Principles of hand replantation with patient approach and surgery principles

1. Hand Replantation
Dr. Dagmawi Kelemu
R4
ALERT CENTER
January 2020
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2. Outline
• Introduction
• Prehospital care
• Timing of surgery
• Indications
• Contraindications
• Surgery
• Outcomes
• Summary
• References
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3. • Replantation is the reattachment of a severed
body part, with attempts to restore
neurovascular and musculoskeletal integrity,
function, and aesthetics.
• On September 7, 1964, the first extremity
replantation a completely amputated hand by
vascular anastomosis technique was
successfully performed.
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4. • Boston in 1962, Malt and McKhann
successfully replanted the completely
amputated arm of a 12-year-old boy.
• In 1968, Komatsu and Tamai of Japan
reported the first successful replantation of an
amputated digit by microvascular technique.
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6. • Replantation is the reattachment of a part
that has been completely amputated—no
connection exists between the severed part
and the patient.
• Revascularization is repair of a part that has
been incompletely amputated—some of the
soft tissue (e.g., skin, nerves, or tendons) is
intact
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7. • 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.
• replantation of a part that will not perform
useful activity should be avoided.
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8. • Injuries can arise from multiple potential
etiologies including
• trauma (often industrial),
• machine injuries,
• assault
• RTA
• or even self-mutilation
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9. • Trauma 77%
• Disease 8%
• Tumour 8%
• Congenital 9%
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10. • Majority of traumatic amputation victims 15 –
40
• 80% are male
• 10% upper body amputations are wrist &
hand
• 60% are transradial occuring below the elbow
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11. • guillotine-type amputations are ideal
candidates; however, this type of amputation
is uncommon.
• Most limbs are amputated by crushing or
avulsion injuries, which makes surgical repair
more difficult
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13. Indications
• One of the strongest indications for
replantation surgery in the upper extremity is
hand amputation at the level of the wrist
• studies have shown that in young patients,
• replantation success was highest with
guillotine amputations (94%)
• and lowest with avulsion injuries (74%)
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14. • The following are indications for replantation:
• Amputations in children
• Multiple finger and hand amputations
• Thumb
• Single finger injuries
• Ring avulsion injuries
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15. • Contraindications to replantation include:
• Severe crush injury
• Prolonged warm ischemia, especially of muscle
• Severe contamination
• Medical co-morbidities that can affect anesthesia,
healing, therapy or ability to cooperate with care
• Life threatening injuries
• Refusal to accept blood transfusions or blood
products in cases of major amputations
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16. Pre Hospital Care
• The amputated part, if completely detached from
the patient, should be wrapped in saline-soaked
sterile gauze, placed in a sealed plastic bag and
then onto ice.
• The bag should be labelled with the patient’s
details.
• No ice should come directly into contact with the
tissue, as this can cause a thermal injury.
• Saline rather than water should be used in order
to prevent tissue damage caused by hypo-
osmolarity
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17. • There are two methods of preserving the
amputated part:
• wrapping the part in gauze moistened with
lactated Ringer’s or saline solution and placing
the bundle in a specimen container or plastic bag,
which is then placed on ice,
• or (2) immersing the part in one of these
solutions in a plastic bag or specimen container
and placing the bag or container on ice
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18. Timing of Surgery
• If the warm ischemic time is greater than 6 hours
for an
• amputation proximal to the carpus or 12 hours
for the digits,
• replantation is not usually recommended. In
addition, if the
• cold ischemic time is greater than 12 hours for a
proximal
• amputation, replantation is not generally
performed.
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19. • The viability of the amputated part declines over
time, especially if it contains muscle.
• Cold ischemia refers to a part which has been
correctly stored at 5°C.
Part with muscle Part without muscle
• Warm ischaemic time 2 hrs 6
• Cold ischaemic time 12 24
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20. Pre Theater/ surgery
• Adequate resuscitation and treatment of other injuries takes place as
per ATLS guidelines.
• Bleeding from the stump should be controlled by direct pressure
and elevation alone.
• Attempting cautery or ligation of bleeding vessels carries a high risk
of damage to potentially valuable vessels needed for the
replantation,
• or indeed mistaking other structures such as nerves for the source of
bleeding.
• The patient should be cannulated on the contralateral limb or lower
limb and blood drawn for FBC, U&E, G&S and coagulation profile,
plus other tests as appropriate.
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22. • Tetanus booster if appropriate
• Commence broad spectrum antibiotics as per
guidelines
• ECG and CXR should only be performed if appropriate
for that patient.
• Both the stump and amputated parts should be x-rayed
in at least 2 planes
• (usually PA and lateral), with the digits fully extended
to allow an assessment of bony injury or bone loss.
• Clinical photographs should be taken
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24. • Theatre must be pre-warmed
• Operating table with hand table attached
• Tourniquet
• Operating microscope
• An operating microscope, preferably a diploscope with
magnification at least to 20×, is essential
• Mini C-arm
• Instruments
• Basic hand set
• Microvascular set with heparinised saline
• K-wiring and hand fracture plating sets
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25. Surgery
• replantation team divides into two subteams
in an effort to save time.
• One team transports the amputated part to
the operating room, where it is cleansed with
sterile lactated Ringer’s solution
• amputated part), is débrided carefully and the
nerves and vessels are identified and tagged
with small silver vascular clips (hemoclips
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26. • Appropriate bone trimming and shortening are
performed on the amputated part.
• Retrograde insertion of one or more
intramedullary Kirschner wires in the amputated
part is performed so that the part is ready for
immediate reattachment.
• Miniplates and miniscrews can be used if they
can be applied without damaging the dorsal veins
and soft tissue.
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27. • other team débrides the stump and identifies
and tags the nerves and vessels in a manner
similar to that used on the amputated part
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28. • order:
• Temporary arterial shunting in major
replantation. [Not necessary in parts without skeletal muscle]
• Osteosynthesis with or without shortening of
bone.
• Flexor tendon/muscle repair.
• Extensor tendon/muscle repair (this may be
deferred to just before venous repair so the
the hand does not need to be turned over and
turned back again).
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29. • Nerve repair.
• Arterial repair (with vein grafts if necessary).
• Venous repair (with vein grafts if necessary).
• Skin grafting or local flap if necessary.
• Microvascular transplant coverage of major
wounds if necessary after improved potential
part survival.
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30. • Dextran, 3,500 units, administer intravenously
• Intraoperatively
• Heparinised saline flush of vessels
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31. • patient post replantation requires a warmed
side room and intensive nursing care,
• This will be the case for the first 24-48 hours
while the initial successful reperfusion
becomes established.
• Inadequate nursing observations and input at this stage
jeopardise the success of surgery and
• replantation should not be offered in a centre that
cannot match the surgical expertise with appropriate
nursing support
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32. • kept on heparin, postoperatively for 7 days
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37. Summary
• Replantation is a limb saving procedure in
select and appropriate patients
• Surgeon and patient factor affect outcome
• 2 team approach is advised for better results
• Pre hospital care & transport is vital
• Post operative care is important for the
success
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38. References
• Greens operative hand surgery 6th
Edition[2011]
• NHS hand/digit replantation protocol
• Journal of plastic surgery
• Online atlas of microsurgery
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