Reimplantation and Reimplantation and microsurgical microsurgical

techniquestechniques

Reimplantation

Definition: Preserve and surgically reattach amputated extremity/digit

Aim: Restoration of function and cosmesis

Historical

Malt(1962): Massachusetts first reimplantation of severed arm

Chen (1962) Shanghai, China first hand reimplantation

Emerging microsurgical technology Kleinert (1966), revacularised thumb Komatsui(1968), thumb reimplantation

Factors related to outcome

Level of amputation: proximal v distal Mechanism of injury: Guillotine v crush Contamination of wound Age of patient Ischaemia time Delay to theatre Smoking/caffeine/diabetes Patient motivation/expectations/compliance

Level of amputation

Transhumeral, elbow, mid forearm most favourable outcome

Distal tip amputations fare worse

Thumb attempt at reimplantation/toe transfer

Level of amputation

Multiple digit loss-aim to have at least pincer grasp(thumb-index/middle)

Aim for power grip (ring/small)

May require autogenous salvage harvest from amputated extremity

Mechanism of injury

Sharp, clean, guillotine amputations most favourable outcome

Avulsions, crush injuries worse

Compounded by thermal, chemical injury

Age related factors

Children best outcome:though technical difficulty operatively.

Improved healing potential, better neuroplasticitySpontaneous neurotisation. Faivre(2003). France

Outcome less favourable with age/concomitant disease

Ischaemia time

Warm ischaemia time < 6hrs, but reports up to 20 hours Increased risk of systemic complications,

dependant on muscle mass, myonecrosis

Cold ischaemia temp, cooling to 40

Reports up to 30 hours preservation

Transportation

Physiological saline Moist swab Sterile container

preferable Placed on ice/water-

temp ~40

Digit functions

Thumb-post in pincer grasp

Index-with thumb, prehensile function

Ring and small-grip Loss index

tolerated,middle compensates

Indications-summary

Thumb amputations Multiple digits Any digit in child Wrist/forearm amputations Amputation distal to FDS insertion

Contraindications

Crushed, avulsed extremities/digits Amputations at multiple levels Amputations distal to DIPJ Arteriosclerotic disease Severely injured patients Mentally unstable patients

Surgical strategy

Wound debridement Identification and tagging of structures Shortening and Stabilisation of bone Flexor tendon repair Arterial anastomosis Nerve repair Extensor tendon repair Venous anastomosis Skin coverage/closure

Microsurgical techniques

Developed for the repair/anastomosis of small BV and nerves

Transfer of composite tissue grafts Loupe magnification –x5 Microscope-x16-40 Microsurgical instrumentation Microsurgical skill/experience

Immediate post op care

Well padded dressing, tips exposed Elevation Warm environment Analgesia Thrombolysis Regular 30 min circulatory assessment initially No tobacco smoke/caffeine

Vascular monitoring

Colour- Turgor Capillary refill Pulse oximetry Fluorescein – dermal fluroscanning

Failing replant-vascular compromise

Vasospasm- treat underlying cause

Arterial insufficiency:pale cold digit, treat with vascular recon

Venous engorgement-most common, either vascular recon or venous drainage.

Rehabilitation

Individualise to patient 5 anatomical ‘systems’ involved(skin,tendon,

nerve, vascular and bone) Splintage-dorsal blocking- after anticoagulation-

usually -day 5 post op Early protective motion and exercise 3/52-

Silvermann regime:J Hand Surg2:2 Apr-Jun 1989

Chen grading of recovery

Grade I- >60% recovery function. Gd4/5 above motor/sensory recovery.Full work

Grade 2->40% recovery motor/sensory grade ¾ above. Suitable work

Grade 3->30% recovery, Activities of daily living

Grade 4-no useful function of replanted limb

• Chen et al: World J Surg 2-513 (1978)

Results

Survival: variable results above elbow 60-80%, forearm, 40-60%. Digit: 80% adults

Function- Chen grading. 68% excellent/good outcome Largest study: Waikakul et al, Thailand

– 1018 replantations in 552 patients.(336m/186f)– Minimum 2 year FU– 92% ‘successful’ outcome– 69%- Chen I/II grades. 7% in gradeIV– Poor prognosis with type injury, smoking,prolonged

ischaemia• Injury 2000 Jan;31 (1):33-40

Composite free tissue transfer from foot

Foot versatile donor for tissue transfer Sural nerve nerve graft EDB /neurovascular pedicle First and second toe transfers Dorsalis pedis cutaneous/nv transfer First web space neurovascular transfer Other techniques(toe wrap,trimmed toe

transfer,twisted two toes, free vascular joint transfer)

Toe to thumb transfer

Most studies less than 10 patients

Tsubokawa et al (2003) Longest FU 10-22 yrs 80% grip strength

achieved Main problems: extension

lag, flexion contracture, early OA– J Hand Surg(Am).2003

May:28(3):443-7

Toe wrap technique

Harvesting of distal great toe with neurovascular pedicle and transfer

Harpf et al (2002) 5 male patients, no

complications. 2pd 8-15mm. 79% grip strength, 90% pinch grip– Harpf et al :Handchir

Mikrochir Plast. Chir.2002 Mar:34(2):95-102

Toe wrap technique-cont.

Free vascularised toe joint transfer to hand

Kimori et al: Hiroshima Hand and Microsurgery centre

12 patients Age range 7-47 Post op FU: 9-48 months Av ROM: PIPJ: 590 – MCPJ:540

No donor foot problem– J Hand Surg (Br).2001 Aug:26(4):314-20

Rehabilitation cont

Sensory relearning

Improvement of prehensile and power grip strength

Aim to get patient to working capacity again

Psychological counselling

Summary

Reimplantation successful procedure Careful pre-op assessment and case

selection required Outcome influenced many factors Importance of rehabilitation Aim to preserve function and cosmesis

Thank you