replantation

1. Replantation
“Restoring life to the lifeless extremity”
DR SAMIK SHARMA

2. • Replantation is the reattachment of a
completely amputated body part by
reestablishing arterial inflow and venous
outflow.
• Reattachment of incompletely amputated
parts (irrespective of the nature or amount of
tissue holding them together) is called
revascularization.

3. • The term revascularization should ideally be
restricted to incomplete amputations that
require restoration of both arterial inflow and
venous outflow.
• If the incomplete amputation needs only an
arterial repair for restoring circulation, the
correct term is critical arterial repair.

4. • Replantation cannot really be considered
successful, until function is restored
• Function is related to the adequacy of bone,
tendon, nerve, and skin repairs and the
postoperative rehabilitation.

5. HISTORY
• Balfour provided the first scientific report of
digital reattachment in 1814.
• He reported the successful reattachment of
the partial amputation of his son’s index, long,
and ring fingers at mid-distal phalanx
following a door crush injury.
• These reattachments were performed
without vascular anastomoses and most likely
survived as composite grafts

6. • Murphy in 1896 reported the first successful
critical arterial repair. He resected a femoral
pseudoaneurysm and performed an end-to-
end repair in a 29-year-old male 1 month after
a gunshot injury.

7. • Carrel performed the first extremity
replantation with vascular anastomosis in a
mid-femoral amputation of a dog hind limb in
1906.
• He won the Nobel Prize in 1912 for his
pioneering work on vascular anastomoses and
organ transplantation.

8. • Kleinert performed the first successful
extremity revascularization in 1958 , proximal
forearm level.
• 1962 – 1st arm replantation (Malt)
• 1965 – 1st digital replantation (Komatsu &
Tamai)

9. Classification of amputations
Completeness
of amputation
Anatomic level Mechanism of injury
•Complete
(Total) – needs
replantation
•Incomplete
(Subtotal /
Near total) –
needs
revascularizati
on
•Proximal to
radiocarpal jt. –
needs major
limb
replantation
(higher risk of
systemic
complications)
•Distal to
radiocarpal jt. –
flexor tendon
zones 1-4
•Clean-cut (sharp cut / guillotine) –
narrow sharp edge, needs minimal
debridement
•Blunt cut (dull cut) – narrow blunt
edge, moderate debridement
•Crush – broad blunt edge, extensive
debridement
•Avulsion (Traction / Degloving
caused by tight ring – ring avulsion) –
different levels of tissue separation
based on tensile strength
•Combined

10. Pathophysiology of ischemia
Ischemia
Tissue hypoxia
Anaerobic metabolism
↓ATP, ↑ Lactic a., ↑ Na+, Ca++ Chemical mediators (PLA2, Lysozymes)
Cell death

11. Pathophysiology of reperfusion
Reperfusion
ROS
Direct cell damage Complement, leukocyte adhesion
Cell death, ↑Vascular permeability
Systemic effect (Acidosis, Myoglobinuria,
Jaundice, Arrhythmia, MODS)

12. Prevention of reperfusion injury
• Hypothermia
• Interarterial flushing
• Ischemic preconditioning
• Antithrombotic agents
• Free-radical scavengers
• Leukocyte inhibitors
• Once arterial flow is established, the vein
should be allowed to bleed to eliminate ROS,
prior to establishing flow to the systemic
circulation

13. Transportation
• Stabilize patient
•Avoid direct contact
with ice
•Timely transport
•Digit cold ischemia
times in days
•Muscle ischemia
times 2hrs (normal),
6-9hrs (cold)

15. Replantation center criteria
• An efficient ground and air transportation system to transfer the
patient from the injury site or referring hospital to the replant
center
• Experienced microsurgical teams, able to work in shifts
• A well-prepared emergency room staff to stabilize and quickly
evaluate the patient with physical examination, X-rays, and
laboratory tests
• Experienced anesthetists, operating room, and microsurgical staff
available 24 hours/day, 7 days/week
• Proper microscopes, instruments, and sutures (min. 2 sets)
• A carefully trained nursing staff for postoperative care and
monitoring
• Physical and occupational therapists trained in post-replantation
rehabilitation
• Psychologists and social workers to help the patient cope with his
or her injuries and continue an active and useful life

16. Indications for replantation
Strong indications Relative indications
• Multiple digital amputations
• Thumb amputations
• Whole hand
• Transmetacarpal and partial
hand amputations
• Any amputated part in a
child
• Single digit amputation
distal to FDS insertion
• Sharp injuries at elbow or
proximal forearm
• Humeral-level amputations

17. Contraindications to replantation
Absolute Relative
•Life-
threatening
injuries
(Delayed
reimplantation
after 24hrs if
patient stable)
•Multiple
medical
problems
•Concomitant life-threatening injury
•Systemic illness (e.g., small-vessel disease)
•Poor anesthesia risk
•Mentally unstable patients
•Single finger proximal to FDS insertion in adults
•Multiple segmental injuries in the amputated part
•Severe crushing or avulsion of the tissues
•Extreme contamination
•Prior surgery or trauma to the amputated part
•Prolonged warm ischemia time
•Ribbon sign, red line sign
•Most index finger amputations

18. Relevant anatomy
Mid-lateral incision & raising a thick
dorsal skin flap superficial to extensor
tendons to expose the venous plexus

20. Operative sequence
Amputated part Patient Replantation
•Explore & identify
structures under loupe
magnification / op.
microscope
•Evaluate tissue loss &
level of amputation
•Tag NV structures
•Core tendon sutures
•Bone fixation
•Stabilization
•Anesthesia
•Catheterization &
warming
•Explore proximal
level of injury
•Bony fixation
•Tendon repair
•Artery repair
•Vein repair
•Nerve repair
•Closure

22. Bone fixation
Cross K Single Longitudinal K I-O & K wires 90-90 I-O wires
Intermedullary fixation Compression plate H-plate Lag screw

23. Bone fixation
Methods Advantages Disadvantages Indications
Skeletal
shorteni
ng
Secure bone
fixation, less need
for NV grafts
Longitud
inal K-
wire
Easy, rapid,
universally
available
No rigid fixation, rotation, go through
joint
Distal replants
(longitudinal
K-wire)
Need for rapid
fixation
Children
Cross K-
wire
Control of
rotation
Difficult in simple fracture
I-O wires Rigid fixation,
compression,
correct rotational
deformity prior to
tightening
Difficult
Plates Rigid fixation,
compression
Need for periosteal stripping (scarring, tendon
adhesion), lack of adjustability, time consuming

24. Tendon repair
• Extensor tendon  flexor tendon
• Dorsal epitendinous  Modified Kessler core
 volar epitendinous
• Preserve pulleys
• Zone 2 –
Guillotine amputation – FDS + FDP repair
Crush, avulsion – FDP stumpproximal FDS

25. Artery repair
• Adequate debridement, exclude
intimal flaps, red line / ribbon sign
 flush & irrigate with heparin
100u/ml  check flow  check
gap & assess need for vein graft 
anastomosis  post-op
anticoagulation
• Repair both digital a., prefer –
 Thumb, index, long finger – ulnar
digital a.
 Small finger – radial digital a.
• Vein graft – from thenar eminence,
distal volar forearm, dorsal foot,
GSV, SSV
Ribbon sign
– avulsion
of digital a.
Red line
sign –
disruption
of digital
a.
branches

26. Vein repair
• Small skin bridge in devascularized part
allow adequate venous outflow
• Complete amputation – needs vein
repair
• Repair after repair of one/both digital a.
• To gain additional length of dorsal veins
– divide interconnecting branches
• Other means of venous outflow
(applicable in more distal amputations)
– leeches, A-V anastomoses, nail plate
removal, heparin rubs, subcutaneous
heparin instillation, nail ablation,
dermal implantation

27. Nerve repair
• Goal – sensibility
Injury factors Patient factors Surgical factors
•Clean guillotine-
type injuries
allow primary
repair
•Bone shortening
will facilitate
primary repair
Factors
influencing nerve
recovery –
•Age
•Level of injury
•Mechanism of
injury
•Digital blood
flow
•Quality of
nerves
•Need for nerve
grafts / conduits
•Post-op sensory
re-education

28. Nerve repair
Nerve grafts Nerve conduits
Indications –
•For larger defects
•For motor & sensory nerve
defects
Donor nerves –
•PIN
•Median antebrachial cutaneous n.
•Sural n.
Advantages –
•Sural n. fascicles match digital
nerve topology
Indications –
•For defects < 2cm
•For sensory nerve defects
Conduit materials –
•Segments of vein
•Collagen
•Silicone
•Gore-Tex
•Polyester
•Polyglycolide
Disadvantages –
•Rigid conduits
•Impede motion over joint
•Risk of skin erosion

29. Skin closure
• Avoid constriction of arterial inflow / venous
outflow
• STSG if necessary
• Venous flowthrough flap –
Indication – skin deficit with artery defect
Supply – digital a.
Technique – Harvest skin flap from distal I/L volar
forearm centered over a vein  vein is reversed &
used to bridge arterial defect  skin island covers
skin defect

30. Thumb replantation
• There is considerable
variation in the
anatomy of the digital
arteries of the thumb
proximal to the
metacarpophalangeal
joint as the vessels dive
deeper to pass below
the thenar muscle
insertions.

31. • Positioning the thumb to repair the dominant
ulnar digital artery is also challenging.
– One way is to pronate the forearm and repair the
ulnar digital artery hand by viewing it through the
first web space.
– Its easier to use a vein graft to connect the distal
ulnar digital artery to the radial artery in the
anatomical snuffbox.

32. Multiple digits replantation
• Time factor – 3-4hrs/digit
• As many digits as possible – replanted
• Digit with best chance of function replanted first
• Ulnar digits (ring & little) replantation emphasized for
optimal hand closure & good grip
• Need for opposable thumb, satisfactory 1st web space,
stable wrist, min. 2 fingers – heterotrophic
replantation (e.g., amputated index replanted to
thumb stump – microvascular pollicization)
• Need for functional MCP jt. – heterotrophic transfer of
digit amputated through MCP jt. to another ray with a
functional MCP jt.

33. Transmetacarpal replantation
Loda classification
Zones Description Revascularization General measures
A Proximal to SPA Repair of ulnar / radial a. •Intrinsic ms. In amputated part debrided
•Bone shortening by 1cm
•Ligate all br. of deep palmar arch & deep
palmar MC arteries
•Carpal tunnel & Guyon’s canal
decompressed
B Distal to SPA •Multiple common
digital vs. repair
•SPA can be divided &
advanced distally

34. Proximal
amputations
• Technically easier
• Time constraint
because of muscle –
12hrs cold
ischemia, 6hrs
warm ischemia
• Injury around level
of palmar arch –
arterial graft /
reverse “Y” vein
graft to
revascularize
multiple common
digital arteries

35. Silicone temporary vascular stent is used in major limb replantation
prior to bone fixation if ischemia time is prolonged

36. Distal amputations
• Distal to DIP jt.
• Ishikawa & Tamai classification Tamai
Ishikawa
Base of nail
DIPJ
Midway b/n tip & nail base
Midway b/n nail base & DIPJ
Zone I amputation (Distal to FDS
insertion)
Zone I distal (distal
to FDP insertion /
root / nail bed)
Zone I proximal
(b/n FDP & FDS
insertions
Zone IA
(Distal
to
lunula,
through
sterile
matrix)
Zone IB
(b/n
lunula &
root of
nail
bed,
through
germina
l matrix
Zone IC
(b/n
FDP
insertio
n &
neck of
middle
phalanx,
periartic
ular
Zone ID
(b/n
neck of
middle
phalanx
& FDS
insertio
n)
Z
O
N
E
IA
Z
O
N
E
IB
Zone IC

37. Distal amputations
Arterial repair Venous outflow
•Transfer of digital
a. from adjacent
digit
•Step-down
arterial graft
•Temporary
intravascular
stenting with 4-0,
6-0
monofilament,
anastomosis with
11-0, 12-0 
remove stent
•Repairing volar veins
•Temporary venous outflow till collateral circulation
develops
1. Medicinal leeches under antibiotic coverage (3rd
gen. cephalosporins / AMG) against Aeromonas
sp (apply for 10-40mins, can reapply after 4hrs if
needed)
2. Removal of distal nail plate & mechanical
rubbing of sterile matrix, heparin soaked
dressing repeat hourly
3. S.C. heparin (1000u in 0.1ml saline) in fingertip
4. S.C. pocketing of de-epithelialized pulp of distal
replantation into palm / thenar crease for 7days
 detach

38. Digital avulsion injuries
Kay’s modification of Urbaniak’s classification (further modified by Adani)
Class Description Treatment
I Circulation adequate No microvascular surgery
II Circulation inadequate, no skeletal injury Repair
a – Arterial circulation inadequate only
v – Venous circulation inadequate only
av – Arterial & Venous circulation inadequate
III Circulation inadequate, skeletal injury DIP fusion / bone
shortening  Arterial
bypass / Vein grafts / artery
from adjacent digit 
Venous repair  Nerve
repair closure (direct /
skin graft / venous flap)
a – Arterial circulation inadequate only
v – Venous circulation inadequate only
av – Arterial & Venous circulation inadequate
IV Complete amputation / degloving
IVp – Proximal to FDS insertion
IVd – Distal to FDS insertion

39. Pocket-plasty

40. Digital avulsion injuries

41. Ectopic replantation / transplantation
• Godina (1983) – transferred amputated hand to
axilla  replanted to forearm after 65dys
• Indications –
 Contaminated injury
Multilevel injury
Need for soft tissue coverage
• Relevant situations – Amputation of fingers,
thumbs, ears, penises, scalps
• Recipient vessels – thoracodorsal, DIE, SIE, Radial,
Dorsalis pedis

42. Ectopic replantation / transplantation
• Steps – Adequate debridement of amputated
part  Selection of ectopic site outside zone
of injury  Transplant amputated part at
ectopic site anastomosing an artery & a vein
 Transfer amputated part along with skin
paddle & soft tissues to stump site as pedicled
flap / free flap after 8-12wks

43. Post-op care
• Anticoagulation
• Post-op monitoring
• Post-op therapy
• Psychosocial aspects

44. Anticoagulation
Pre-op Intra-op Post-op
Aspirin
10hrs
before
surgery
•Heparin (100u/ml)
irrigation
•Heparin bolus of 50–
100 units/kg before
release of
microvascular clamp
•Continuous brachial block
•Dextran40 0.4 cc/kg/hr for
2 days, then 0.2 cc/kg/hr on
day 3 & 4, weaning on day 5
•Loading dose of aspirin,
1.4 mg/kg (100 mg in a 70-
kg adult) f/b aspirin 1.4
mg/kg/day for 2 days
•Aspirin 325mg/d for 1mo
•LMWH 40mg/d s.c. for
2wks

45. Post-op monitoring
Parameters Normal
circulation
Venous
occlusion
Arterial
occlusion
Color Pink Blue/ Purple,
Cyanotic
Pale, mottled
Capillary refill
time
1-2sec <1sec >2secs
Temperature Warm Warm-cool Cold
Turgor Full Distended,
swollen
Hollow
Dermal bleeding Bright red Dark red /
bluish, bleeds
briskly
Minimal
bleeding, only
serum
Other aids Pulse oximetry, Doppler, Digital thermometry

46. Post-op therapy
• Gentle range of motion at non-affected joints
 Post-op D5-7 dressing changes, passive
splint
• Neurovascular repairs – protected for 3-4wks
• Tendon therapy – early active & passive
mobilization if rigid bone fixation &
multistrand tendon repair  full ROM after 6-
8wks
• Sensory re-education

47. Factors influencing outcome
• Mechanism of injury – crush/avulsion or clean
• Total no. of anastomosed vessels
• Cigarette smoking

48. Chen classification of functional results
Grade Return to
work
Active
ROM (%)
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
returned
to work
30-40 Protective Yes Slight
IV The limb survived, but is functionally severy disabled

49. Complications
Immediate Long term
Anastomotic failure •Cold intolerance
•Functional disability

50. Secondary procedures
Immediate Late
Re-exploration related
to vascular
anastomosis & skin
closure
Procedures related to
bony non-union or
tendon adhesions