This document discusses various aspects of replantation surgery including: 1. It describes different types of amputation mechanisms and different levels of replantation from fingertips to major limbs. 2. It provides details on preoperative management, bench work to prepare tissues for repair, and the sequence of replanting arteries, veins, nerves, tendons, and skin closure. 3. Postoperative management focuses on monitoring for thrombosis, use of anticoagulants like aspirin and dextran, and rehabilitation through gentle range of motion exercises.

1. REPLANTATION
Dr Mujtuba Pervez Khan
Resident Plastic Surgery
DUHS/CHK

2. • Replantation vs Revascularization
(complete vs incomplete)
• Anatomical level
Major replantation (prox. to radiocarpal joint – ↑ systemic complications)

3. • Mechanism
1. Clean cut (Sharps, knife)
2. Blunt cut (Saw, fan blades, extends
limited distance prox./distal)
3. Crush (torn) – press machine, extends
significant distance prox./distal
4. Avulsion (torn) – rope, ring avulsion, bone
+ tendon preserved
5. Combined - initial incomplete crush
amputation by a machine followed by an
avulsion when the patient reflexively
withdraws the hand resulting in a complete
amputation

5. PRESERVATION

6. PRESERVATION
• Direct contact -> Frost bite
• For incomplete, nonviable amputations, the wound is wrapped in moist
gauze, dressed, splint applied to prevent kinking, and ice packs used to
surround the distal portion of the amputated part.

7. Pre-op Mx
• Life before limb
• Rule out associated injuries
• Resuscitate and stabilize
• Brief history (age, hand dominance, occupation, preexisting systemic
illness, allergies, and the mechanism of injury, history of smoking, alcohol or
drug dependence, psychiatric illness)
• Bleeding control (temporary tourniquet), pressure dressing, ligation
• Evaluation (indications/contraindications)
• Radiograph
• Blood test and cross match
• Prophylactic Abx

9. Operative MX
• 2 team approach
• Bench work
• G/A +/- regional anaesthesia pre/post op -> vasodilataion
• Catheterize

10. Sequence of steps
• B E F V A N
• Deep to superficial, more manipulating structures first
• Veins first
- ↓blood loss
- Difficult step first
• Artery first
- Easier selection of vein
- Bloody field
- Re-inflating tourniquet -> ↑ thrombosis
• Indications for artery first
1. Identifying vein 2. ↓ warm ischemia time

11. Bench work
• Wash
• Dissection on ice pack, mid lateral incision
for digits
• Preservation of nerve, artery, vein, skin,
bone graft from non replantable parts
• Debridement
• Damaged arteries often show separation of
the endothelial layer.

12. Bench work
• Stretch -> rupture of vasa vasorum ->
measles/paprika sign
• Avulsion -> ribbon sign
• Severe avulsion with disruption with
disruption of branches
• Replantation unsuccessful in these cases

13. Bench work
• Nerve for fascicles protruding from
the end of the cut nerve (snail eyes or
yeux d’escargot sign) that indicates a
repairable nerve.

14. Bench work
• Dissection for vein
• Thin dermo-epidermal flaps on the dorsum
and identify the veins in the subdermal fat.
• Thicker dorsal skin flap in a plane superficial
to the extensor tendon paratenon.
• Bone shortening is a key maneuvers to allow
primary repair
• It is preferable to shorten the bone in the
amputated part.This will maintain a greater
length of the stump and facilitate a
prosthesis should the replant fail.
• The extent of bone shortening is also
dictated by the proximity to the joint.

15. Stump preparation
• Debridement, tagging
• Positive spurt test – good vessel quality
• Poor outflow -> bath with 2%
lidocaine/papaverine to relieve vasospasm
• Still poor flow -> shorten vessel -> vein graft
• Bone fixation (k-wire, lister technique)
• Plating preferred for radius, ulna, humerus
• Intra articular wire loop for fractures close to
the joints (PIPJ)

16. • Tendon repair (4/0 horizontal mattress for extensors,
4/0 and 6/0 for core and epitendinous repair)
• Vein repair should exceed artery by one, 3 veins for 2
arteries
• Mobilization of the veins by dividing side branches or
dissecting a vein of sufficient length from the
dorsum of an adjacent digit will permit tension-free
primary repair
• ReverseVein graft, fill with heparinized saline
1. Corrects spasm 2. identify leaks 3. corrects twisting
4. lengthens the graft
• Venous flap

17. • Repair both arteries
• Ulnar digital artery dominant in thumb and
fingers except little finger
• If a primary repair is not possible, the
available options include vein graft, cross
anastomosis (radial digital artery to ulnar
digital artery or vice versa), or transposition
of a digital artery from one of the adjacent
fingers
• Nerve repair (primary/graft)
• Loosely approximate skin +/- grafts
• Prophylactic fasciotomy (thenar,
hypothenar, carpal tunnel, dorsal
interosseous spaces)
• Bulky non compressible dressing

18. Post Op MX
• Highest risk in 1st 72 hrs
• Arterial thrombi due to platelet aggregation on day 1
• Venous thrombi due to fibrin clotting by day 2 or 3
• Room is kept warm, maintain hydration
• Pain and anxiety can cause vasoconstriction
• Avoid smoking and caffeinated drinks

19. Post Op MX
• Anticoagulation: (1) decrease platelet function (e.g aspirin)
(2) increase blood flow or decrease blood viscosity (e.g., dextran)
(3) counteract the effect of thrombin on platelets and fibrinogen (e.g.
heparin).
Protocol:
• 100ml dextran 40 bolus IV before release of clamps
• 500ml dextran 40 for 5 days (10ml/kg/day)
• 5000 unit heparin after clamp removal
• Aspirin 100mg x OD for 3 weeks

20. Post Op MX
Monitoring: color, turgor, refill, temperature
• Pulse oxymetre: loss of the pulse rate indicates arterial occlusion, whereas a
fall in oxygen saturation below 90% indicates venous occlusion
• Thrombosis requiring re exploration will need vein graft
• If congested, remove nail plate, wedge excise nail bed and apply heparin
soaked gauzes
• Leech therapy, infection with aeromonas hydrophillia

21. Post Op MX
• Therapy: After 1 week, gentle active ROM
• Continued till 2-3 months, decision for secondary reconstruction

22. Fingertip replantation
• Warm ischemia time: 6-12 hrs, cold ischemia time:
up to 24 hrs

24. • If a suitable vein cannot be found, the options to prevent venous congestion
include
1. delayed venous repair (veins get engorged after 24 hours and may be easier to
find)
2. removal of a wedge of the nail bed, and application of heparin-soaked pledgets,
3. application of leeches
4. creation of an arteriovenous fistula between a distal artery and a proximal vein.
5. Pocket plasty
Nail bed stabilization
Fingertip replantation

25. Finger avulsion
• Recommended replantation with preserved PIPJ and FDS insertion
• Arthrodesis of DIPJ

26. Thumb Replantation
• Difficult to repair ulnar digital artery of thumb. Repair in pronation
• Vein graft anastomosis with the radial artery easier
• Avulsion injuries.Tendon transfer EIP -> EPL, FDS RF -> FPL

27. Multiple digits replantation
• Number of digits, position of fingers, order of repair
• Priority:Thumb, Middle finger, Ring finger
• Although the index finger restores pinch, it comes at the cost of a narrow
span and loss of grip strength
• Digit by digit, part by part sequence (faster, ↑ warm, ischemia time)

28. Transmetacarpal replantation
• The intrinsic muscles (interossei, lumbrical, thenar, and hypothenar) in the
amputated part are debrided -> 1. fibrotic mass 2. infection -> vascular
compromise
• 1 cm bone shortening
• Ligation of branches of deep palmar arch (DPA), prevents post op
hematoma
• Prophylactic decompression of carpal tunnel and guyons canal

29. Transmetacarpal replantation
• Zone A amputations, possible
to revascularize all the digits by
repair of the radial or ulnar
artery. Zone B amputations,
need to repair multiple
common digital vessels.
• Primary repair may be
possible. If not, the SPA can be
divided in the middle and
advanced distally to allow a
primary repair

30. Major limb replantation
• Technically easy
• Bone shortening (proximal row carpectomy, wrist arthrodesis, or shortening
osteotomy of the radius and resection of the ulna)
• Proximal forearm warm ischemia time 4-6 hrs
• Upper arm warm ischemia time 3-4 hrs
• Temporary vascular shunt
• Veins are allowed to bleed to prevent return of acidotic blood high in
potassium and lactic acid
• IV sodium bicarbonate given prior to release of clamps

31. thanks