factors influence the use of loupes in surgery; working distance, magnification field of view and illumination [68].
Sometimes magnifying loupes are more practical than a microscope particularly for microdissectional surgery. The advantages of loupes for use in microsurgery are obvious. They are compact light weight optical systems with no obstructing suspensions between the surgeon and the operation site. As a magnifying instrument they are relatively inexpensive and once they have been perfectly aligned to the user’s forehead-nose-eye condition, they are easy to use. One can easily view the operative field without removing them simply by glancing downward, underneath the optical system (figs. 23 & 24) [66].
Figure (23): Light weight loupe [66]
Figure (24): Wide field of view loupe [66]
4.5.2.1. Choice of proper magnification:
A. 2.5x, 3x: for beginners who is in surgical training, or just need to perform simple surgical cases.
B. 3.5x,4x, 4.5x: for attending level to perform more delicate and complicated cases or for upgrade from 2.5x.
C. 5.0x, 5.5x, 6.0x: for microsurgical procedures to concentrate on small areas.
D. 6.5x, 8x: the highest magnification in loupe industry, can be used to perform most of the microsurgical procedures and replacing the microscope procedures [10].
4.5.2.2. Types of magnifying loupes:
The first is the Galilean Loupe which is a basic level magnification loupe which can consist of three lenses. Its advantages are easy to use, lightweight and affordable. Its disadvantages are that there is a central circle in the field of view when using the galilean loupe. However, the area within that central circle can be only clearly viewed. Also it has limited magnification capacities (only 2.5x) (fig. 25) [10].
Figure 25: Field of view by Galilean loupe [10]
While the second is the Wide Field Prism Loupe which is a precision loupe consisting of seven lenses. It has more magnification capacities (3X, 4X, 5X, 6X, 8X), a very fine field of view including the surrounding outer areas, thus, the field of view is sharp, more long term usage and depth of field better (fig. 26) [10].
Figure (26): Field of view ruler for loupes [10]
Some microsurgeons now advocate the use of loupes for all microsurgery, but we believe that the operating microscope affords better visualization, particularly if an assistant is used. Experimental studies have confirmed that suture placement is more precise with the higher magnification afforded by the microscope [68].
Though loupes up to the range of 8x are available, it has been found that the level of magnification coupled with unavoidable random head motion makes these extremely difficult to adjust to [68].
4.5.3. Jeweler’s Forceps
Two pairs of no. 5 Jeweler’s forceps are used for picking up and holding tissues during dissection and suture handling and knot tying. The tips of Jeweler’s forceps must be perfectly adjusted and aligned if they are to function well. A good pair will pick up precisely what the surgeons intends it the first time. A bad pair will DROP tissue it is intended to hold, will traumatize the tissue once a grip is obtained, and will break fine thread as it is being tied. These repeated and accumulated exasperations have a seriously damaging effect on both one’s technique and temper [10].
The Jeweler’s forceps tips may be straight or curved (figs. 27, 28 and 29) and must be aligned with a precision of 1/100 inch, since that is the diameter of 10/0 nylon. When closed with moderate pressure the jaws should meet not only at the tips, but evenly over a length of 3 mm, so that the thread can be picked up easily [66].
Figure (27): Jeweler’s forceps, straight [66]
Figure (28): Jeweler’s forceps, angled 450 [66]
Figure (29): Jeweler’s forceps, angled 900 [66]
4.5.4. Vessel Dilator
A vessel dilator is a modified Jeweler’s forceps with a slender, smoothly polished, non-tapering tip. It is put inside the vessel end and opened a little to produce gentle dilatation. It is also useful as a counter-pressor for suturing in confined places (fig. 30) [66].
Figure (30): Vessel dilator [66]
4.5.5. Needle holder
The needle holder must be without lock because of the coarseness of the action required to release the lock. Its tips are fine, the jaw surface is flat with rounded edges to prevent needle bending. Curved tips are usually preferred. The selection of the needle holder is closely related to the anastomsis technique (fig. 31 & 32) [66].
Figure (31): Straight needle holder [66]
Figure (32): Curved needle holder [66]
4.5.6. Scissors
There are two types of microscissors. The first one is the dissecting scissors which should be spring handled, should have gently curved blades and should be lightly rounded at the tips. The rounded tips are important as they enable the microsurgeon to dissect very closely around a vessel without a danger of making hole in it. The second is the adventitia scissors that is used for the special task of trimming the adventitia off the vessel end. A pair of fine straight microscissors with very sharp pointed is needed. The adventitia scissors is good for stitch cutting as it does not damage them [66].
Figure (33): Microscissors [66]
4.5.7. Microvascular Clamps
Vascular clamps should exert only gentle pressure and should grip the vessel positively without slipping off. Double clamps with a sliding approximation adjustment are of enormous help in carrying out a carefully controlled anastomosis (fig. 34) [69].
Figure (34): Microvascular clamps [69]
However the use of clamps can be very harmful. A study was done by Stamatopolous et al. (1980) to determine the effect of pressure and time in the damage produced by application of surgical microclips. The carotid arteries in rats (1 mm in diameter) were used. Different clamps are used for different periods of time. The vessels were then examined by scanning electron microscopy following the removal of clamps. Two types of vessel changes were observed [69]:
1. Changes in the areas of both sides of the area of compression caused by the clamp.
2. Changes in the area directly compressed by the clamp.
In the first group the endothelial lesions are attributed to ischemia. The endothelial cell changes were swellings, holes or craters, balloon like lesions and areas showing fragmentation of cells and disruption of endothelial continuity [69].
The second group of changes also resulted from ischemia but mainly from direct mechanical injury caused by the clamp pressure. These changes depended greatly up on the length of application. In the group with clamp application inferior to an hour, thrombus formation commenced immediately after removal of the clamp. This thrombus formation becomes progressively larger, reaching a maximum dimension after 24 hours. After this time there is a progressive resolution so that by the sixth day, only local traces are detected. The extent, intensity and time of resolution of these changes varied directly with the type of clamp used [69].
When the time of application was three hours, similar findings were found, but the endothelial damage was more severe, permanent and resolution took longer. In the circumscribed pressure areas, endothelial desquamation resulting from cell death was observed. This exposed the very thrombogenic internal elastic lamina. Thus the pressure effects appeared to be most important following short time of clamp application. The extent of damage is related directly to the pressure exerted by the microclamp. Therefore clamps with a low pressure would appear to be preferable. Following a long period of clamp application, the individual pressure exerted by microclamps becomes less important and the resulting damage is much more severe and is very slow to resolve. Clinically, vessel segment which has been compressed for a long period of time for hemostasis or marking should not be included in the anastomosis to restore circulation. They should be excised [69].
4.5.8. Instrument Case
The microsurgical instrument must be kept in a safe case, otherwise they will quickly become damaged. A proper instrument case is autoclavable and has a rack with a slot for each instrument [68].
4.5.9. Microsuture
The most significant technical advance in microvascular surgery has been the development of microsutures. A plethora of microsutures and needles has become available in recent years. It has been shown that the size of the suture and the material appear to make significant difference in the patency rate of a microvascular anastomosis [68].
A suture consists of suture material joined to a needle. For microsurgery, monofilament nylon and prolene are the principle suture materials in common use. Polyglycolic acid sutures are also used in specific indications [66]. As you master suture-tying techniques, you will need less and less suture for each knot. A single suture can suffice for an entire anastomosis. Because these sutures are small, they are difficult and unfortunately costly to manufacture. Ethilon 10–0 black monofilament nylon is a good general-purpose suture that is available with a variety of needles. The tapered BV-130–3, BV-130–4, and BV-130–5 offer a good range of needle sizes and curvatures for most applications. Suture material ranges in size from 8-0 for larger vessels to 11-0 for very small vessels. Microsurgical needles are now manufactured in varying diameters, and varying shapes, either straight, three-eights, one-half or one-fourth, circle, taper, cutting or spatula and selection is based on the type of tissue being repaired. The three-eights type is most frequently used; its length is usually 3-4 mm [66].
The ideal needle has a tapered, noncutting point and a flat body with a range of curvatures. The tapered tip prevents laceration of the vessel edge during suture placement and the flat body forces the needle to align properly and hold securely when grasped with the needle applier. The degree of curvature varies according to the depth and confines of the surgical field and the mobility of the tissues being approximated. Narrower and deeper exposures are better suited to needles with a tighter curvature. [68]
4.5.10. Instrument Care
The tips of microvascular instruments should never touch another hard object. They must be kept away from heavier instrument. Only one instrument is picked at a time. The tips should not be put down on the table. The best way to clean microinstruments is to submerge it completely for 30 minutes in hemolytic enzyme solution such as hemosol. This dissolves even the hardest blood clots. Then rinse the instruments in water. Rinse the clamp hinges especially well with a brisk jet of water from a syringe. Then dry the instruments thoroughly before putting them away [68].
4.6. Indications and Contraindications of
Digital Replantation
The decision to attempt replantation of a severed part is influenced by many factors as shown in a study done by Wilhelmi et al. (2003), including the importance of the part, level of injury, expected return of function, mechanism of injury, associated injuries, patient age, work status, motivation of the patient and ischemia time. Thumb and multiple finger replants should be attempted, as function is severely compromised without opposition [6].
Also replantation must be attempted in hand amputations at the palm or wrist and in childhood amputations. Moreover, functional outcomes following replantation vary significantly with the level of injury. Good functional results can be achieved with replantation of injuries at the level of the fingers distal to the flexor superficialis insertion, the hand at the wrist, and the upper extremity at the distal forearm (Fig. 35). Less functional recovery is expected for replants at certain levels including amputations proximal to flexor superficialis insertion within zone II of the fingers and at the muscle belly and elbow level [70, 71, 72, 73, 74].
As zone II replants can be expected to result in stiffness and rehabilitation that significantly delays return to work with minimal or no functional benefit, Urbaniak et al. (1985) found that a relative contraindication to replantation exists for single digits amputated within the zone II level [75].
Perhaps the most predictive indicator for success with replantation is the mechanism of injury. O’Brien (1974) demonstrated higher success rates with replantations of guillotine versus avulsion amputations. It may be an unrealistic expectation to successfully replant severely crushed and mangled body parts. Avulsion injuries with traction along the neurovascular bundles create intimal tears and disruption of small branches to the skin. Small hematomas in the skin along the course of the neurovascular bundle result in the ‘‘red line sign’’. This sign signifies such detrimental injury to the neurovascular bundle that replantation is often fraught with poor success [76].
Figure (35): Levels of replantation. [74]
Replantation attempts in digits with the red line sign require vein grafting across this zone of injury. Another indication of injury to the vessels of an amputated digit is the ‘‘ribbon sign.’’ The ribbon sign is an indication of torsion and stretch on a vessel. Van Beek (1973) stated that vessels that have the ribbon sign often are not amenable to sustaining blood flow, precluding replantation attempts (Fig. 36) [78].
Loss of a single digit, excluding the thumb or ring finger avulsion injuries is considered controversial by many. However, in appropriately selected cases, with motivated cases, results can be excellent as demonstrated by Boulas (1998) [79].
Ischemia time refer to the total time the part is lacking circulation and therefore not receiving oxygen. Boulas (1998) reported that the longer the ischemia time the worse the prognosis. This is particularly true for warm ischemia where oxygen consumption and free radical formation increase. For this reason, parts are kept cool, but not frozen, on ice. [79]
Figure (36): (A) The red line and ribbon signs are poor prognostic signs for replantation. (B) This patient degloved a hand in a log crusher splitter, resulting in multilevel neurovascular and bone injuries. [78]
Other relative contraindications to replantation include multiple level injuries, mentally unstable patients (especially self mutilation cases, psychotic patients) and extreme contamination. The only absolute contraindication exists when associated injuries or preexisting illness preclude a prolonged and complex operation. In this circumstance temporary ectopic replantation has been described for preservation of the amputated extremity before eventual elective replantation later (Fig. 37) [80, 81, 82].
Figure (37): (A,B) This patient underwent ectopic implantation of an amputated hand before eventual replantation when he was stable from other injuries. [81]
4.7 Surgical Technique of Digital Replantation
4.7.1. Preoperative considerations:
Digital replantation has become common in many institutions. Physicians, paramedics, and even the patients themselves are more educated on the possibility of replantation. Because of this, it is common to have the amputated part arrive with the patient at the emergency department. Even if not replantable, this amputated part can provide a valuable tissue source for reconstruction. The amputated part should be wrapped in a saline moistened gauze sponge and placed in a plastic bag. The plastic bag should be sealed and placed on ice (Fig. 38). Hayhurst et al. (1974) demonstrated that the amputated part should not be placed directly on ice because this can lead to a frostbite injury to the tissue [83]. The part should not be immersed in water because this makes digital vessel repair more difficult and less reliable. Bleeding vessels in the stump should not be clamped. Hemostatic control of the stump can be achieved with a compressive dressing and elevation [84, 85].
The recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits, and 6 hours of warm and 12 hours of cold ischemia for major replants (ie, parts containing muscle). Reports of successful replantation after longer ischemia times exist. May (1986) reported a successful digit replantation after 39 hours of cold ischemia. [86] Then, Wei et al. (1988) reported successful digital replantations after 84, 86, and 94 hours of cold ischemia [87].
Before surgery, radiographs of the amputated parts and the stump should be performed to determine the levels of injury and suitability for replantation. Both parts should be photographed for documentation. An informed consent should be obtained, discussing with the patient and family regarding the failure rates, length of rehabilitation, realistic expectation of sensation, mobility, and function. The preoperative preparation also should include prophylactic antibiotics, updating the patient’s tetanus status, fluid resuscitation to prevent hypotension, warming the patient to prevent hypothermia and vasoconstriction/spasm, Foley insertion for volume monitoring, and protection of pressure points during an expected long operation. [6]
Figure (38): The amputated part is wrapped in gauze and placed in a plastic bag. The plastic bag is set on ice. [77]
4.7.2. Operative considerations:
The preparation of the amputated part can be initiated before the patient is brought to the operating room. This preparation was described by Gallico (1990). It is performed on a back table under sterile conditions in the operating room. The use of a microscope assists with the assessment of the digital vessels for replantation. Signs of arterial damage should be noted, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel (Fig. 39). Resection of the vessel distal to the zone of injury may result in a defect requiring a vein graft that should be harvested before osteosynthesis to minimize warm ischemia time [77].
If the amputated part is grossly contaminated, it should be cleansed gently with Normal Saline (N/S) irrigation. Care must be taken not to further injure the digital vessels or soft tissue. The neurovascular structures of the fingers are exposed with either bilateral longitudinal incisions in the midaxial line or volar zigzag and dorsal longitudinal incisions (Fig. 40). The neurovascular structures are then identified and tagged with 5-0 nylon sutures or hemaclips to facilitate and expedite identification at the time of coaptation [77, 88].
Figure (39): Signs of arterial damage should be appreciated, including the telescope, cobweb, and ribbon signs or terminal thrombosis, which would require freshening of the vessel. [77]
Figure (40): (A,B) Exposure of the neurovascular structures to be labeled on the amputated part. [77]
Usually there is enough time before the patient is transported to the operating room for preparation of the amputated part. Alternatively a second team can be recruited to begin the preparation of the stump. The neurovascular structures are isolated, identified, and tagged on the stump side under tourniquet control. Before the arterial anastomosis, the tourniquet is deflated to assess inflow pressure by the proximal vessel spurt (Fig. 41). If the spurt is inadequate, additional proximal vessel shortening is required. Furthermore, in preparing the stump, exposure of the proximal flexor tendon for placement of a core suture is better at this point than after bone fixation [77].
Figure (41): The tourniquet is deflated to assess inflow pressure by the proximal vessel spurt. If the spurt is inadequate, more vessel shortening is required. [77]
4.7.3. Operative Sequence:
The order for repairing the various structures is individualized. The sequence of repairing the bone, extensor, veins, dorsal skin, artery, nerve, and flexor is preferred by O’Brien (1974) and others, as it efficiently allows for repairing all the dorsal structures before the volar structures [76]. Wilhelmi et al. (2003) reported that if the warm ischemia time is unusually long, the artery can be repaired earlier [6].
4.7.3.1. Bone Fixation
Bony stabilization is the foundation of the replantation. The benefits of adequate osteosynthesis are two fold. One, it provides intra-operative stability to protect tension on multiple micro-anastomoses. Two, during the postoperative period, it allows early mobility to reduce stiffness while protecting bony healing. To limit ischemia time in replantation, fixation methods must be rapid and relatively easy to apply, and minimize additional soft tissue injury [10].
Currently, a number of techniques available for small bone fracture repair are applicable to replantation: mini screws and plates, various tension band techniques, intraosseous wires, mini-external fixators, intramedullary bone pegs and devices, and Kirschner wires. Fundamental to the selection and application of these techniques is an understanding of the mechanism of bone and soft tissue healing, as well as the biomechanics of the hand [10, 89].
Trauma to the extremities resulting in amputation or devascularization can vary greatly with respect to the amount of energy imparted to the tissues and the size of the zone of injury. A clean, guillotine type of amputation has markedly less tissue destruction than a crushing avulsive injury. Theoretically as described by Buncke (2002), fractures heal by a mechanism similar to that of soft tissue, with fibrosis and inflammatory reaction that will be influenced by the extent of injury [10].
Primary bone healing, as with soft tissue, occurs only under ideal circumstances. These require a lack of motion at the fracture site and close apposition of bone ends, which allow primary membranous bone regeneration with minimal fibrosis or callus formation. With primary healing, there is limited involvement of surrounding soft tissue. If compressive forces can be applied across the fracture, union can occur by direct lamellar growth of osteoblasts into the fracture defect without a fibrous intermediary. Secondary bone healing occurs when there is motion or inadequate bony contact at the fracture zone. Bony gaps stimulate fibrous growth and the production of callus as a temporary internal splint, allowing capillary growth into the area of bony instability. Osteogenesis occurs, and the fibrous bed becomes calcified with membranous bone that must undergo later remodeling. Surrounding soft tissue structures may undergo calcification during this process, and local scarring and fibrosis may occur [10].
X-ray analysis of the initial injury, as reported by Rogers (1982), yields key information: location of fractures, pattern, displacement, comminution, joint involvement, skeletal age, density, and absolute bone loss. Bony fixation is likely to be difficult with extensive, high-energy injuries and may require a combination of fixation methods to reduce bone gaps and limit motion. By careful analysis of the injury and the x ray, the fixation requirements and the expected course of soft and hard tissue healing can be anticipated and postoperative splinting and therapy can be planned [90].
Internal fixation implies only some degree of immobilization by the internal splinting provided by implant placement. Rigid fixation, however, implies that the fracture segments are secured by a means so strong that there is essentially no motion at the fracture site. Compression indicates not only that the fracture is held rigid, but that there is a net compressive or impacting force between fracture fragments. This force can be applied in either a static or dynamic fashion. [10]
With the skeletal system at rest, an implant can be placed across the fracture so that interfragment compression will occur. The implant accepts a static load applied as a net impacting force based on the stable nature of the bone/implant interface. For hand fractures, the screws and plates of the mini-fragment set are a typical static compression device, with the implant itself providing compression and stabilization. If the implant has significant stability, advantage can be taken of the dynamic forces at work on the fracture during postoperative motion. Dynamic compression is particularly important during rehabilitation after digit replantation, although the general principles of anatomic reduction, stabilization, and compression are important at all replantation sites. [10]
With movement, the bones of the longitudinal arches of the hand have unequal forces acting upon them. Functionally, the palmar flexor forces are relatively greater than their extensor counterparts, particularly for the metacarpal fracture. This imbalance of forces creates a net compressive force or the volar cortex, with distraction or tension occurring at the dorsal cortex. This inequality is responsible for the loss of reduction and motion at the fracture site, but can be used to advantage with proper placement of a stabilizing fixation device. If the distracting force on the cortex under tension can be neutralized by a dorsal plate or ”tension band” wire, fracture motion can be markedly reduced. With increasing flexion and subsequent dynamic volar cortex compression, the implant accepts the tension load without allowing distraction. An ideal healing environment is thus created with limited motion and bony compression, permitting motion of the structures distal to the fracture without disrupting the fracture interface. This system of dynamic compression and tension banding assumes the presence of a complete volar cortex accepting the compressive load. Without this cortex, forces created by motion must be carried solely by the implant, increasing the risk of failure and eliminating the stress-sharing capacity of bone. Bone shortening or contouring is often required to provide sufficient bony contact. [10, 89]
The forces acting on proximal phalanx fractures are somewhat different. The tension side is the volar cortex because of three forces: flexor, extensor, and lumbrical. The lumbrical pull is directly on the dorsal hood. The flexor acts through the A-2 pulley, pulling the proximal fracture fragment volarly, while the extensors act by pullthrough to the insertion on the middle phalanx. These forces together tend to collapse the proximal phalanx fracture into an apex-volar angulation. [10, 89]
Gallico (1990) prefer to shorten the bone to avoid the potential need for arterial, venous, and nerve grafts later. The tagged neurovascular structures are gently relocated during the bone shortening (Fig. 42A) [77]. Approximately 5–10 mm of bone shortening may be necessary for tension-free vessel repairs. Urbaniak et al. (1978) found that through the bony shortening, nerve or vein grafts may be avoided [91].
The bone shortening should be performed on the amputated part. Bone can be resected on the stump side for the fingers, but not for the thumb where length preservation is more critical, if the amputation level is near the joint on the amputated part. Hand function is compromised with thumb loss proximal to the interphalangeal joint. If the amputation level is through the joint, fusion in the functional position is required. Primary implant arthroplasty has been described in replantation by Wray (1984) but with increased risk for infection [92]. Then, retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part (Fig. 42B) [77].
The Kirschner unthreaded sharp-point wire remains a common method for fracture fixation in the hand, owing to the inexpensive cost of the implant, and the resulting adequate and rapid immobilization provided to the fracture. K-wire fixation in complex fractures may be both difficult and time-consuming. Disadvantages are a possible distraction of the fracture during multiple wire placement and the impingement on surrounding soft tissue when placed percutaneously. Moderate to poor stabilization with later loosening can occur, requiring protective splinting. The external pin sites in percutaneous wires provide a site for infection that may progress into soft tissue and bone. Buried subcutaneous pins, particularly if destined to remain in place for an extended period, may be desirable but require incision for removal. [10]
Urbaniak et al. (1978) and Wray et al. (1984) prefer cross K-wires, because they are quick and safe (Fig. 43). Controlled, low-speed drilling with adequate wire size provides the most secure placement. Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire as 90-90 wires [91, 92]. Ninety-ninety wires are two intraosseous wires placed perpendicular to each other. Whitney et al. (1990) found this technique to have lower nonunion rates with replantation procedures because 90-90 wires actually compress the fracture site [93] (Table 2). Another advantage of 90-90 wires is that they are low profile and easy to work around. [6]
Crossed K-wire fixation allows bicortical purchase, provides reasonable stability, limits rotation, and leaves adjacent joints and tendons free. Parallel K-wires, although controlling the same forces, often require crossing a joint surface and limit early mobilization. In some complex injuries, wires must be placed across one or more joints. Early removal with protected motion and splinting is started when possible. A single K-wire may be ideal in distal amputations, or in children, because of size constraints, with soft tissue closure controlling rotational forces. [6, 10, 89]
Figure (42): Once the neurovascular structures of the amputated part have been identified and tagged, they can be carefully retracted for bone shortening. (A) Approximately 5–10 mm of bone shortening is necessary for tension-free vessel repairs and the avoidance of neurovascular defects requiring grafts. (B) Then retrograde K-wires or intraosseous wires can be placed through the bone on the amputated part. [77]
Many different wire loop techniques are listed in the literature, and can be grouped into two main types, those with and those without tension band function. [94, 95, 96]
Non-tension band wires are usually 26- or 28-gauge steel wire placed through drilled holes in the proximal and distal fracture fragments with minimal periosteal dissection. Comminuted fractures may have to be wired fragment to fragment with fine wire before the major parts are fixed. Advantages include commonly available equipment, quick placement, reasonable strength, and minimal implant bulk. Disadvantages include the prolonged presence of a buried foreign body, slightly increased soft tissue dissection compared with K-wires, and wire fatigue and breakage that may result in loss of fracture reduction. [94, 95, 96]
Figure (43): In performing the bone fixation, many prefer K-wires, which are quick and safe and can be placed in cross or axial configuration. Union rates have been reported to be better with intraosseous wires, however, either in combination with a K-wire or as 90-90 wires. Ninety-ninety wires are two intraosseous wires placed perpendicular to each other, which was found to have lower nonunion rates. [93]
Table (2): Nonunion rates for various techniques of osteosynthesis with replantation [93]
Group Method (digits) Nonunion Required osteotomy
I Crossed K-wire (38) 8 (21%) 5
II Single K-wire (7) 1 (14%) 1
III Perpendicular interosseous (8) 0 0
IV K + intraosseous (12) 1 (8%) 1
V K + Cassel (3) 1 (33%) 1
VI Cassel (7) 1 (14%) 0
Cerclage or encircling wire loops were described by Lister (1978). They are useful with oblique, tubular, or diaphyseal fractures, containing multiple fracture fragments and reducing the area of required callus. They may be combined with other implants and are not compressive. Care should be taken to groove or drill the cortex to anchor the loop in place and to place the twist or knot closure away from gliding tissue [94].
These methods are not forms of rigid fixation. They act only to limit gross motion at the fracture ends and provide some degree of anatomic reduction, reducing the area requiring secondary healing. External splinting or a combination with other implants may be required [ 95].
As previously stated by Lister (1978), dynamic forces result in distraction or tension across the fracture site. Wire loops can be placed to reduce these distraction forces and encourage bony union [94]. For metacarpal fractures, placing perpendicular interosseous wires with the transverse wire dorsal to the midaxis of the fracture may provide a tension band to limit dorsal cortical distraction. We have also used this perpendicular technique in more distal replants with good results. In a study done by Jabaley & Freeland (1986), it is reported that combining wire loops, both intra- and extra-osseous, with K-wires may also help to reduce distraction forces [ 96].
The principles of the Arbeitsgemeinschauft fur Osteosynthesefragen / Association for the Study of Internal Fixation (AO/ASIF) are applied to the hand through the use of the plate and screw implants of the small fragment set. These achieve rigid bony fixation that can be combined with compression of static or dynamic nature [97, 98].
Freeland & Jabaley (1986) explained that the basic implant of the rigid fixation technique is the screw itself. To use the screw effectively alone, the threaded portion of the screw must be separated from the head by a zone with no matrix contact. This allows the force created on the distant bone by the threads to be transferred to the plane of the head by the ”lag screw” principle. This gliding zone can be created by overdrilling of the first cortex. Its value can be heightened by the use of compression plates with the screw, causing the force created by the distal threads to extend along the plate and into the opposite fracture fragment [99].
In the small fragment set, screws are available in three sizes, 1.3, 2.0, and 2.7 mm in diameter. Screw length selection is done by matching a depth-gauge measurement of the fracture and cortical thickness, allowing for adequate bony contact without impinging on surrounding soft tissue. Using the lag principle, the screw alone can be used to provide excellent fixation, but it has limited ability to control rotatory or bending forces. Screws should be either placed at an oblique angle to the fracture axis or used in combination with other screws or fixation methods. Although the method is often not applicable to the digit replant, associated injuries (metacarpal fractures, small avulsive fractures) can be managed well in this manner. [10]
Freeland & Jabaley (1986) reported that plate fixation can satisfy a variety of splinting functions that apply to other sites as well as the hand: first is Neutralization - correction of axial forces without using compression. Second is Buttressing - supporting multiple fragments or metaphyseal fractures. Third is Bridging - stabilizing in areas of cortical loss. Fourth is Compression - directly impacting fracture fragments by plate contouring, screw offset or compression plating [99].
Buncke (2002) stated that soft tissue dissection and plate fixation are usually prolonged compared with other methods; moreover, the hazards of a retained foreign body remain. Reoperation may be necessary to remove the implant because of bulk, osteopenia or pain. This may be done concurrently with secondary soft tissue reconstruction. [10]
Although this method can provide rigid fixation, it too is subject to failure. If the fracture has poor cortical contact, any force applied across the fracture must be borne by the plate and transmitted into the bone through the bone/plate interface. Micromotion at the bond/screw interface results in absorption of adjacent bone and subsequent loosening. The plate itself may bend or fracture. Recently, the Luhr system of plates and screws has been adapted for use in stabilizing hand fractures. The plates are extremely thin and have offset screw holes to make compression easy. Recent laboratory and clinical evidence has shown that these plates do well in hand fracture applications. [10, 100]
External skeletal fixation is a reliable method for maintaining bony alignment under certain replantation situations, and are applicable in proximal injuries as well as the hand. Although it is not a replacement for internal fixation implants, external fixation may serve as an adjunct in complex injuries undergoing staged debridement and reconstruction or in situations of loss of bone substance. Comminuted bone injuries can be held in anatomic alignment despite disrupted architecture. Advantages of the external fixation techniques are as follows [10]:
1. Application can often be carried out with a small number of tools, requiring limited additional dissection. 2. With experience, it can be performed quickly. 3. Early motion can begin. 4. The device causes minimal interference with dressing changes or surgical intervention [10].
Disadvantages as reported by Hill & Buncke (1988) are those related to damage of the soft tissue during pin placement, the risk of infection at percutaneous pin sites, and the difficulty in placement into distal phalanges. We seldom use this device in children because of limited bone sites, the small amounts of bone stock holding the pins, and the risk to epiphyseal growth centers. Adequate bone-to bone contact is necessary, by either bone recontouring or bone grafting, if external fixation is to be successful in long-term application [100].
Other fixation techniques include the intramedullary screw and the expandable intramedullary (Lewis) device. The results appear to be good at their respective centers [10, 101].
The actual determination of bony union is more a clinical than a radiologic judgment. The ratio of cancellous to cortical bone is of prime importance: cortical midshaft fractures take longer to heal than those of the cancellous metaphyseal type. For hand fractures, the healing cancellous fracture is generally stable in 3 weeks and the midshaft cortical fracture in 4 weeks. This varies with the type of injury, the degree of ischemia, the adequacy of bony contact, and the presence of extensive soft tissue injury or infection. Clinical unity is shown by a lack of motion or tenderness with stress at the fracture site. At this point, implants such as Kirschner wires can be removed. A reduction in therapy is sometimes made for 7 days, and the fracture reassessed at 1 week. If the injury includes more extensive soft and hard tissue damage, there is an anticipated delay in healing, and the fracture is then stabilized for an additional 1 to 2 weeks [10].
Radiologic signs of early bone healing show only loss of definition of the fracture edges because of resorption of dead bone. If callus formation is required, it begins to appear at 3 to 4 weeks with calcification beyond the cortical margins. Within 6 to 8 weeks, the bone is undergoing reorganization, and x ray shows a loss of the fracture line. Failure of the x ray to demonstrate these sequential changes, or the appearance of increased callus or translucency at the fracture zone, indicates an implant failure with motion at the fracture site. Corrective steps should be taken to reduce the external stresses by either adding external splints or reinforcing the internal splinting of the implant [10].
There are some important complications that occur with bony fixation. Rough application of the implant increases the damage to the soft tissue and underlying periosteum. The poorly reduced bone and the fixation implant are subject to unbalanced micro and macro stresses in the postoperative period, and unnecessary motion may compound a poor reduction, leading to further problems and pain. Collapse of the reduction removes any ability of the bone to share the stress load, causing further stress on the implant and the bone-implant interface. Additional external splinting must be applied, placing the extremity at risk for further stiffness. A delayed union, non-union or osteomyelitis may require reoperation [10, 93].
4.7.3.2. Extensor Tendon Repair
The course of the extensor tendon is divided into 6 zones [102]:
- Zone I: mallet finger
- Zone II - middle phalanx:
- extensor apparatus extends over the dorsal half of the digit;
- at this point the lateral bands are traveling in a volar to dorsal direction, and are merging with fibers of the central slip;
- at this level the lacerated tendon is repaired w/ 4-0 Vicryl figure of 8 sutures;
- Zone III - PIP joint
- Zone IV: (proximal phalanx):
- at the level of the proximal phalanx, there is only 2-3 mm of tendon excursion, and therefore, minor amounts of adhesion can result in significant amounts of loss of extension;
- it is important to repair the lateral slip separately if they are involved;
- tendon can be repaired w/ figure of eight 4-0 Ethibond sutures, but take care to avoid tendon shortening;
- Zone V - over MP joint:
- it requires individual repair w/ interrupted-inverted 4-0 Ethibond sutures;
- failure to perform this repair may result in tendon subluxation;
- Zone VI - dorsum of hand and wrist
After the osteosynthesis, Gallico (1990) pronates the hand and repair the extensor tendon first (Fig. 44) [77]. If the amputation is at the proximal phalanx level Wilhelmi et al. (2003) repair the lateral slips, to prevent loss of extension at interphalangeal joints [6].
The ultimate strength of a tendon repair depends on the number and size of sutures crossing the laceration site, where as, resistance to gap formation depends on suture purchase. Perhaps the easiest and quickest technique is a running horizontal mattress technique. This technique is especially well suited for tendon lacerations distal to the MCP joint, where the tendon is relatively flat. The repair allows multiple suture strands to cross the repair site, and when carefully performed, there is minimal tendon shortening [10].
As noted by Newport et al. (1990) Kleinert modification of the Bunnell technique is stronger than the modified Kessler but both of these are significantly stronger than the horizontal matress and figure of 8 [102].
As noted in the report by Howard & Greenwald (1997), the MGH tendon repair technique (crossing running suture repair) was significantly more resistant to gap formation than the Bunnel or the Krackow technique. MGH tendon repair has superior suture purchase which is probably related to superior resistance to gap formation [103].
In some instances of severe avulsion injuries, no extensor tendons are available for repair. In these situations, arthrodesis or tendon grafting as a secondary procedure may be necessary [52].
Figure (44): The hand is pronated, and of the dorsal structures, the extensor is repaired first. If the amputation is at the proximal phalanx level it is important to repair the lateral slips to prevent loss of extension at interphalangeal joints [77].
4.7.3.3. Dorsal Veins Repair
At least two veins should be repaired in finger replants, especially for replants proximal to the proximal interphalangeal joint. Dorsal veins are preferred because they are larger and don’t interfere with subsequent repair of volar structures (Figs. 45 & 46) [77, 6]. Because the veins become smaller and more difficult to identify and repair the more distal the injury, arterial repair may be required first to locate the veins by back bleeding [6].
Avoidance of microclips in venous repair must be done because of the more fragile structure of the vein. With the careful use of the tourniquet, the venous anastomosis can be done easily [52].
Figure (45): At least two veins should be repaired in finger replants, especially for replants proximal to the PIP joint. Dorsal veins are preferred because they are larger and don’t interfere with repair of volar structures later [77].
Figure (46): This is an example of a dorsal vein repair with 10-0 nylon sutures in simple, interrupted fashion over the previously repaired extensor tendon [6].
Free venous flaps from a normal finger are used by Tsai et al. (1987) to provide venous drainage and skin coverage when an amputated finger has a substansial dorsal soft tissue defect [104]. This free flap has only venous inflow and outflow. Survival rate of 100% is noted when the flap is raised from the dorsal aspect of an uninjured finger. Failures were noted when it was raised from the forearm or dorsum of the foot. The advantages of such a flap are two fold:
- Venous drainage
- Flap coverage, avoiding complications such as vessel occlusion or hematoma formation associated with skin grafting over a venous anastomosis, with subsequent loss of the graft and anastomosis (fig. 47) [104].
Figure (47): Schematic illustration of possible sites for harvesting a venous finger flap [104].
Replantation of amputated digits at the level of distal interphalangeal joint or distal to it represents a difficult problem because the venule diameter becomes too small for microsurgical repair or no suitable vein is found in the revascularized part. In most cases, arterial diameter is still large enough to obtain a patent microvascular anastomosis [104].
It was reported by Amin et al. (1992) that the digits can survive with only an arterial anastomosis. However, the survival rate of these “artery only” replantations is less than 20% for a surgeon who achieved 80 to 90% survival rate when both arteries and veins are anastomosed [52].
Many techniques have been proposed as a solution of absent venous drainage by Urbaniak (1982). Removal of the nail and subsequent scraping of the raw nail bed with a cotton application every two hours to encourage bleeding with a heparin soaked pledget applied afterwards, with or without systemic heparin administration [65].
Obtaining adequate circulation in the replanted part can be done by creating an A-V fistula by using the contralateral artery in the replanted digit as a venous outflow pole and connect this, with or without a vein graft, to a vein in the proximal stump of the digit. Although it is claimed that A-V shunts introduce a low resistant non-nutrient vascular circuit, it was demonstrated Smith et al. (1983) that new capillaries could be formed in an artificially produced A-V fistula (fig. 48) [105].
Figure (48): A-V fistula as a solution of absent draining veins [105].
Medical leeches can be utilized when veins in the distal segment could not be found. Leeches are applied twice daily for five days postoperatively onto paraungual incisions made to obtain a leakage point for blood [10].
The leech is an animal whose use dates back to ancient times. Weighing from 6-9 grams, it can be kept in a bottle for two to four weeks in fresh water provided one changes the solution regularly. When positioned on a wound which is oozing blood, it fixes itself rapidly and sucks out up to six times its body weight in 5-15 minutes. At the end of this time it detaches itself spontaneously. One can estimate the amount of blood absorbed by the leech by submerging it in ether whereupon it disgorges all the blood. In addition to its mechanical decongestant effect, the leech injects an anti-coagulant (hirudine) which has a molecular structure similar to heparin. This produces the double advantage of a local action on the capillary circulation preventing thrombosis and prevention of the clotting of the blood leakage from the open wound for a further 30-90 minutes after detachment of the leech [52].
The leeches are applied twice daily for five days as it is the necessary period for re-establishment of capillary circulation across the wound interface [10].
Serafin et al. (1973) reported a survival of a distal part of a thumb in which no draining veins were found by leaving the entire volar portion of the wound open and making a moist saline dressing to the hand and forearm. Elevation was instituted. The thumb survived. This was probably due to bleeding from the volar surface of the wound or from a cancellous surface of the bones into the bulky saline dressing (fig. 49) [106].
Figure (49): The dorsal skin is loosely approximated. No venous anastomosis was done (right), ulnar arteriorrhaphy (left) was done without soft tissue closure [106].
4.7.3.4. Dorsal Skin Repair
Once the dorsal structures have been repaired, the dorsal skin is loosely approximated with small-caliber, simple, interrupted sutures [6].
4.7.3.5. Arterial Repair
The hand is then supinated to repair the injured volar structures. At least one digital artery is repaired. Arterial repair is performed to re-establish circulation and perfusion quickly and to assess the viability of the amputated part. Venous and arterial anastomoses are performed with similar microsurgical techniques [6, 10, 107].
These delicate procedures must be performed with the utmost precision. To avoid fatigue and improve control of the microinstruments, the surgeon must sit comfortably, with wrists and hands well supported [6].
Before beginning the repair, confirm that there is good bleeding from the proximal artery (apply the ”squirt test”) and the distal veins. If this is not evident, steps to induce flow include [52]:
- Relief of vascular tension or compression.
- Proximal resection to healthy wall.
- Warming the operating room and the patient.
- Adequate hydration of the patient.
- Elevation of the patient’s blood ressure.
- Irrigation of the proximal vessel with warm Ringer’s lactate solution.
- External application or gentle intraluminal flushing with papaverine solution (1:20 dilution) or lidocaine (4:20%).
- Checking with the anaesthesiologist about metabolic problem that could incite vasospasm e.g. acidosis
- Being certain that the tourniquet is not inflated.
- Wait
Urbaniak (1982) prefers to use a tourniquet and inflate and deflate it as necessary during the procedure rather than to use microvascular clips. It should be released at the end of each anastomosis. This avoids the effects of microvascular clip application and allows a considerable reduction of the operative time and blood loss [65].
It is critical to the success of the anastomosis to choose vessels at a level at which they appear normal. This is difficult to assess with crush or avulsive injuries. The color of normal vessel is an opalescent, pearly gray. Stretched or traumatized vessels are speckled because of multiple ruptures of the vaso vasorum, producing the ”measles sign.” Inspect the vessel ends and clear them of any blood or platelet clots [10].
Trim and clean the vessel ends of adventitia and cut the ends squarely for accurate approximation with no intervening tissue. After the vessels are dilated, inject heparinized saline beyond the vascular clamps. The artery or vein being anastomosed should be well exposed and easily seen; retract any overhanging tissues that may obscure the vessels. Large microvascular clamps are helpful in preventing the vessel from retracting into the tissues. Vascular clamps and gentle suction create a dry, ”bloodless” field [10].
If the vessel ends cannot be easily approximated, one should not hesitate to use vein grafts several centimeters long for a tension-free anastomosis. Thumb replant is a common indication for arterial interposition vein grafts. Also, in ring avulsion injuries, coiled arteries should not be straightened by dissection as intimal separation is always present. Resection and vein grafting should be done. If possible, the vessel ends should be of equal size. Although discrepancies of 2:1 are acceptable, patency rates fall off abruptly at 3:1 [10, 52].
Potential vein graft harvest sites for distal digital replants include the palmar forearm and wrist. The wrist is preferred by many because the volar wrist veins match the digital vessels. The leg or contralateral arm may be used to harvest vein grafts for major replants of the hand, forearm, or multiple fingers, as they can be harvested by a second team simultaneously (Fig. 50) [6]. Vein grafts must be reversed for arterial interposition because of the valves [108].
Y-shaped vein grafts from the dorsum of the foot have been used to bridge the arterial defects in multiple digital replantation. The two outflow limbs are anastomosed to the distal digital arteries of the two adjacent fingers before osteosynthesis. The stem is anastomosed after osteosynthesis to a common digital artery or the superficial palmar arch to provide rapid and reliable restoration of arterial inflow simultaneously to two adjacent digits (figs 51 & 52) [109].
Figure (50): A,B This is a vein graft interposing this arterial defect between the two forceps. Notice the size match with this vein graft harvested from the palmar forearm [6].
Figure (51): Diagramatic representation of the Y-shaped vein graft outflow limbs anastomosed end to end to the distal digital arteries [109].
Anastomosis can also be established by a crossover vessel technique such as the radial digital artery to the ulnar digital artery, or by vessel transposition using the digital artery of the adjacent digit as the proximal vessel [10].
Figure (52): Diagramatic representation of : A. proximal end to end anastomosis of a vein graft to a common digital artery. B. proximal end to side anastomosis of the vein graft to the superficial palmar arch [109].
4.7.3.6. Performing Microvascular Anastomosis
The techniques of microsurgery, which are both exacting and initially difficult, should be learned in the laboratory and not on patients as demonstrated by Silber (1979). The principle is that as long as one can see the structure well, he can manipulate it adequately to perform a reliable anastomosis. Attention is directed to optical loupes and the operating microscope; suture and needles; instruments; microdissection, placing sutures, and tying knots; the various types of microsurgical anastomoses -- end-to-end vascular anastomosis, end-to-side microvascular anastomosis, microanastomosis of other structures, including peripheral nerves; and factors affecting the patency of a microvascular anastomosis [110].
Although many surgeons use the operative microscope every day, Acland (1989) stated that the techniques for suturing very small vascular and neural structures are substantially more complex and unfamiliar than the routine. Practice is the key and requires dedication of time and effort [111].
MacDonald (2005) clarified that magnification and illumination are essential when working with delicate tissues and fine suture material. A good-quality microscope should be used for both practice and surgery. Familiarity with the operative microscope will minimize the struggle to achieve optimal visualization. The microscope should be positioned to provide a comfortable neutral neck position and a relaxed posture of the arms as they rest on the operative surface. These adjustments prevent fatigue and tension in the neck and arms, which can amplify a native tremor [112].
The microscope should be fitted with 10× to 15× eyepieces and a 200- to 300-mm focal length objective lens. For most exercises, a maximum magnification of 25× should suffice. If you are tall, you may prefer a longer focal length [111].
It is helpful to use a foot switch to control the zoom and focus of the microscope. This will free your hands to concentrate on suture placement and tying rather than microscope adjustments. You should practice placing suture at higher magnification and zooming out to tie and trim sutures. This maneuver expands the visual field and depth of field so that the entire suture strand can be seen. You will quickly develop the coordination with your feet to optimize the zoom and focus automatically. The value of your practice time can be maximized if you eliminate distractions and free your mind from other concerns. Try to focus only on the task at hand and avoid struggle. If you are having problems, a root cause usually can be identified and modified. At first, you will fatigue easily. Plan to work in brief sessions and rest frequently. The following exercises will help you get started [112].
Tremor is the enemy of microsurgery as demonstrated by Murbe et al. (2001). Everyone has some degree of tremor. Involuntary tremor can be exacerbated by several external, yet modifiable factors. Avoid smoking, sleep deprivation, strenuous exertion, and coffee and other stimulants. You can learn to conquer your tremor with a comfortable position, relaxed hands, and a peaceful mind. Familiarity with the microscope and the instruments will develop with practice and will also help control tremor [113].
Microsurgical proficiency begins with a foundation of BASIC TECHNICAL SKILLS. The first step is to learn to hold the instruments properly. Microsurgery is performed almost entirely with the fingertips with only small input from the wrists. The instruments must be held between the fingertips in such a way as to provide comfort and control. Begin by placing the tool in your hand as you would hold a pencil. Apply pressure between your thumb and index finger and then bring your middle finger underneath the tool to establish three points of contact (Fig. 53). The instrument will be stable in your grasp and every subtle movement of your fingertips will be transmitted to the tip. The grip is identical for each hand and is suitable for all of the necessary instruments [112].
Figure (53): Basic position for holding the instrument. The thumb and index finger grasp the tool while the middle finger supports it from behind [112].
For the right-handed surgeon, the forceps is primarily a left-handed instrument. The scissors and needle applier are used in the right hand and intermittently exchanged for tying and cutting purposes. It is helpful to have an assistant to pass instruments to your right hand so that you do not have to look away from the microscope repeatedly. Frequently, looking away from the microscope wastes time and increases neck and shoulder fatigue and eye strain [113].
With a forceps in the left hand and a needle applier in the right, bring the tips together and rest your hands on the table surface. Only the hypothenar aspect of the palm should touch the table. For additional stability, bring the tips of the fourth and fifth digits of each hand together until they just touch (Fig. 54). This creates three points of contact between your hands and the table. Practice making small inputs with your fingertips and notice the magnitude of movement and range of motion of the instrument tips. It is possible to turn the needle applier through enough curve to place a needle with only a slight twisting of the fingertips and partial pronation of the hand [112].
Figure (54): The grip for each hand is identical. Additional support comes from touching the tips of the small fingers. [112]
RUBBER (NON-ANIMAL MODEL) provides a good substrate for learning the basic skills of microsurgery. A practice platform can be fashioned by stretching a rubber glove over a dish. Avoid stretching the rubber too tight or else the edges of your practice incision will not come together without tension during suture tying. This assembly can then be positioned under the microscope and rotated to mimic the circumstances of a true anatomic situation. It is easiest to begin with a linear incision in the rubber and orient the incision at a 45-degree angle sloping from your left to right. Begin your first stitches at the distal aspect of the incision and work toward yourself. Placing interrupted stitches and tying them one at a time will emphasize the sequence of movements. It is helpful to start with larger suture material, such as a 6–0 or 7–0 monofilament. This material is more easily visualized and manipulated and therefore requires lower power magnification on the microscope. The mechanics of manipulating the suture and tying knots can be ingrained more easily and transferred to smaller material with experience. [114]
Choose the suture material that you intend to start with and begin by placing the needle in the needle holder. Grasp the suture material with the forceps held in your left hand a few centimeters distal to the shank of the needle. Lift the needle gently from the surface until it dangles with its tip just touching the table (Fig. 55) [55]. This will facilitate rotating and orienting the needle appropriately for pickup with the needle applier. Place the needle in the needle applier just past the halfway point along its curvature (Fig. 56) [112]. If you grab the needle too close to the tip, the tip will point downward. Conversely, if you grab it too close to the shank, the tip will point too far upward. Optimal placement of the needle within the applier will facilitate not only puncturing the tissue but also rotating the needle through the necessary curvature to engage both edges of the tissue in one smooth movement. Also, pay attention to the angle of the needle within the applier. Initially, it should be placed at a right angle to the jaws. In the anatomic situation, particularly with deeper structures, an angled vector of the needle may be required but avoid this complexity during the practice phase. [112]
Figure (55): The suture is lifted until the needle tip just touches the surface below. This enables proper grasping of the needle. [55]
Figure (56): Grab the needle just past the halfway point toward the shank. [112]
With the needle adjusted properly in the needle applier, use the forceps in your left hand to grasp the far edge of the incision. Insert the needle through the rubber precisely and at a right angle so as not to skive the edge. Use the forceps to apply gentle counterpressure as you drive the needle through the edge. Next, use the forceps to grasp and slightly evert the near edge of the rubber and complete the passage of the needle through this surface (Fig. 57) [112, 114].
Zoom out with the microscope and gently pull the redundant suture through until there is 5 to 8 mm of suture material extending through the far side puncture site. Estimate a length of suture material approximately twice the amount extending from the far side of the suture and pick up the suture material with the forceps in your left hand from the near side. Be sure that the suture material emerges from the upper surface of the forceps (the surface facing you). By simply moving the tips of the forceps toward the puncture site, you will notice that the suture material automatically forms a loop (Fig. 58) [112].
The suture material has an intrinsic memory, which is related to its natural stiffness. This maneuver will force the suture to form a loop and will markedly facilitate tying. Reach through the loop and grasp the distal end of the far suture strand and pull it through the loop by bringing the needle applier directly toward you and pulling the forceps directly away from yourself. As the knot tightens, this suture will stretch slightly and the suture strands will remain in the orientation they were in during the tightening. No light should be visible through the coils of the knot. Without letting go of the long suture strand with your left hand, repeat the maneuver in reverse by bringing the forceps tips back to the incision line passing the needle applier through the loop and grasping the end of the short suture segment [114].
Three throws are all that are required to form a secured knot, but during the practice phases, it is a good habit to place four knots in alternating direction. If you remember to grasp the long strand at the correct length before initiating your tie, do not let go of the long strand, and always maintain the needle applier within the inside surface of the loop during tying, you will minimize effort and time delay related to tying. Each time you DROP a suture you waste time and increase frustration, which ultimately affects the quality of your results [112].
Once you are comfortable with the basic skills required for needle placement and suture tying, you can begin to manipulate the orientation of the rubber incision or use a trimmed cardboard tube to mimic a deeper anatomic situation. [114]
ANIMAL MODELS (RAT VESSELS) provide an excellent model for practicing microsurgical techniques. They are inexpensive and easily obtained, they are comparable in size to small vessels encountered during real microsurgery, they have similar characteristics to native tissues. These vessels can be used for any of the basic exercises and they can be pressurized with fluid to test the integrity of a completed anastomosis. [115]
Once the animal is anesthetized, the groin area should be shaved and the animal should be placed in a supine position with the extremities secured to the corners of a dissection board. The skin is incised along the groin crease (fig. 59). Use your thumbs to spread the edges of the incision and expose the fat pad overlying the femoral neurovascular bundle [116].
Figure (59): Skin incision (left).
Dissection of the subcutaneous tissues (right) [116].
The fat pad can be incised circumferentially, beginning at the 2:00 position of an imagined clock face, near the edge, and ending at approximately the 11:00 position, and then reflected superiorly. This will expose the neurovascular bundle between the quadriceps and the hamstrings group. This ligament is a dense white fibrous band that marks the limit of the proximal arterial exposure (fig. 60) [116].
Figure (60): The fat pad is incised and elevated with exposure of the neurovascular bundle. [116]
The microscope is then used at low power to prepare the vessels. Working distally, the adventitia overlying the artery and vein is grasped with the forceps in the left hand and the microscissors are used in the right hand to sharply open the adventitial sleeve and expose the vessels. At approximately the midpoint of the artery, along its back wall, lies a small arterial branch known as the Murphy’s artery. This vessel must be sacrificed to provide mobility to the artery. The vessel can either be ligated with 10–0 suture and divided or, alternatively, coagulated with a disposable coagulation unit (fig. 61) [116]. Heparinized saline should be used liberally to irrigate the vessel surface and prevent it from desiccating under the heat of the microscope lamp. Cotton swabs are helpful to blot blood and fluid away from the vessel surface. Topical papaverine is useful to reverse signs of vasospasm after manipulation. At this stage, the vessels are ready for the basic anastomosis exercises [112].
Figure (61): Visualization of femoral vessels (left) and ligation of profunda vessels (right). [116]
END-TO-END MICROVASCULAR ANASTOMOSIS [52, 110, 112] begins by focusing the microscope at low power over the center of the exposed femoral artery. Using the forceps, elevate the artery by its adventitia away from the vein. Place a small piece of rubber glove or other colored plastic material to serve as a background underneath the artery (fig. 62) [116]. A temporary clip approximator should then be applied to the artery with the clip assembly facing away. The microscissors are then used to divide the artery perpendicular to its long axis (fig. 62) [116]. The vessel dilator is then inserted into each end of the divided vessel and gently opened to expand the arterial orifice (fig. 63) [116]. Heparinized saline and a 30-gauge blunt needle are used to flush residual blood from the lumen [112].
At higher power, the adventitia is further trimmed near the edge of the arterial opening to prevent incorporation in the suture line (fig. 64) [116]. The temporary clips are then gently adjusted until the cut ends of the artery are approximated. This will allow the anastomosis to be performed without tension. The initial sutures should be placed on the dorsal surface at approximately the 10:00 and 2:00 positions. If the initial sutures are placed opposing each other at the 9:00 and 3:00 positions, the dorsal and ventral surfaces of the vessel will coapt, which will make it difficult to place the needle through the vessel edge and seek its lumen without stabbing or catching the back wall.
Figure (62): Clip application (left) and division of the artery (right). [116]
Figure (63): Expansion of the arterial orifice by vessel dilator. [116]
Figure (64): Trimming of the adventitia. [116]
Zoom in with the microscope to pass the needle through the arterial edge. Avoid grasping the edge of the artery with the forceps. Try to pick up the adventitia if you must move the vessel. Place the forceps gently within the vessel lumen and slightly spread the tips to provide counter pressure as the needle punctures the tissue. Zoom out to trim the suture and tie the knot (fig. 65) [116].
Once the initial two sutures are in place (fig. 66) [116], the temporary clip approximator is then rotated 180 degrees. This will cause the vessel to twist and bring the ventral surface of the anastomosis into view (fig. 67) [116]. The correct placement of the initial sutures will cause the orifice of the anastomosis to gape. The third suture is placed at the 6:00 position. The remaining sutures are then placed at equal intervals between the initial sutures [112].
Figure (65): Making the first knot. [116]
Figure (66): The two stay sutures. [116]
Figure (67): Suturing the back wall. [116]
Before removing the temporary clips and restoring flow, the anastomosis should be inspected for any obvious gaps in the suture line (fig. 68) [116]. If none are present, begin by removing the distal temporary clip. The backpressure in the femoral artery should fill the vessel to the proximal temporary clip and demonstrate any deficiencies in the suture line. Removal of the proximal clip will restore antegrade flow and pressure. Occasionally, transient leakage from the needle puncture sites along the anastomosis will occur. Bleeding can be managed easily by folding the femoral fat pad against the anastomosis and applying gentle pressure. The fat tissue contains intrinsic tissue factors that rapidly promote clotting. After a few moments, the anastomosis should be inspected for patency [116].
Figure (68): The completed anastomosis. [116]
Signs of patency are examined under medium-power magnification, the anastomosis site should appear pulsatile and should subtly dilate with each systole. Pulsation proximal to anastomosis does not mean that the anastomosis is patent. Pulsations must be observed distal to the anastomosis. If the vessel appears to oscillate in a longitudinal direction, this usually suggests an obstruction to antegrade arterial flow [112].
The uplift test is a more reliable method for determining patency. Using closed forceps beneath the artery proximal to the anastomosis, the vessel is elevated until flow is obstructed. The artery will appear to blanch over the surface of the forceps. The forceps are then passed distally under the vessel across the anastomosis. The lumen should appear to refill briskly both proximally and distally to the forceps [112].
The empty and refill test is a crude but definite test of patency which is traumatic and should be used as seldom as possible. With one pair of forceps, the vessel distal to the anastomosis is occluded. With a second pair of forceps, a short length of vessel distal to the first pair is emptied. Then, holding the second pair of forceps closed, the proximal pair is released and the emptied length of vessel should refill. The test is done distal to the anastomosis (fig. 69) [68].
Figure (69): Empty and Refill test [68].
THREE ALTERNATIVE ANASTOMOSIS TECHNIQUES are frequently used clinically in situations where presentation of the vessel is not optimum for standard end to end anastomosis. There are:
- End-to-side anastomosis.
- The back wall first technique.
- Flipping of a mobile vessel.
End-to-side Technique [112] is used when a single vessel maintaining a vascularity of a limb is present or for marked size discrepancy. Better patency rates have been reported with this method over the end-to-end method, because the retraction of the muscular layer of the vessel which has been cut laterally maintains the wound open, opposing the occluding circular retraction of the muscular layer of the transversely severed vessel.
The arteriotomy into the donor vessel is the most critical and irreversible step in the procedure. It may be done by excising a wedge of vessel wall with straight scissors, or begun with micro-knife and enlarged carefully to elliptical and circular defect with micro-scissors. The arteriotomy should match the size of the vessel to be anastomosed. A ninety degrees angle of take off is preferred as blood flowing from an arterial wound always springs in a right angle direction. Also oblique cuts through the vessel wall produce a fragile tip of tissue with the intima and media at different levels, which is weak because of interruption of the vessel wall. In most cases, the front wall is first repaired and then the back wall is sutured (fig. 70) [64].
Figure (70): Standard end-to-side technique. (A, B): The creation of the arteriotomy. (C, D): Suturing the near side. (E): Suturing the far side. (F): The final end-to-side anastomosis [64].
A back wall first technique can be used if the donor vessel is deeply placed and mobilization of the recipient vessel is difficult (fig. 71) [64].
Figure (71): An optional end-to-side technique. The far side can be sutured using the “back wall first” technique, and the near side then completed [64].
Back wall first technique is most useful with vessels of approximately equal size where one or both presenting ends cannot be rotated with a double clamp. This most commonly occurs when the repair is made close to a parent trunk or large branch that cannot be sacrified. The anastomosis should begin with the point furthest away from the surgeon. Interrupted sutures are then sequentially placed towards the surgeon, until the back wall is completed. Then the front wall is repaired. The initial suture is left long to aid in traction and rotation of the vessel (fig. 72) [52].
Figure (72): The back wall first technique [52].
Flipping Technique [52] is used in many situations. One vessel end is freely mobile and can be flipped end-over-end to repair the back wall (fig. 73). Examples include: Vein grafting, where the first anastomosis can be completed in this manner and the second by standard technique and Free tissue transfer where the flap may be freely mobile if it is re-vascularized prior to fixation.
The technique is useful when a vessel presents for anastomosis in such a manner that double clamp placement and rotation are difficult.
Figure (73): “Flipping” a mobile vessel. When the free flap, digit, or vein graft is attached to the mobile vessel, it can be flipped to exposed the back wall for repair if rotation of the vessel is difficult [52].
OTHER ADVANCED TECHNIQUES are sometimes used. An interrupted anastomosis is suitable for most applications and has the advantage that over time, the point of connection can expand. A running closure technique is useful in many situations and has the advantage of being faster but it will tend to remain the same size over time. The running technique is probably not ideal for the end-to-end anastomosis because the suture line has a tendency to act as a purse string when the sutures are tightened. In the end-to-side anastomosis, this tendency can be avoided by running the suture line loosely and then tightening each loop. After placing the fixation stitch at the corners of the donor and recipient vessel, the first loop of the suture line is passed. With each subsequent stitch, the redundant suture is pulled through until a small loop remains. The diameter of each subsequent loop should be slightly smaller than the last. After all of the stitches are placed, a right-angled, ball-tipped probe and the forceps are used to tighten each loop sequentially. Once the final loop is snug, the suture is tied to the proximal fixation stitch. The lumen is then inspected and the remaining side is closed. Because this technique does not involve the exchange of instruments for tying and cutting between each stitch, it can be performed much more rapidly than an interrupted technique [111].
A side-to-side anastomosis can be used to create a wide connection between parallel vessels. Two linear enterotomies of equal length are required along the opposing surfaces of the vessels. Proximal and distal fixation stitches are placed using double-arm suture at the extremes of the enterotomy. The complexity of this exercise lies in the necessity to close the ventral side of the anastomosis by using a running technique from within the lumen. One of the arms of the distal tacking suture is passed between the two vessels to the ventral surface of the vessels and then used to puncture the vessel edge from outside in. The remainder of the ventral portion of the anastomosis is then closed in a running fashion by working the needle from the luminal side. The dorsal surface of the anastomosis is a straightforward closure [117, 118].
Small segments of artery or vein can be used as substrate for interposition techniques. The main difficulty lies in completing two anastomoses without introducing a twist in the recipient vessel. Twisting will lead to obstruction of flow and subsequently, thrombotic occlusion [112].
4.7.3.7. Nerve Repair
Most nerves can be repaired primarily, usually with tension-free anastomoses, owing to the bone shortening done earlier. The ends of the nerve are examined under the microscope for a ”yeux d’escargot” sign (fascicles protruding from the cut end of the nerve). The end usually requires some trimming, which may be more extensive in avulsive injuries. This can be performed before or after the tourniquet has been deflated [10].
In severe avulsive injuries, Wilhelmi (2003) found that primary anastomosis is frequently not possible because of excessive gapping. The nerve ends are tagged with a silver clip for identification at a secondary nerve graft procedure. The gap can also be bridged with carefully placed bridging sutures, which helps to identify the nerve later. The suture also prevents retraction of the nerve ends. In these more severe injuries, primary nerve grafting is seldom performed because, most often, the gapping is caused by crushed or torn nerve tissues, or in the case of a major amputation, the larger nerves have been injured at several levels, and the final zone of nerve injury is not apparent. Furthermore, there is no significant advantage of primary repair over secondary repair [6].
Weber et al. (2000) reported a statistically improved return of sensation using the polyglycolic acid nerve conduits when compared with end-to-end coaptation. Upper extremity nerve graft donors include the medial antebrachial and posterior interosseous nerves. Alternatively, a vein graft can be used for small defects of 2 cm or less [119].
All nerve repair is done under the operating microscope. For digital nerves, Buncke (2002) used 9-0 microsutures, and placed only as many epineural sutures as necessary to coapt the ends without tension. 10-0 for individual fascicles and distal repairs in digits can be used [10].
4.7.3.8. Flexor Tendon Repair
Primary flexor tendon repair should be done whenever possible. In some cases, a primary tendon transfer from a non-replantable digit may be used. If the wound is clean, placing a primary tendon rod may be considered. Stiffness caused by flexor tendon adhesions is a primary cause of unsatisfactory function after replantation. Rehabilitation of the flexor tendon should be started as soon as possible, despite the risk of tendon rupture [6].
The course of the flexor tendon is divided into five zones [42]:
- Zone I: FDP has emerged from between & beneath decussating FDS and travels to its insertion in the distal phalanx. It contains A4, C3, and A5 pulley.
- Zone II: The 2 tendons enter fibro-osseuous tunnel at mid-palm level. Once the FDS and FDP tendons enter the flexor tendon sheath, the FDS separates into 2 segments, which pass around the FDP tendon and which then reunite at Camper’s chiasma (dorsal to the FDP).
- Zone III: extends from base of palm or distal end of transverse retinacular ligament to transverse crease in the palm. It extends just proximal to the IP joint and to the MP joint. In this region tendons are essentially free of a tendon sheath.
- Zone IV: extends from distal end of transverse retinacular ligament to proximal margin.
- Zone V: extends from the proximal transverse carpal ligament at the wrist to musculocotinous junction of flexor tendons in forearm.
In digital replants, tendons can usually be recovered with tendon retrieval forceps. To accomplish this, the assistant holds the forearm while maintaining the wrist in a flexed position to retrieve flexor tendons, or in an extended position to retrieve extensor tendons. A transverse Bunnel needle will hold the tendons in place to prevent retraction while the ends are trimmed and half a modified Kessler suture of 3-0 Prolene is placed before osteosynthesis. The repair can be completed easily after osteosynthesis is performed. Some authorities prefer to place hemi-Kessler sutures and to complete neurovascular repairs before repairing the flexor tendons. With this technique, the neurovascular anastomoses can be done with the digits in extension, allowing a better view of the structures [10].
4.7.3.9. Soft Tissue Repair
The wound should be closed loosely without undue tension on damaged tissue and without compressing underlying vascular structures. Good initial soft-tissue coverage results in more rapid healing and faster resolution of inflammation and edema. The limb can be mobilized more quickly, which improves the function of underlying tendons and joints [10].
If primary closure cannot be accomplished, Amin et al. (1992) prefer a meshed skin graft. Local flaps may be used with meshed skin grafts, or, in some cases, free flaps can be transferred at the initial operation (fig. 74) [52]. Pedicle flaps are sometimes used as described by Neumeister & Brown (2003), but the necessary immobilization and the resultant patient discomfort make pedicle flaps more difficult to use than free flaps. Moreover, free flaps offer a greater choice of tissue components (muscle, skin, etc.) than do pedicle flaps [5].
Figure (74): Skin coverage without tension [52].
Meredith & Koman (1999) concluded that severe crush injuries may be covered temporarily with wet-to-dry dressings, allowing a day or two for debridement and final coverage. Moistened vital structures will not be jeopardized, and this time can be used to stabilize the patient, especially if the patient has multiple injuries [8].
4.7.3.10. Dressings
Dressings protect the replant, absorb wound drainage, and prevent desiccation and maceration of the tissue. Thus, the wound requirements govern the dressing techniques [5].
Protection is enhanced by careful splinting with either plaster splints or bulky pillow splints that immobilize and cushion the replanted part. The wound edges are dressed with non-constricting gauze [10].
Dressing changes should be limited to avoid undue manipulation of replant, which may cause vasospasm. Nevertheless, clotted blood in a gauze bandage can quickly cause a constricted dressing, especially if there is postoperative edema. Therefore, change bloody dressings frequently and inspect them for potential compression and constriction. Elevate the replanted part to minimize edema and prevent venous congestion. A room temperature of 33°C is maintained, and a sterile towel is placed over the replanted extremity and covered with a heating pad (40°C for 5 to 7 days to encourage vasodilation and circulation [8].
4.7.3.11. Special Considerations
In the thumb, the ulnar digital artery is usually of larger caliber than the radial digital artery. Arterial revascularization in thumb replantation therefore is more reliable when based on the ulnar digital artery. This vessel is difficult to expose for the microsurgery and requires extreme arm pronation or supination. An arterial interposition vein graft from the radial artery in the anatomic snuffbox to the distal end of the ulnar digital artery in the amputated thumb helps avoid the cumbersome position of extreme rotation. Alternatively, the digital artery repair could be performed before the osteosynthesis. Care certainly must be taken to prevent disrupting the anastomosis during the bony fixation if this method is chosen (Fig. 75) [120].
Figure (75): First, the vein graft is repaired to the distal ulnar artery. Then the vein graft is pulled through a subcutaneous tunnel to the snuffbox and repaired endto- side to radial artery. [95]
When the thumb has been amputated at or near the MCP joint and the proximal ulnar digital artery has retracted and is difficult to expose, Wilhelmi et al. (2003) stated that a vein graft can be used from the ulnar digital artery distally to the radial artery in the snuffbox, end to side. In using this vein graft to radial artery technique for replantation of the thumb, retrograde K-wires are placed first into the bone on the amputated part. Then core sutures are placed in the proximal and distal ends of the flexor pollicis longus (FPL) tendon. The digital nerves are labeled with long sutures for easier identification later. A subcutaneous tunnel is created from the ulnar aspect of the thumb base to the snuffbox. The radial artery is exposed in the snuffbox and double pott’s ties are placed on the radial artery proximally and distally in preparation for end-to-side anastomosis of the vein graft to the radial artery [6].
The vein graft is first anastomosed end-to-end to the ulnar digital artery with the microscope. Again this provides much better exposure for the microanastomosis of the ulnar aspect digital artery to the thumb. The vein graft is then pulled through the subcutaneous tunnel to the radial artery in the snuffbox. The digital nerves also can be repaired at this point with better exposure. The osteosynthesis is carefully performed by passing the previously placed K-wires retrograde through the proximal bone. At this point the extensor tendon and dorsal veins are repaired. The vein graft is then repaired end to side to the radial artery in the snuffbox [95].
If the amputation level is distal to the MCP joint and the proximal end of the ulnar aspect digital artery is well exposed, Caffee (1985) demonstrated that a primary arterial anastomosis can sometimes be performed without the need for a graft [120].
A technique that has been described by Caffee (1985) to optimize exposure of the ulnar digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis (Fig. 76). The K-wires are placed retrograde through the distal amputated part first. The ulnar digital artery and nerve are then repaired with the hand in supination that provides a better angle for the microscope and exposure for the anastomosis. The bone ends are then aligned and the osteosynthesis is completed carefully. The digital artery clamps are left in place until the extensor tendon and dorsal veins are repaired. Finally, the flexor core sutures are carefully tied and the skin loosely approximated [120].
Figure (76): A technique that has been described to optimize exposure of the ulnar aspect digital artery during the microanastomosis involves performing the microanastomosis before the osteosynthesis. [120]
In multiple finger replantation, the finger with the best chance for successful replantation, best expected recovery, and contribution to function should be repaired first. If all the fingers are injured at the same level and with the same chance for success, the authors prefer to repair the middle, then index, then ring, and finally the small finger. If the index finger is stiff or insensate, the patient will bypass this to use the middle finger. When all the fingers are stiff, the index finger can actually impede the function and opposition of the other fingers to the thumb. Because it is essential to minimize ischemia time with multiple digit replantations, each finger is replanted separately [6].
The amputated fingers should be brought to the operating room as soon as possible, where the digital vessels, nerves, and tendons can be identified and tagged with sutures or clips, to save time and minimize ischemia. The order for repairs can be improvised with multiple replantations. Initially, the osteosynthesis, extensor tendon, one dorsal vein, and one digital artery can be repaired for each finger to minimize overall ischemia time. Another dorsal vein, the digital nerves, and the flexor tendon core sutures can be repaired later, once the blood flow to the fingers has been re-established [10].
Proper selection and treatment of some ring-avulsion injuries yields good results. Indications for replantation include intact sublimus insertion, undamaged PIP joint, undamaged distal vessels, and degloved skin suitable for revascularization and coverage. The surgical techniques required for success include adequate debridement of neurovascular structures and skin, bone shortening and fusion of DIP, liberal use of vein grafts, and use of local flaps and skin grafts to protect the proximal portion of the replant. Usually, one artery and two veins must be repaired. If adequate wound healing has occurred, rehabilitation can usually be started within 10 days. Rehabilitation is vital to avoid PIP joint stiffness and flexion contracture that often follow ring-avulsion replantation [6, 121].
4.7.3.12. Postoperative care
Postoperative care has traditionally included warming the patient’s room to avoid vasospasm and positioning the extremity at the heart level to minimize edema but not compromise arterial or venous flow [6].
Anticoagulation is generally recommended. Several investigators recommend the routine use of aspirin and dextran with replantation, and therapeutic heparin for crush avulsion injuries [95]. Depending on the mechanism of injury, antibiotics are considered. Patients are encouraged to abstain from smoking and caffeine use for one month [122]. The replanted part is monitored by checking color, capillary refill, tissue turgor, and temperature. Sympathetic blocks have been described for high-risk replantations after crush avulsion injuries [77].
Arterial insufficiency is the most common cause for replantation failure, accounting for approximately 60% of failures in two studies. Arterial insufficiency is suggested by decreased capillary refill, tissue turgor, and temperature. Treatment of arterial insufficiency includes removal of potentially constricting dressings and tight sutures, decreasing extremity elevation to promote inflow with gravity, and sympathetic blockade. Finally, early operative intervention can be considered if there is no improvement with the above measures. Re-exploration to correct arterial insufficiency has been reported to be successful in 50% of return visits [6].
Venous congestion is a less common cause for replantation failure. Venous congestion should be suspected with rapid capillary refill, increased tissue turgor, or bleeding of wound edges. Treatment of venous congestion includes removal of tight dressings and sutures and increasing elevation to promote venous drainage with gravity. Leeches are also effective at treating venous congestion in replantation. Nail plate removal and application of a heparin soaked sponge to the nail bed has been described for distal replantations when a vein cannot be repaired and the patient refuses leeches. Finally, operative revision can be considered, but is less successful than re-exploration for arterial insufficiency [6, 52].
4.8. Pharmacologic Agents in Microsurgery
Siegel (2005) reported that at each stage in the development and application of microsurgical techniques, pharmacologic adjuncts have been used to help ensure vessel patency and tissue survival [123].
Prolonged spasm in arteries, veins, and vein grafts has been described as a physiologic complication in microsurgery for over 20 years. Vasospasm results from several processes including intrinsic smooth muscle contraction, local noradrenaline metabolism, neurogenic and hormonal processes, and prostaglandin metabolism [124].
Buncke & Valauri (1988) attributed early clot formation following experimental microvascular repair to platelet aggregation at the site of the vascular repair. Later clinical and experimental investigations have continued to emphasize the role of platelets in microvascular thrombosis and clinical failures [125].
4.8.1. Antiplatelet and anticoagulating agents:
Aspirin is used clinically in all aspects of microsurgery as a supressor of platelet aggregation. Published animal and human studies document aspirin’s inhibition of platelet function and its utility in protecting vascular anastomoses [126, 127].
Wieslander et al. (1986) had used dextran in microsurgery as an antiplatelet agent. They demonstrated that its effects may include volume expansion, decreased blood viscosity and enhanced fibrinolysis. Dextran’s use helps ensure patency following vessel repair. Low molecular weight dextran-40 is the most commonly used dextran in microsurgery [128].
Systemic heparin is now used primarily as an anticoagulant adjunct in the management of traumatized replanted tissue and anastomotic revisions. Heparin is also used as a vessel irrigant before anastomosis and topically to promote bleeding from the nail beds of replanted digits with known or suspected venous impairment [129].
O’Reilly (1984) reported that fibrinolytics are used routinely in replantation surgery. Experimental studies report that human plasiminogen activator can promote patency in a microvascular thrombosis model [127].
4.8.2. Vasodilators:
Bupivacaine, lidocaine, magnesium sulfate, papaverine, and chlorpromazine are commonly applied topically to relieve vasospasm. These agents appear to have reproducible effects experimentally and clinically. The ability of lidocaine to preserve the volume of blood flow as well as to prevent vasospasm in small vessels following microvascular repairs has been demonstrated in a rat model [129]. Geter et al. (1986) bupivicaine and lidocaine are used in continual brachial plexus and regional blocks to produce sustained vasodilation [130].
Numerous systemic vasodilators have been investigated clinically and experimentally, with no agent achieving a status of clear efficacy or widespread use. British reports describe intraoperative administration of sodium nitroprusside or thymoxamine intraoperatively with a decrease in observable vasospasm. Postoperative of systemic chlorpromazine and isoxuprine1 are part of the routine postoperative care of some reported microsurgical series, but their use has not been shown to be critical for success. Anecdotally, intravenous guanethidine, intra-arterial papaverine, and intra-arterial reserpine have been given to reverse apparent impending microvascular failure [124].
Experimental attempts to find roles for modifiers of prostaglandin function, sympatholytics, calcium channel blockers, and numerous other drugs have generally not succeeded in producing either clearly applicable models or reproducibly positive results. Eddy et al. (1986) impregnated microvascular suture with a prostaglandin analog and decreased venous thrombosis in a microvascular rat model. Incorporation of locally active agents into sutures may be a promising new research area [131].
4.8.3. Agents affecting blood viscosity:
Experimentally, anemia appears to promote skin flap survival. This observation suggests that decreased blood viscosity enhances flap survival, and dextran is used in this context as a volume expander and platelet inhibitor [128]. A fibrinolytic, ancrod, experimentally decreases viscosity and increases flap perfusion in dogs. Pentoxifylline and pluoronic F68 have had some experimental successes in promoting tissue survival or vascular patency [10].
4.8.4. Agents investigated as detrimental to vascular patency and/or tissue survival:
Nicotine is considered a complicating agent in microsurgery and patients must be advised strongly against smoking perioperatively. Continued tobacco use is a relative contraindication to elective microsurgery [122]. Yaffee et al. 1984 described the effects of tobacco and nicotine in microsurgery. Smoking is compromising and circulatory failure of replanted digits in patients who smoked postoperatively occurs [132].
Caffeine in high intravenous doses decreased dermal blood flow in a rat model, but there is no evidence that this drug impairs perfusion in humans in doses consumed with coffee and tea drinking [10, 125].
4.8.5. Current drug therapies:
Perioperative aspirin, dextran, and chlorpromazine are administered to replantation patients. Patients receive aspirin preoperatively (when possible) and postoperatively for 8 weeks at a dosage equivalent of 3.0 mg/kg per day. Three 80 mg pediatric tablets for a 70 kg adult every day is an acceptable approximation. This dose reportedly interferes with platelet aggregation and preserves some prostacyclin (PGI2) production by vessel endothelium. Prostacyclin is a vasodilator and an inhibitor of platelet aggregation. Aspirin suppresses prostacyclin production by acetylating the same enzyme (cyclo-oxygenase), essential for both endothelial prostacyclin production and platelet release of aggregating factors. Small amounts of prostacycline are reportedly still produced at aspirin doses as high as 10 mg/kg, and these small amounts of prostacyclin appear to effectively exert local anti-platelet effects [10, 123, 126].
Low molecular weight dextran-40 is administered at a rate of 7 to 8 cc/kg per day as a continuous intravenous infusion, begun at the completion of the first microvascular anastomosis and continued for three to five days. Chlorpromazine, 10 mg administered orally or intramuscularly every 8 hours, is given to adults for the first 5 postoperative days as a systemic vasodilator [10, 124, 128].
Intraoperatively, vessel irrigation with heparin solution (100 units per cc of saline) is routinely performed before anastomosis. Lidocaine (1%), bupivacaine (2%), and papaverine (0.3%) are used empirically to treat intraoperative vascular spasm [124, 126].
Therapeutic doses of heparin (a bolus injection followed by continuous intravenous infusion determined by clotting studies) are given in instances of extensive tissue trauma, anastomotic revision, or prolonged tissue ischemia. The heparin is begun intraoperatively and continued for 7 to 10 postoperative days. Patients with replanted digits known or suspected to have impaired digital venous circulation receive systemic heparin and topical heparin scrubs to the exposed nail beds of the replanted digit until venous return appears established. Dextran is usually not given simultaneously with heparin [10, 123].
4.9. Hand Therapy
Stewart (2002) divided the general rehabilitation process into the early, intermediate, and late phases [133].
4.9.1. Early phase (protective):
This refers to the first 5–10 days after the injury and is usually a part of the patient’s inpatient stay. The therapist communicates with the physician to obtain details of the injury and surgery and working with nursing and social service staff to prepare for the patient’s discharge from the hospital [133,134,135].
As demonstrated by Chan & LaStayo (2003), the therapist should interview the patient to obtain information pertaining to the medical and social history and begin patient education regarding positioning, precautions, the rehabilitation process, and the expected outcome. A protective splint to protect repaired structures is frequently fabricated at this time and daily wound care is initiated. Depending on precautions and other medical factors, the patient may begin gentle range of motion (ROM) exercises to the uninvolved joints. Active and active assistive exercises are preferred if they do not cause excessive stress to the repair site. Early mobilization to the involved structures also may be introduced, depending on precautions and contraindications [136].
4.9.2. Intermediate phase (mobilization):
This phase begins 5–7 days after the injury and lasts until 6–8 weeks after surgery. At this stage, gentle controlled stress is introduced to decrease adhesions, promote intrinsic healing, improve nutrition, promote collagen remodeling, increase tensile strength of soft tissues, and prevent joint contractures. The program is progressed as the repaired structures undergo wound healing and gain tensile strength. The protective splint needs to be remolded as edema subsides and the need for wound dressings decrease. Once the wound is healed and the chance for dehiscence is low, scar management begins. In this phase the patient takes an active role in therapy and in their home exercise program. Activity of daily living (ADL) needs and training are addressed, especially if the dominant hand is involved. The patient also may need psychologic intervention to assist with adjustment to the physical and psychologic trauma [136].
4.9.3. Late phase (strengthening):
This stage begins 6–8 weeks after surgery and lasts until the patient is discharged from therapy. This is the time when hand function retraining and strengthening become the focus of therapy. Progressive physical demands are placed on the repair to promote strength, hand function, coordination, and endurance through resistive exercises and functional activities. ADL training may focus on specific problems as they emerge, such as opening the car door or buttoning. The protective splint is usually discontinued and splints used at this time are usually for overcoming joint stiffness, increasing tendon glide, or as an assist to function. Depending on the rehabilitation goals and outcome, the therapist also may be involved in work retraining or communicating closely with the physician to plan further reconstructive surgeries [122, 136].
Chan & LaStayo (2003) started the initial protective stage in the operating room when the surgeon places a plaster splint to protect the repairs. For a finger repair, the protective position is wrist neutral, metacarpophalangeal (MCP) joint flexion at 60O-90O, and interphalangeal (IP) joint extension [136]. Buncke et al. (1995) clarified that in this position both tendon systems are protected, collateral ligament length is intact, and flexion contracture of the proximal interphalangeal (PIP) joints is avoided [134].
A thermoplastic protective splint is fabricated as soon as the patient is off anticoagulants, usually on the 4th to 7th postoperative day to allow for ease of wound care and exercises in the mobilization phase [134, 137].
In selected cases, as advised by Buncke et al. (1995), gentle controlled stress is applied as early as the second postoperative day if the repairs are strong and there is no complication. Because the flexor and extensor systems are involved, special considerations must be given to the exercise program. An early protective mobilization program is designed to prevent joint stiffness and minimize adhesions while protecting the repairs. This program is subdivided into two stages. Early protective Motion I (EPM I) consists of gentle wrist flexion and simultaneous finger extension by virtue of the tenodesis effect (Fig. 77A). The motion occurs in a ratio, that is, if wrist flexion is limited, only a proportional amount of MCP extension is allowed [134].
Following this the wrist is brought to neutral extension with gentle passive and gravity-assisted flexion of the MCP (Fig. 77B) [134]. This is designed to move the MCP and the wrist to prevent joint contractures while maintaining balanced tension between the flexors and extensors, at the same time still protecting the repairs. The wrist extension-MCP flexion position preserves MCP collateral ligament length while the wrist flexion-MCP extension position provides relief from the intrinsic plus position and prevention of PIP volar plate shortening. Edema control, wound care, patient education, and psychologic adjustment are also important aspects of the treatment [136].
Figure (77): Early protective motion (EPM) I. (A) Gentle active wrist flexion and simultaneous assisted finger extension by tenodesis effect. (B) Gentle assisted wrist extension to neutral with passive MCP flexion [134].
EPM II, the second phase, begins at 10–14 days and consists of the intrinsic minus and the intrinsic plus position, also known as the ‘‘hook’’ and ‘‘table’’ positions respectively [134]. With the hook position, the wrist is supported in neutral while the MCP joint is gently brought into extension and IP joints into flexion (Fig. 78A) [136].
Using the radian concept, Brand has calculated that for every 57.29O or 1 radian of PIP flexion, there is 7.5 mm of excursion to the central slip [136]. In other words, to achieve 3–5 mm of tendon excursion, the PIP joint needs to flex 22.9O–38.2O [133]. Clinically, 25O–35O of PIP flexion is allowed initially and is increased gradually in subsequent weeks. If there is extensor tendon tissue loss, the amount of PIP flexion is further reduced. To prevent attenuation of the central slip, PIP flexion is limited to 60O until 4–6 weeks [134]. This ‘‘hook’’ position is followed by the ‘‘table,’’ or intrinsic plus position of MCP joint flexion and IP joint extension (Fig. 78B) [136].
Figure (78): Early protective motion (EPM) II. (A) Passive intrinsic minus or the ‘‘hook’’ position. With the wrist in neutral, the MCP joint is brought into extension while the PIP joint is gently flexed. (B) Passive intrinsic plus or the ‘‘table’’ position. With the wrist in neutral, the MCP joint is gently flexed and the IP joints are extended [136].
Again, the wrist is supported at neutral. Studies have shown that the ‘‘hook’’ position provides the most differential gliding between the flexor digitorum superficialis and flexor digitorum profundus tendons, whereas the ‘‘table’’ position maintains intrinsic muscle function [137]. These positions also produce less excursion to the extrinsics as compared with composite motion, therefore protecting the newly repaired tendons [134]. Obviously, the exercise program and positions need to be augmented when there are limiting factors such as unstable fractures, K wires crossing joints, or tendons and nerves repaired under tension [136].
Between 14–21 days, active intrinsic plus and intrinsic minus exercises are introduced, starting with ‘‘place and hold,’’ and progress to active exercises. The goals during this time include protection of repairs, maintaining intrinsic function, minimizing adhesions, improving tendon tensile strength and differential tendon gliding, and promoting longitudinal reorientation of collagen fibers [136].
Chan et al. (1994) advised that for thumb replantation, a dorsal protective splint is fabricated with the wrist in neutral and the thumb positioned midway between abduction and extension to maintain the web space. Thumb C bars are generally avoided to minimize pressure at the anastomosis site. The timeframe for introducing exercises is similar to that of the other digits. The EPM I for the thumb consists of gentle passive CMC motion and active and passive wrist flexion to tension and extension to neutral. After several sessions of passive CMC joint exercises, active CMC joint motion can begin. Passive EPM II begins 10–14 days after replantation with the wrist in neutral. It consists of gentle MP and IP joint flexion with the CMC joint extended and gentle MP and IP joint extension with the CMC joint flexed. Progression to active EPM II and composite motions of the wrist and thumb are the same as in finger replantations [138].
For finger or thumb repairs, Buncke et al. (1995) introduce wrist extension beyond neutral, blocking exercises, and tendon gliding exercises at 4–5 weeks. At 5–6 weeks, composite motion and functional activities are introduced. Blocking and dynamic splints can be added, whereas the protective splint is discontinued at 6 weeks. Strengthening begins at 6–8 weeks. Cold intolerance is a common problem and can last for months [134].
4.10. The order and Speed of Sensory Recovery after Digital Replantation [52]
The order of sensory recovery was measured by Frey hairs to determine pressure (30 gm) and touch (2 gm). Pain (5 gm) was measured by an algesiometer and cold (00C) and warmth (500C) were measured by a thermometer. Perspiration was measured by the bromophenol blue printing method.
The mean times of appearance of sensibility in the replanted digits were: pressure 9.8 weeks, touch 11.6 weeks, pain 13.4 weeks, cold 15.3 weeks, warmth 16.8 weeks and perspiration 26.9 weeks.
The speed of sensory recovery was measured by dividing the number of months required for sensory recovery by the distance from the replant level to the finger tip. The mean speed of sensory recovery for touch was 14 mm per month and for pain 13.2 mm per month.
The following observations were noted:
1. Regardless of the type of nerve injury, recovery occurred in the somatic nervous system in the order of pressure, touch and pain.
Sharp nerve severance recovered faster than crush or avulsion injuries. The recovery in the autonomic sensory modalities was in the order of cold, warmth and perspiration. Sharp sections were the most rapid, followed by crush or avulsion injuries.
2. Younger patients had faster return of sensory modalities. The order of recovery for all age groups was pressure followed by touch, pain, cold, warmth and perspiration.
3. Usually the results were better the more distal is the level of amputation. However, sensory return was quicker if the level of amputation was at the proximal phalanx when compared to the PIP joint level. This is due to the fact that digital nerves at the level of PIP joints are more securely bound to surrounding structures than they are at the proximal phalangeal level, and so they required more dissection for repair. This added surgical trauma may be responsible for delaying the sensory recovery.
4. Contrary to expectations, sensory recovery occurred earlier in complete than in incomplete amputations. This is felt to be due to the bone shortening procedure that takes place in complete amputations and which provides a situation where damaged nerve ends could be more easily trimmed and repaired without tension.
In previous reports on sensory recovery after nerve injuries, pain was the first modality to appear. Amin et al. (1992) reported that the order of sensory recovery was pressure, touch, pain, cold, warmth and perspiration. This is due to the prolonged period of ischemia that accompanies amputation. Even after prolonged period of ischemia and vascular anastomosis, the blood flow is relatively compromised, and this period of ischemia may result in nutritional imbalances that not only delay the maturation of regenerating fibers, but also promote changes in the skin structures.
It should be noted that nerve repair and the resulting sensory function in replantations cannot be compared with simple digital nerve injuries, as the distal stump of the nerve remains well vascularized in the latter condition, as well as the presence of cross-over innervation from the contralateral digital and dorsal cutaneous nerves.
4.11. Cold Sensitivity after Replantation
A common complaint of patients successfully undergoing replantation is that of cold intolerance or cold sensitivity. In a cold environment the replanted digit becomes blue and painful to a varying degree. The exact mechanism of cold sensitivity after hand injuries is not known [52].
Freedlander (1986) examined 21 patients who had undergone difital replantation, from less than one year to ten years. An assessment was made for cold symptoms. If present, they ranged from mild discomfort to pain when the fingers were exposed to a cold environment. 2 PD was measured on the replanted digital pulp. Cutaneous blood flow was measured using laser Doppler flowmeter. Patients rested on a bed in light clothing at least 20 minutes (room temperature 22-250C) before recordings were made. No smoking or drinking alcohol or coffee was allowed in the preceeding two hours. Measurements at room temperature were also obtained from the corresponding normal digit to act as control [139].
Further recordings were taken immediately following [139]:
1. Immersion of the polythene gloved hand in water at room temperature (cooling stimulus) and
2. Immersion of the hand in water at 10-110C for 60 seconds (cold stimulus).
In all but one case flow fell in both normal and replanted digits with lowering of temperature. The patients were separated into two groups: n group A, there was a noticeably greater DROP of flow in the replants at lowering the temperature compared with the normal digits. In group B, this difference was not apparent. In group A, 10 patients had had a single digital artery repaired, one patient had had both. In group B, 5 patients had had a single artery repaired and 4 had both. This study showed that cold intolerance was not related to 2 PD, cutaneous blood flow and did not decrease with passage of time [139].
Digital vasoconstriction occurs during exposure of the body to cold to preserve the body temperature. This response is governed by the sympathetic nervous system constricting the A-V shunts in the digital pulps and the arterioles and veins of the skin. This is evident that in normal individuals the sympathetic nervous system exerts a greater effect on finger A-V shunt flow than on capillary nutritional flow. It should follow that interruption of the sympathetic discharge may have a greater effect on A-V flow than on capillary flow [5].
In cases of digital replantations, the fingers have been totally denervated and sympathectomized. Following nerve repair, regeneration of both somatic and autonomic fibers takes place. Presumable, the A-V regulating mechanism also returns to a varying degree. It was found that in a patient whose finger was sympathectomized, the response to direct cooling was very pronounced and the re-warming period was prolonged. Following surgical denervation, there is an increased tendency towards vasoconstriction on exposure to cold, at least due to direct effect of cold on smooth muscle cells in the capillary bed. It was concluded by Freedlander (1986) that cold intolerance after injury results from a disorder of the vaso-regulation and is not caused by an organic arterial insufficiency of the circulation [139].
It is concluded by Wilhelmi et al. (2003) that further improvement of the microsurgical technique for vascular anastomosis will probably not solve the problems of cold intolerance [6].
4.12. Psychological Aspects after Mutilating Hand Injuries
4.12.1. Injury-related issues
Severity and extent of injury plays a predominant role in the individual’s psychological, social, and occupational adjustment to that injury. There is, however, limited correlation between tissue damage and functional loss and the psychological adjustment to traumatic injury [140]; there is limited correlation between mutilating hand injuries and psychological adjustment as well. Meyer (2003) examined the relationship between severity of hand injury and subsequent psychological, social, and occupational adjustment and found no correlation. They concluded that even though health care professionals tend to place significant importance on the severity of a physical injury in attempting to predict psychological and social adjustment to injury, it is not the sole or necessarily the most significant determinant of long-term recovery and reintegration into society. It is more beneficial to focus on the individual’s perception and attribution of how the injury was sustained when attempting to predict or understand psychological adjustment. [141]
4.12.2. Psychological responses to a mutilating hand injury
Individuals experiencing a mutilating hand injury likely experience intense emotional reactions as a result of their injury, subsequent treatment, and immediate or long-term disability as demonstrated by Johnson (1993). Reactions may be experienced as a wide range of emotions including anxiety, depression, guilt, fear, frustration, sadness, and anger, among others. Such a range of emotions is normal, and strong emotional reactions should not necessarily be viewed as abnormal. Whether the affective response warrants a clinical diagnosis depends on the severity, duration, and the incapacitating nature of the response [142].
Mutilating hand injuries can be associated with psychological disturbances such as acute stress disorder (ASD), PTSD, other anxiety disorders (panic and obsessive-compulsive disorders), major depression, pain disorders, and adjustment disorders [142]. Schubert et al. (1992) stated that assessing the individual’s psychiatric history can help determine the likelihood that a diagnosable disorder will occur. Pre-injury personality dysfunction and presence of psychopathology have been correlated with poorer postinjury adaptation and should be assessed as a possible risk factor to optimal adjustment [143].
In one of the few investigations examining factors contributing to emotional distress in the early stages of traumatic hand injury done by Gustafsson et al. (2000), the occurrence of the traumatic event itself was found to be one of the core factors contributing to distress. Symptoms of ASD, such as flashback memories and re-experiencing the event, were detected in 25% of the injured individuals. Adding to the degree of emotional distress were practical problems in daily functioning, dependence on others, involuntary decrease in activity level, unknown functional prognosis, the uncertainty of persistent pain, and the disfigured appearance of the hand [144].
In another study by Grunert et al. (1988), the acute (2 months or less postinjury) psychological impact of a traumatic hand injury was examined. Ninety-four percent of the individuals screened experienced one or more symptoms associated with ASD or PTSD, with the most common symptoms being nightmares and flashback memories. Other acute psychological symptoms included mood swings, cognitive difficulties (impaired concentration and attention), concerns regarding disfigurement, phantom limb sensations, and fear of dying. These symptoms generally resolved or were significantly alleviated by 1 month postinjury. Although flashback memories and nightmares continued, they were greatly diminished by the second month postinjury [145].
4.12.3. Promoting healthy adjustment to injury
The course of adjustment will vary greatly among individuals, as will the factors that influence their adjustment. For some individuals, impaired functioning is the primary concern; for others, disfigurement of the hand is primary; for yet others, financial concerns take precedence. Regardless of the primary concerns for the individual, there are strategies in which a health care provider can promote positive adjustment for persons with a mutilating hand injury. Promotion of a healthy adjustment should begin as soon after the injury as possible [145]. The hand surgeon is likely one of the first health care providers to have contact with the injured individual. For that reason, it is important that the attending surgeon begin to create ‘‘a realistic picture of acute and long-term goals for the patient and family’’. Positive pre- and postsurgical interactions foster faith in the physician, set the stage for patient compliance with medical recommendations, and increase satisfaction with care. Patients should be provided with a very realistic but hopeful perspective on what life will be like after a mutilating hand injury or amputation [141].
As stated by Pulvertaft (1990), the surgeon should not ‘‘be unduly optimistic and give promises that cannot be honoured. There are ways in which we can combine sympathy with truth.’’ The attending surgeon can further promote optimal adjustment by referring the individual to a mental health professional who specializes in traumatic physical injuries and disability [146].
There is considerable evidence that early psychological intervention after traumatic injury can substantially reduce psychological morbidity and maladaptive coping and facilitate more rapid return to work. It is beneficial for the patient to understand that many of their emotional reactions to the traumatic event and subsequent injury are not abnormal [141].
Psychological intervention should focus on promoting the patient’s strengths and discouraging dependence, feelings of victimization, or loss of personal control [144].
4.12.4. Replantation issues
In addition to experiencing the hand injury as a lifethreatening event, these individuals are typically admitted to the hospital as emergencies, with decisions regarding surgical interventions rapidly occurring. As a result, there is minimal opportunity for psychological or emotional preparation [141].
As with other mutilating hand injuries, replant patients experience significant disruption in body image and bodily integrity. The replanted hand or digit may be perceived as foreign or altered because of its appearance or changes in sensation. Because of the visibility and functional importance of the hand, the individual must confront potential social stigma and the potential for functional impairment with subsequent loss in vocational, avocational, and interpersonal pursuits [141].
The hand surgeon is advised to consider the psychological characteristics of the individual before determining that replantation is the most appropriate option. Situations in which replantation may be contraindicated because of psychological issues include self-inflicted amputations or if the individual is insufficiently motivated or is unable to comply with rehabilitative efforts and recommendations [142].
McCabe (2001) encourages the involvement of the patient, when feasible, in the replantation decision. He suggests that patients are more likely to be satisfied with their care when given the opportunity to participate in decision-making, which would then lead to more favorable treatment outcomes [147].
Obtaining a psychiatric or psychological evaluation may be particularly helpful in instances in which the psychological factors present as particularly complex or convoluted. Such an evaluation may provide guidance to the hand surgeon regarding potential psychological factors that would negatively influence the functional outcome of a replantation procedure [141].
4.13. Alternatives to Thumb Replantation
Patients in whom alternatives to thumb replantation are considered are those in whom replantation cannot be performed because of severe mangling or complete loss of the amputated portion [148].
4.13.1. Patient selection
Lister (1985) demonstrated that a possible algorithm for thumb reconstruction is oriented to the level of amputation. Distal and tip amputations may require resurfacing with sensate flaps. Amputations of intermediate length may be reconstructed with a combination of “phalangization” (web deepening) and distraction lengthening. A level of amputation close to the metacarpophalangeal joint is the perfect indication for toe-to-hand transfer. The closer the amputation is to the basal joint, the less thumb motion that can be restored by any procedure other than pollicization. Indeed, if the metacarpal base is absent, pollicization (if a digit is available) is almost mandatory. Other factors influencing decisions are the patient’s age, health, occupation, and functional demands, and the condition of the remaining hand [149].
An athlete may be ill-advised to surrender a toe. A woman may be dissatisfied by the appearance of an osteoplastic thumb reconstruction [148]. The presence of multiple amputations is a relative contraindication for pollicization; on the other hand, a damaged finger can be pollicized with good results as reported by Foucher et al. (1996) [150].
Low functional demand on the part of the patient may result in phalangization being the procedure of choice. A toe-to-thumb transfer may best treat a proximal amputation in a patient with high functional demands [151, 152, 153].
4.13.2. Non-microsurgical techniques:
4.13.2.1. Revision Amputation:
Eaton & Lister (1992) stated that revision of an amputation is undertaken when the amputated part is unsalvageable. Whether this is the final procedure or the first step in a more complicated reconstruction often is determined by the length of the residual thumb. Very distal amputations involving minimal bone loss can be treated with soft-tissue coverage, including such techniques as palmar advancement flaps and neurovascular island pedicle flaps from the ring finger or the first dorsal metacarpal artery flap [154].
The indication for the palmar advancement flap is a distal, midpalmar defect of the thumb (Fig. 79) [155]. This flap has the advantage of bringing well-innervated palmar thumb skin distally to resurface the defect, thereby restoring nearly normal sensory perception with durable skin and subcutaneous tissue. To gain maximum length, Z-plasties, Burow triangles, or a proximal releasing incision at the base of the flap can be performed [148].
A defect of the entire palmar surface of the distal phalanx of the thumb can be covered with a conventional cross finger-to-thumb flap. This flap is reliable, but being a random pattern flap, it requires the attachment of the index finger to the thumb for 3 weeks with possible joint stiffness and thumb web contracture. An alternative method is the first dorsal metacarpal artery flap (Fig. 80) [155]. This flap incorporates the same donor site as the conventional cross finger flap, but through dissecting the first dorsal metacarpal artery to its origin, it is changed to an axial pattern flap. The sensate component is a terminal branch of the superficial radial nerve [156, 157].
4.13.2.2. Phalangization:
More proximal amputations involving the middle third of the thumb ray can be treated with phalangization as revealed in a study done by Winspur (1981) [158]. Kleinman & Strickland (1999) Simple Z-plasty and deepening of the web space can greatly enhance grasping ability [152]. More frequently, Emerson et al. (1996) reported that a double opposing type of right angle Z-plasty is needed to provide the required web deepening and apparent functional thumb lengthening. Release of part of the first interosseous muscle and proximal transfer of the insertion of the adductor pollicis can be added for additional length [159]. Phalangization as the only treatment is rare; it is frequently used as an adjunct to another technique for thumb reconstruction [148].
Figure (79): Drawing of a palmar advancement flap for the thumb [155].
Figure (80): Drawings of the first dorsal metacarpal artery flap [155].
4.13.2.3. Distraction Lengthening:
Distraction lengthening of the thumb metacarpal, as described by Matev (1980), can be used to distract bone and soft tissue to an appropriate length for functional restoration [160]. The osteotomy site is usually at the base of the first metacarpal. Mov et al. (1992) revealed that if any portion of the proximal phalanx is present, the metacarpal phalangeal joint should be pinned to prevent future flexion deformity [161]. Cobb et al. (1990) explained that the distraction apparatus is applied with the proximal and distal bony segments in contact. Gradual lengthening can start several days after osteotomy, and the metacarpal may be lengthened 1 to 1.5 mm daily. Once adequate length is achieved, corticocancellous bone grafting and internal fixation of the distracted gap are performed to provide more rapid healing, more stabilization, and quicker mobilization [162]. Lengthening of up to 4 cm has been described by Matev (1980) [160]. After distraction is completed, a Z-plasty of the first web space is normally required, because the apex of the web skin gets dragged out distally with the lengthening (Fig. 81) [155, 162].
Figure (81): A. A right hand after amputation of the thumb at the midlevel of the proximal phalanx. B. The right hand with the distraction apparatus in place. C. Anteroposterior and lateral radiographs of the first metacarpal, showing the result of distraction lengthening of 2 cm. D. Right and left hands in comparison. Notice that the patient wears a finger prosthesis attached to the previously lengthened thumb remnant [155].
4.13.2.4. Osteoplastic Thumb Reconstruction:
Osteoplastic thumb reconstruction was one of the preferred methods of reconstruction in the 1950s and 1960s, before microtechniques became popular. Osteoplastic thumb lengthening, which involves placement of a corticocancellous graft and coverage with a tubed pedicle flap (most often the groin or abdominal flap), can be used for very proximal amputations [149].
4.13.2.5. Prosthetic Replacement:
Prosthetic replacement of the thumb can be satisfactory in patients who have at least 1.5 cm of residual thumb (Fig. 81-D). Modern prosthetic designs provide excellent cosmesis and can be fabricated such that a stable post for light grasping is created [148].
Manurangsee et al. (2000) explained the development of the osseointegrated digital prosthesis which has advanced prosthesis design and function. The prosthesis attaches securely by means of an osseointegrated socket placed within the intramedullary canal of the residual bone of the amputated thumb. The prosthesis can deliver some tactile sensation because of its intimate association with the bone of the residual digit [163].
4.13.3. Microvascular techniques:
4.13.3.1. Pollicization:
Pollicization is a one-stage procedure that restores length, provides motion, and results in near-normal sensation, with acceptable deficits in function or appearance of the remainder of the hand [152, 164].
If no other rays are injured, either index or ring finger pollicization can provide good results [164, 165, 166].
In the post World War II era, there was a controversy as to which digit was best transferred. The French transferred the index finger or the ring finger, the German school favored the transfer of the middle finger and the United States predominantly used pollicization of the index finger. The current preference is to transpose the adjacent index finger, which is technically easier to transfer to the thumb position. If other rays are injured, a “spare parts” approach can be used. An injured digit can be used in the acute setting for immediate reconstruction of the thumb, or it can be “banked” for delayed reconstruction [148, 149].
4.13.3.2. Composite Free-Tissue Transfer
Morrison (1992) described the various sites of tissue for use in thumb reconstruction with good results, such as the first dorsal metacarpal artery island flap or the osteocutaneous radial forearm flap. The method of choice is the toe-to-thumb transfer [167].
Foucher & Binhammer (1995) reported that the possible options in that particular field are second toe transfer, twisted two toe transfer, and variations of the great toe transfer such as entire great toe transfer, trimmed toe, and wraparound toe flap [168].
The transplanted toe remains somewhat larger than the normal thumb but provides strong pinch and good motion. The great toe wraparound flap is ideal for the reconstruction of thumb amputations, which are just distal to midproximal phalanx level [169, 170].
The great toe is degloved except for a strip along the medial and distal aspect of the toe that is retained for donor-defect closure. The entire rest of the distal phalanx of the toe is then transferred to the amputation site. In addition, an intercalated bone graft segment is needed between the proximal phalanx of the thumb and the distal phalanx of the toe. The wraparound flap provides excellent cosmetic results but no motion at the former interphalangeal joint [148]. In 1988 Upton and Mutimer (modified toe) [171] and Wei et al. (trimmed toe) [172] used the same surgical approach to provide both acceptable cosmesis and joint motion. In this approach, the bone, nail plate, nail matrix, and soft-tissue pulp of the great toe are reviewed from the medial aspect of the toe to achieve an appropriate circumference of the reconstructed thumb (Fig. 82) [155].
Second toe transfer is performed less often (Fig. 83) [155]. Chung & Wei (2000) demonstrated that the transferred second toe is less satisfactory in appearance than the great toe or the wraparound procedure, provides less strength, and is more difficult in terms of harvest [173]. The twisted two toe transfer, as originally described by Foucher (1999), combines a partial transfer from the great toe (pulp, vascularized bone, and nail) and a compound joint from the second toe (bone, joint, and extensor mechanism) based on the same vascular bundle [174, 175]. This technique combines joint motion and excellent cosmesis of both the donor and recipient sites. The patient should be aware that the failure risk for free toe transfer has been quoted as high as 10 percent as reported by Lister (1983) [176].
Figure (82): A. A right hand after traumatic thumb amputation at the middle of the proximal phalanx. B. The design for a trimmed toe transfer. C. The donor site. D. The result after the trimmed toe transfer [155].
Figure (83): A. A left hand showing thumb amputation at the metacarpophalangeal joint level and malrotation of the index finger because of nonunion of the second metacarpal. B. The result after second toe transfer. C. The donor site after second toe harvest [155].
4.14. Alternatives to Finger Replantation
Wei et al. (1988) stated that second-toe transplantation is indicated in a hand in which all fingers have been lost and there is no ulnar post against which the thumb can oppose (fig. 84). In this situation, two second-toe transplants may further increase the grip strength and ability to manipulate objects in the hand [177].
When multiple fingers have been injured, but at least one or two digits remain as a post against which the thumb can oppose, the indications are less clear. Patients with either the long or ring fingers missing often have smaller objects fall through the gap during grasp. This disruption in the normal digital arcade is often unacceptable, especially in women [10].
Generally, Buncke (1989) preferred ray amputation and/or transposition, but occasionally, to preserve strength and the breadth of the palm, second-toe transplantation is performed [178].
Toes are particularly valuable in partial digital reconstruction because they are much shorter than fingers, and full digital length cannot be restored. The toenail is also considerably smaller than the fingernail, so even the best toe transplant, other than that of a large toe, will always appear smaller than adjacent normal digits. Additional nail length can be gained by cutting back on the proximal nail fold, exposing more of the nail plate. Patients can visualize what the final result will be by being shown the transplant on clay or plastic models [177].
Figure (84): All finger loss except the thumb. A & B. This patient lost all fingers except the thumb at the distal metacarpal level in a printing press. C. The entire second toe and the second metatarsal shaft plus a large skin flap have been removed as a unit to provide a digit on the ulnar side of the hand. D. The second toe with the metatarsal joint has successfully built up the ulnar side of the hand, providing a wide area for grasp. E. The elongated ulnar digit now opposes to the tip of the thumb, restoring tactile sensation and pinch or grip to the hand. F. The patient has developed strong tubular grip [177].
5. MATERIALS AND METHODS
The study was carried out as a systematic review. All possible available data on the results of digital replantation after traumatic finger amputation were collected.
5.1. Materials:
1. Papers published on the internet.
2. Literatures from orthopedic and microsurgical textbooks.
3. Published articles from orthopedic and microsurgical journals.
4. Unpublished data e.g. thesis…etc.
5.2. Search strategy:
PubMed and emedicine were searched - using standardized methodological filter for identifying trials - which represent the most famous scientific sites on the Internet.
The most famous journals and internet sites, which represent honest references to most of the orthopedic surgeons, were searched as:
• AO orthopedic journals (AOfoundation.com).
• Journal of bone and joint surgery (JBJS.org).
• American journal of orthopedics (AMJorthopedics.com).
• American academy of orthopedic surgery (AAOS.org).
• American Society for Surgery of the Hand.
• British Society for Surgery of the Hand.
• Microsurgeon.org.
• Microsurgeryusa.com.
• Annals of plastic surgery (annalsplasticsurgery.com)
• British journal of plastic surgery (journals.elsevierhealth.com)
Internet explorer 6 was used for searching different internet sites. Keywords for searching in electronic databases included “digital replantation”, “severed finger”, “digital amputation” and mutilating hand injuries”.
5.3. Time of the study research:
The studies to be searched those published after 1970.
5.4. Criteria for selecting those studies:
a. Initial screen to exclude studies not relevant to the review questions.
b. Second screen determines which of the relevant studies are strong enough and of the highest quality to be included in the systematic review to be as free from bias as possible.
5.5 Inclusion and exclusion criteria:
Most of the relevant studies were included and all studies not relevant to the review question were excluded using methods of critical appraisal.
5.6. Study preparation:
By the latest versions of Microsoft Word program in typing the essay.
5.7 Time table
o Preparation of protocol:
November 2006 – February 2007.
o Preparation of materials and internet search:
March 2007 – May 2007.
o Preparation of the essay and copy writing:
June 2007 – October 2007.
o Work design and coping:
October 2007 – January 2008.
5.8. Budget
o Internet search:
200 L.E paid by the candidate.
o Copy writing:
300 L.E paid by the candidate.
o Photocoping of materials:
500 L.E paid by the candidate.
o Preparation of the essay:
500 L.E paid by the candidate.
6. DISCUSSION
During the last years, several microsurgical centers around the world have reported impressive series of successful replantations with viability rates of more than 80 per cent [179, 180, 181]. So the aim of this study is to review the value of digital replantation after traumatic finger amputation during the last 35 years.
Most amputated parts can now be reattached and can remain viable. Survival, however, should not be equated with success in restoring useful function to the replanted part [20].
Overall success rates for replantation approach 80%. In reviewing large volume retrospective reports these success rates range from 54% in China’s Sixth People’s Hospital to 82% in North Carolina (Table 3) [182].
Table 3: Survival rates for replantations [182]
Author Number Survival rate
Tamai (1982) 157 80%
Kleinert (1980) 347 70%
Urbaniak (1979) 107 82%
Sixth People’s Hospital (1975) 320 54%
The 86 % survival rate for single digit replantation, as reported by Urbaniak et al. (1985), is comparable with that reported in other studies [183, 184]. The survival rate, however, was lower in children. In a recent review of limb replantations at all levels in children at the Duke University Medical Center, the survival rate was only 62 % [185]. The smaller blood-vessel size and the increased anxiety level in children most likely account for this lower survival rate. Anxiety incites peripheral vasospasm, which may result in insufficient digital perfusion [186, 187].
Tark et al. (1989) have determined the average replant to achieve 50% of normal function (ie, 50% total active motion and 50% grip strength) [188]. Russell et al. (1984) published the largest review of major limb replantations and found 11/24 achieved >50% total active motion and 19/24 achieved protective sensation, and 22/24 patients were satisfied with the function and appearance of their replanted part [73].
In eight patients with traumatic complete amputation of one or more digits in a study done by O’Brien & Miller (1973), microsurgical anastomosis of the arteries and veins was supplemented by the other procedures needed to re-establish the digit as a functional element nerve suture, tendon suture, skeletal fixation, and reconstructive surgical procedures as needed. Success was obtained in eleven of fourteen digits in which an attempt was made to reattach the digit. The essential elements in the successful outcomes were: surgery completed soon after the injury (within fourteen hours), cooling of the severed member prior to surgery, a careful meticulous postoperative regimen, including antibiotics, anticoagulants, and prompt re-intervention when signs of failure of vascular inadequacy arose, besides good surgical technique and measures of rehabilitation. [189]
Urbaniak et al. (1985) also revealed that fingers that had had two veins anastomosed had a significantly better chance of surviving than those that had had only one vein anastomosed. Fingers that had had two arteries anastomosed had a higher survival rate than those that had had only one artery anastomosed; however, this was not a statistically significant difference. Good vascular inflow and outflow are essential to survival of a finger. Experience in replantation surgery is important, and the organized replantation team has learned from its failures. This is reflected in the vastly improved survival rate (97 %) over the last two and one-half years of this study. Factors that did not affect survival were the gender of the patient, which finger was amputated. and the mechanism of amputation. This last factor is important. A crush-avulsion injury does not preclude survival of the finger, as 83 % of such fingers remained viable after replantation. A similar conclusion was reached in a recent review of more than 100 thumb replantations [20].
The mechanism of amputation is the most important factor determining the survival rate. In a study done by Amin et al. (1992), replantation of avulsed hand parts gave poor results (43.8% survival) whereas sharp cuts and local crushes yielded much better results (95.5% and 77.7% respectively) [52]. These results were agreed by O’Brien (2003) who stated that success rates are significantly higher for replantation of guillotine (77%) versus crush (49%) amputations [76]. Urbaniak et al. (1985) emphasized that the operating time was longer for replantation of crushed or avulsed fingers, as more debridement, dissection for isolating vessels, and use of vein grafts were needed in the difficult reconstructive procedures. Through the years, the replantation team has become more adept in the selection of patients for replantation. This knowledge, in part, accounts for the improved survival rates. However, in general, the ultimate decision is usually reserved until the digital vessels have been thoroughly examined with the operating microscope [20].
Factors influencing the active range of motion of a replanted digit include the mechanism of amputation, extent of soft tissue damage, quality of tissue coverage after operations, quality of repair of damaged structures and postoperative physiotherapy. Psychological motivation of the patient is also an important factor affecting the functional result after replantation [10].
Waikakul et al. (2000) noted significantly better mobility after incomplete amputations, when compared to complete amputations [190]. Replantation of distally amputated digits results in better functional outcome than after replantation of proximal replantations as reported by Urbaniak et al. (1985) and Waikakul et al. (2000) [20, 190]. Also Waikakul et al. (2000) added that tendon repair by proximal FDP with distal FDS suture resulted in better function of the finger; despite lack of movement of DIP joint [190].
Walaszek & Zyluk (2008) demonstrated that in a successful distal replantation, the digit immediately becomes functional as flexion of the middle phalanx by the intact FDS is possible [191].
The functional importance of the thumb is evident, even if its mobility is decreased. This was noted by Blomgren et al. (1998), who obtained the best functional results after replantation of thumbs [192], although the active range of motion of replanted/revascularized thumbs in the study done by Walaszek & Zyluk (2008) was only 19% of the active range of motion of the contralateral thumbs [191].
Urbaniak et al. (1985) reported an average active range of motion of 350 (13% of the contralateral digit) after single digit replantation at the level proximally to FDS insertion and a mean active range of 820 (30% of the contralateral digit) after replantation distal to FDS insertion [20]. Holmberg et al. (1996) reported a mean active range of motion of 84% of the active range of motion of healthy digits (24 patient, 39 replanted digits) [193]. In the Blomgren et al. (1998) study, the mean active range of motion of replanted digits amounted to 46% of the active range of motion of the contralateral digits, while that of replanted thumbs was only 19% of the active range of motion of the contralateral thumbs [192]. In the study done by Walaszek & Zyluk (2008), which included 64% complete amputations and 36% incomplete amputations, the average active range of motion of replanted digits amounted to 50% of the unaffected side. The average active range of motion of replanted thumbs was 560, index fingers 1330, middle fingers 1200, ring fingers 1240 and little fingers 1440 [191].
Holmberg et al. (1996) had a higher rate of incomplete amputations (35 of 39) when compared to the study of Walaszek & Zyluk (2008) (21 of 59). This may be the explanation for the mobility of fingers being better in the earlier study [193, 191].
Blomgren et al. (1998) reported strongest power grip after thumb replantation, with an average of 71% of the strength of the contralateral hand, whereas this measurement was only 25% after single or multiple finger replantations [192]. Holmberg et al. (1996) reported mean total grip strength of 72% of the power of the other hand and pinch grip strength of 69% of pinch grip in the healthy hand [193]. In the study of Walaszek & Zyluk (2008), the mean value of the total grip strength approached two thirds of the power of the healthy hand, and the mean value of the pinch grip strength in those cases with thumb, index and/or middle finger injuries amounted to half of the strength of pinch grip in the normal hand. The total grip strength of the hand with at least one replanted digit was affected both by the number of replanted digits and the number of missing digits. The worst results were noted in cases of multi-digital amputations when not all fingers were replanted. The best results were achieved in single digit replantations, particularly in those cases of successfully replanted thumbs [191].
Molski (2000) demonstrated the factors that influence recovery of sensation in replanted fingers which include the mechanism of injury, with better results from cuts than from crush injuries, length of nerve defect, quality of tissue cover and quality of nerve repair [194]. Waikakul et al. (2000) found that the longer the period of warm ischemia, the poorer the nerve regeneration in replanted fingers [189]. Molski (2000) reported a 2PD of 5 to 12 mm in nine of 11 fingers replanted at the level of middle and distal phalanx [194]. Interpreting the results of Lutz et al. (1997) and the Chen scale, 31 of 47 patients achieved a 2PD of 10 mm or less in only two of 23 replanted/revascularized fingers [195]. In the study of Walaszek & Zyluk (2008), a normal 2PD of 6 mm was achieved in only three of the 59 replanted/revascularized fingers. However, 33 of 59 digits had a 2PD of 10 m, which is considered satisfactory sensation. With regard to the monofilament test, 40 fingers had satisfactory feeling of light touch. Six fingers did not recover even protective sensation [191].
In general, approximately 50% achieve two-point discrimination (2 PD) less than 10 mm [6, 196]. Seventy percent of Tamai’s 228 replants achieved 2 PD <15 mm, whereas 65% of Larsen’s 142 replants attained 2 PD <10 mm. In general, younger patients with distal guillotine amputations experienced better return of sensation [6].
To assess functional results after replantation of fingers, the Carlsson’s questionnaire (table 4) [197] and Chen’s scale (table 5) [198] were commonly used. In the study of Walaszek & Zyluk (2008), 29 of 40 patients had a score more than 150 of a maximum score of 230, which indicates satisfactory hand functions and 11 patients had a score less than 150, indicating impaired function [191].
In their study, Holmberg et al. (1996) noted a mean Carlsson’s score of 186. The highest scores were ascribed to the questions concerning personal hygiene, driving a car and using a telephone, while the lowest scores were ascribed to questions relating to the exposure of the hand to cold. These authors noted a statistically significant correlation between Carlsson’s score and active range of motion of replanted/revascularized digits and total grip strength [193].
Chen’s classification of functional results is commonly used in the literature (table 5). It consists of five subscales which document the active range of motion of the replanted digits, grip strength, sensation, cold intolerance and return to work. Patients are classified into four grades according to the results obtained in each subscale. It is a mixed rather than a purely subjective or objective classification [198].
Table (4): Carlsson VAS scale of the influence of the injury on different hand functions [197]
No. Hand function or complaint
1. Overall function, work
2. Overall function, leisure
3. Brush teeth
4. Wash hands
5. Comb hair
6. Personal hygiene
7. Dress, stockings
8. Dress, shirt
9. Dress, pants
10. Dress, shoes
11. Use cutlery
12. Use drinking glass
13. Use door handle
14. Use door key
15. Drive car
16. Write
17. Fold paper
18. Use phone
19. Pain when cold
20. Pain at activity
21. Pain at night
22. People stare
23. I hide the hand
Table (5): The functional results after replantation as assessed by Chen’s classification [198]
Grade Return to work Active range of motion (%) Sensation Cold intolerance Grip strength
(5 grade scale)
I Same profession > 60 Normal 4 – 5
II Other profession 40 – 60 Satisfactory 3 – 4
III Not return to work 30 – 40 Protective Yes slight
IV The limb survived but is functionally severely disabled
But Walaszek & Zyluk (2008) noted that the Chen’s classification underestimated the value of the hand in the final grade. If, for example, one of five criteria was not met, then the hand was unrealistically downgraded. 31 of 40 patients returned to work, 22 to their previous occupation. However, not all patients who returned to their original profession could be assigned to the first grade because the replanted digit had less than 60% of the active range of motion of the contralateral finger or the patient complained of moderate cold intolerance. Four patients who returned to work in different profession were assigned to the third grade for the same reason [191].
Measurements of blood flow profile have only been performed in one previous study of patients many years after digital replantation or revascularization by Nylander et al. (1987). These authors assessed the patency of the anastomosed arteries in eight fingers at a mean of 20 months after replantation. Using Doppler ultrasound, they found mild stenosis in two digits [199]. Walaszek & Zyluk (2008) found undisturbed arterial blood flow in 28 of 38 digits and features of impaired microcirculation in four digits. Flow disturbances in these 10 digits did not affect their survival [191].
The phenomenon of cold intolerance is a common complaint reported by patients after digital replantation [188]. It is defined by Kay (1985) as an exaggerated or abnormal reaction to cold exposure of the injured part causing discomfort or avoidance of cold [200]. The symptoms and signs include pain, numbness, tingling, stiffness, weakness and discoloration (paleness or cyanosis) [199, 201]. Backman et al. (1991) reported that the nature and underlying mechanism remain obscure [202]. These symptoms are not only found among digital amputees and nerve injured patients, but is observed in a variety of post-traumatic and post-operative situations and may also appear in an uninjured digits in the affected hand as reported by Nylander et al. (1987) [199]. These symptoms have been defined as ”trauma induced cold associated symptoms” in an attempt to dispel the inconsistencies of nomenclature [191]. Holmberg et al. (1996), who assessed the dexterity with Carlsson’s questionnaire, noted that, for 24 of 39 patients, the most troublesome tasks were associated with cold exposure of the affected hand [193].
Elliot et al. (1997) investigated the problem of cold intolerance in patients with primary terminalisation, unsuccessful replantation and successful replantation. These authors also found that a similar proportion of patients complained of cold intolerance after finger terminalisation as after replantation. Therefore, they concluded, in this respect, that terminalisation is not a better alternative to replantation and is not a suitable treatment of cold intolerance, as is sometimes presumed [203].
Nystrom et al. (1991) also reported similar severity of cold intolerance expressed by patients with replanted and terminalised fingers. These authors suggest that the phenomenon seems to be primarily a sequel to the original injury and is only marginally affected by the method of surgical reconstruction. They claim also that cold intolerance may represent a greater cause of general disability of the hand than reduction of finger movement, grip strength and sensation. This is likely to be true in colder parts of the world [204].
Nylander et al. (1987) suggested that cold sensitivity after digital replantation is not caused by organic insufficiency of the circulation, but is, rather, related to a defect of vasoregulation as a result of the original injury [199].
Lutz et al. (1997) reported that nearly all their patients complained of cold sensitivity even many years after finger replantation. However, these authors noted that at a 10-year follow-up, these symptoms had tended to cease. Also other factors may affect cold intolerance, including local or seasonal temperature, smoking habits and the age of the patients [195].
In the study of Walaszek & Zyluk (2008), they noted relatively mild expressions of cold intolerance in the majority of patients. Only 11 patients experienced moderate symptoms, which did not affect the dexterity of the hand. Also, they noted a correlation between a disturbed microcirculation in four replanted fingers and a more severe cold intolerance, but, the number of patients was too small to make a definitive comment. The relationship between recovery of sensation and cold intolerance was also inconclusive; a statistically significant correlation was found between intensity of cold intolerance symptoms and the monofilament test results, but no correlation was found between intensity of cold intolerance and the 2PD test. These findings showed that the phenomenon of cold intolerance is not clearly related to better, or worse, nerve regeneration as previously suggested [191].
Scott et al. (1981) evaluated the functional results of 100 patients undergoing replantation and revascularization procedures. Secondary procedures were required for 80% of the replantation group for 49% of the revascularization group, with flexor tendon reconstruction being the most common procedure done with average increase of 560 of TAM for the replanted and 720 for revascularized fingers. In the replantation patients, the time off work averaged 4.4 months. Two-thirds returned to different jobs. In the revascularization group, this period was 3.9 months on the average. One third returned to different jobs. Return to employment did not correlate with the mechanism of injury or level of amputation, but depended largely upon patient motivation. It is the consensus that recovery of motion and tendon gliding are the most difficult and challenging aspects of rehabilitation following replantation or revascularization. Recovery of tendon gliding after replantation proximal to the MP joint is better than distally. Recovery of intrinsic muscle function is generally poor. Proximal interphalangeal motion appears to have the greatest limitation of motion, whether MP motion returns more readily, unless there has been an extensive joint injury. TAM as most significantly reduced for injury at the proximal phalangeal level (average 830), and PIP joint (average 950). Avulsion amputations resulted in the poorest TAM. The survival rate for the replanted units was 79% and for revascularized parts 97%. The average length of follow up was 15 months. The most common level of injury in both groups was the proximal phalanx in the fingers and thumb, with the third decade being the most common age of injury [205].
Jupiter et al. (1989) showed the function of replanted digits could be significantly improved with tenolysis procedures. In his review, the total active motion of 37 replanted digits was significantly improved (P < 0.001) with tenolysis and no digits were lost [206]. The patient in Fig. 85 underwent replantation of the middle and ring fingers after amputation in a log splitter. He went on to experience loss of active and passive flexion. To improve the socially unacceptable posture of his permanently extended middle finger, he required flexor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks. [6]
Figure (85): (A–K ) This patient underwent replantation of the middle and ring fingers after amputation in a log splitter. He went on to experience loss of active and passive flexion. To improve the socially unacceptable posture of his middle finger, he required flexor tenolysis, extensor tenolysis, and capsulotomy procedures. A median nerve catheter was used to provide the patient with better pain control postoperatively, for immediate active range of motion exercises. Postoperatively, he had full active range of motion at 6 weeks. [6]
Figure (85): Continued.
Figure (85): Continued.
Figure (85): Continued.
Also, regarding the TAM, Amin et al. (1992) reported that no excellent results were obtained (2200 or more). 80% had poor results (less than 1800) as regard the fingers. The TAM was not applicable to the thumb as a thumb with stiff IP or MP joints or both still will have a good function as long as the trapezio-metacarpal joint is intact. 72.2% of the thumbs had good function [52]. Scott et al. (1981) had an average replant TAM of 1200 (poor) only 6% of their patients [205]. There are several reasons for this reduced motion. All the complications associated with tendon healing exist. Because of extensor tendon repair and the fracture, one is unable to start immediate flexor dynamic motion and the resulting fibrosis encases all 3 elements in one mass that hinders tendon gliding. In many of these injuries the blood supply to the tenorrhaphy site may have been compromised leading to tendon disruption or elongation of the repair with adhesions to the surrounding tissues [52].
Replantation when indicated must be attempted. Morrison et al. (1977) reported the following: ”When one examine patients and thinks about what the patient’s condition would be if replantation were not done (provided the indication was correct), it is difficult not to be convinced that a service has been rendered, particularly because to date no prosthesis or reconstructive alternative is available” [207].
Regarding transportation of amputated parts, they are rinsed with normal saline to remove gross contamination, then wrapped in dry gauze, placed in dry plastic bag, and placed on ice as described by Buncke (2002) [10]. This is confirmed by Urbaniak (1982) who reported that the gauze and plastic prevent the tissue from coming into direct contact with the ice. This method is preferred to immersion or wrapping in a moist dressing to avoid maceration [65]. Also Buncke (2002) noticed that immersion in ice may cause cold injury to the part and dry ice is too cold and causes tissue damage [10].
Patkin (1975) stated that instruments for microsurgery should suit the operator as well as his task. Their design and selection can be based logically on a study of the human operator, his capacities and his limitations. In the selection and care of microsurgical instruments, the handgrip and instruments design and the more mechanical aspects of instruments and material are considered as they relate to the tissue being operated on and influence the work of the human operator [208]. This was matched with the opinion of O’Brien et al (1970) who defined the microsurgery as the practice of surgery on a scale of minuteness beyond normal unaided human capacities for detailed vision and manipulation. The three main interfaces to be considered are those of grip of instruments by the hand, the resistance of tissues to deformity and penetration, and relations already cited between instruments and materials. However, some attention must also be given to a fourth set of factors, the working environment, in particular some aspects of lighting and colour affecting visual perception [209]. But it was demonstrated by the British Standards institution (1964) that it is still too early for official standards for microsurgical instruments [210]. Patkin (1967) stated that for the finest work using 10/0 or 11/0 sutures, the closing pressure exerted by the fingertips should be about 50 g. This is checked easily with a postal scale, and perhaps more convincingly with sophisticated equipment such as a motorised Chatillon testing gauge [211].
Generally accepted indications for replantation as described by Smith (1986) include the thumb, amputations of multiple digits, or those through the palm or near the wrist [212]. Mutniowetz (1985) added that any amputation in a child should be replanted. Although the technical aspects of vascular repair are more difficult in children and success rates lower, the superior neurologic recovery exhibited, particularly by the young child, makes this effort worthwhile [213].
Smith (1986) emphasized that most patients report excellent levels of satisfaction with replanted thumbs. Significant stiffness at the interphalangeal and metacarpophalangeal joints does not hamper the thumb with an intact carpometacarpal articulation. Perhaps the most important reason for good function of the replanted thumb is that no completely satisfactory substitute for its function is available [212]. This was agreed by McPhee (1987) who applied the same considerations in the case of multiple digital replantations. Although the function of each individual digit may not be improved over that of a single digital replantation, the contribution of these fingers to overall hand function may be significant in the face of few or no remaining normal digits available for substitution. Certainly each additional digit in these cases, unless it is severely impaired, may add significantly to the width and strength of the hand [214]. Indications for replantation of a single digit, except the thumb, are more controversial [212]. However, in appropriately selected cases, with motivated cases, results can be excellent as demonstrated by Boulas (1998) [79].
McPhee (1987) stated the relative contraindications to replantation that include associated life-threatening injury or the presence of systemic disease, particularly any that would affect the patient’s vasculature or ability to withstand a prolonged surgical procedure. Factors pertaining to the injury itself, including severe crush or avulsion, gross contamination, the presence of injury at multiple levels, or excessive delay in treating the patient, may also make attempts at replantation inadvisable [214].
The recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits May (1986) reported a successful digit replantation after 39 hours of cold ischemia. [86] Then, Wei et al. (1988) reported successful digital replantations after 84, 86, and 94 hours of cold ischemia [87].
The order for repairing the various structures is individualized. The sequence of repairing the bone, extensor, veins, dorsal skin, artery, nerve, and flexor is preferred by O’Brien (1974) and others, as it efficiently allows for repairing all the dorsal structures before the volar structures [76]. Wilhelmi et al. (2003) reported that if the warm ischemia time is unusually long, the artery can be repaired earlier [6].
Regarding the technique of bony fixation, Amin et al. (1992) used one axial K-wire in fixing the bone in replantation because it is simple, rapid, does not entail much tissue dissection and it allows easy control of rotation of the distal fragment. Crossed K-wires were better avoided to guard against the potential risk of tethering of the neurovascular bundles [52].
Lister (1987) utilized intra-osseous wiring in addition to the axial K-wire to get better stabilization of the skeleton [94]. However, early motion could not be obtained in replantation in these cases and the technique is more complicated and it takes more time to perform than a single K-wire as noticed by Urbaniak et al. (1978) and Yamano (1982) [91, 215].
Amin et al. (1992) used vein grafts to bridge the gap between the vessel ends in cases of severe crush of a wide segment or extensive resection of the damaged vessels. It yielded a survival rate (60.9%) that is not much inferior to the general survival rate (66.7%) [52]. Wilhelmi et al. (2003) defined the potential vein graft harvest sites for distal digital replants include the palmar forearm and wrist. The wrist is preferred by many because the volar wrist veins match the digital vessels. The leg or contralateral arm may be used to harvest vein grafts for major replants of the hand, forearm, or multiple fingers, as they can be harvested by a second team simultaneously [6]. Beimer (1977) emphasized on the importance of reversing the vein grafts for arterial interposition because of the valves [108].
Klapheke (2000) reported that the immediate and long-term outcome of a mutilating hand injury can be positively influenced by health care professionals adopting a biopsychosocial perspective toward treatment and management [1]. This was emphasized by Meyer (2003) who demonstrated that such an injury produces a psychological and social impact that should be openly and candidly addressed with the injured individual and with the family. The earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome [141].
Microsurgical replantation of hand parts depends in Egypt on individual efforts. No organized service exists until now. This means that a microsurgical service can be denied to patients who find a worse functional outcome without it. The establishment of a microsurgical laboratory and the development of around the clock replantation surgeons are mandatory to give the best possible microsurgical service in Egypt. Replantation of amputated hand parts has become almost standardized in many parts of the world before the introduction of this discipline in Egypt many years ago [52].
Nowadays, there are two large microsurgery laboratories: first is Zagazig University Microsurgery Center and second is Assuit University Microsurgery Center. Both centers have achieved high success rates for digital replantation [216].
Replantation of amputated hand’s parts is a long, difficult and technically demanding procedure. However, it is very important as the functional result of the hand with surviving replanted fingers is much better than without them, provided one follows closely the indications for replantation. Also the hand appearance is important in everybody’s body image and restoration of the amputated parts means a lot from the esthetic point of view [52].
7. CONCLUSIONS AND SUMMARY
With the evolution of surgical techniques and scientific technology, replantation has become more refined, establishing specific indications for replantation, rituals for preparation, efficient techniques to ultimately minimize ischemia times, improved survival rates, guidelines for postoperative care, strategies for treating complications, and goals for outcomes.
Patient satisfaction hinges on their level of expectation as defined and explained in the preoperative discussion and informed consent. Studies have demonstrated patients can be expected to achieve 50% function and 50% sensation of the replanted part. Initially all that were amputated was replanted, as surgeons adopted the philosophy of George C. Ross (1843–1892): ‘‘Any fool can cut off an arm or leg but it takes a surgeon to save one.’’
Forty five years after the first replant (1962–2007), however, the ultimate goal was recognized: not merely to preserve all living tissue through nonselective replantation, but rather to preserve one’s quality of life by improving their function and appearance. This objective to care for the patient with the intent to optimize function and appearance is important not only to the replantation of amputations but to all mutilated hand injuries.
Thus, this study aimed to review the value of digital replantation after traumatic finger amputation during the last 35 years.
The successful survival rate of finger replantation was related to the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeon. Survival rates were not affected by the gender of the patient, which finger was amputated, or the mechanism of injury.
Instruments for microsurgery should suit the operator as well as his task. Their design and selection can be based logically on a study of the human operator, his capacities and his limitations.
Generally accepted indications for replantation include the thumb, amputations of multiple digits, or those through the palm or near the wrist and any amputation in a child.
The relative contraindications to replantation that include associated life-threatening injury or the presence of systemic disease, particularly any that would affect the patient’s vasculature or ability to withstand a prolonged surgical procedure. Factors pertaining to the injury itself, include severe crush or avulsion, gross contamination, the presence of injury at multiple levels, or excessive delay in treating the patient.
The recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits.
The order for repairing all the dorsal structures before the volar structures is preferred by many authors. But, if the warm ischemia time is unusually long, the artery can be repaired earlier.
The functional results of finger replantation were most dependent on the level of amputation. Replantation distal to the superficialis tendon insertion was not detrimental to the over-all function of the hand while replantation proximal to the insertion occasionally was. Complete ring avulsion injuries, whether distal or proximal to the superficialis insertion, generally compromised hand function.
There was significantly better mobility after incomplete amputations, when compared to complete amputations.
Factors that influence recovery of sensation in replanted fingers include the mechanism of injury, with better results from cuts than from crush injuries, length of nerve defect, quality of tissue cover and quality of nerve repair.
The phenomenon of cold intolerance is a common complaint reported by patients after digital replantation. It is defined as an exaggerated or abnormal reaction to cold exposure of the injured part causing discomfort or avoidance of cold. The symptoms and signs include pain, numbness, tingling, stiffness, weakness and discoloration (paleness or cyanosis). The nature and underlying mechanism remain obscure. But, it is suggested that cold sensitivity after digital replantation is not caused by organic insufficiency of the circulation, but is, rather, related to a defect of vasoregulation as a result of the original injury.
Such an injury produces a psychological and social impact that should be openly and candidly addressed with the injured individual and with the family. The earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome. The majority of patients considered the cosmetic appearance of the finger to be satisfactory.
In the future, transplantation of digits may be possible and would be welcome in small percentage of patients.
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