All this information is in your handout. It's an exact copy of my slides. So refer to them as needed. I think I got this from you, Warren. Any replant talk has to begin with this statement. Any fool can cut off an arm or a leg, but it takes a surgeon to save one. So what I'm going to talk to you today is about indications. I'll take you through a replantation step by step and give you my pearls for success. Replants are not really tested that much in your exam. But nevertheless, there are some questions. I'll highlight those. But what this is about is how to make the operation easier for you that are lucky enough to be able to do them. So the definition of a replantation is a body part when it's completely severed. The definition of revascularization is an incompletely severed body part that needs to be reattached. Now, it could be through this tiny little skin bridge that's here. For all intents and purposes, it's the same exact operation. The difference is that you can unbundle the coating for the revascularization. And Dan is shaking his head over there like this. But with a replant, it's just one single coat. So for all intents, it's the same thing other than one coating when it's a replant versus revascularization. So the injury involves the blood vessels, nerves, bones, tendons, muscles, fat, subcutaneous tissues. And when you're getting ready to embark upon a patient that requires a replantation or you're evaluating a patient for replantation, you want to really consider the predicted morbidity to the patient, to expect the chance for replant survival, and the anticipated functional outcome, such as this little boy who had his thumb amputated who had his thumb amputated and ended up being a star football player. In patient selection, you want to look at the nature of the injury. This is actually critical. Is it a sharp injury? Is it an avulsion type injury? Is it a crush injury? What's the health of the patient? What's their physiological age? And what's their occupation? The images that you see on this slide are of a worker who cut off his thumb. Now, this is his non-dominant hand. For a laborer, the non-dominant thumb is really of prime importance. A replantation was critical for him to be able to do his job in the future. So the indications for replantation. This may be asked on your questions, on your exams. The thumb. The thumb is by far the best reconstructive option. The surgeon that trained me would always say, if you have a thumb amputation, you want to replant it. It's the Rolls-Royce of operations versus the reconstruction of the thumb, which is a U-go operation. So by far, the thumb is the best reconstructive option. The thumb replant is by far the best reconstructive option. The other indication of a replantation is multiple digits, transmetacarpal, or partial hands. Any body part in a child is considered to be replantable. That's usually a test question. The wrist and the forearm and single, sorry, and individual digits distal to the FDS insertion. So outside of our zone two, more distal to it. And some consider potentially the left ring finger to be an indication for replantation for wearing a wedding band. Relative contraindications to replantation are severe crush injuries, amputations at multiple levels, amputations on a multi-trauma patient whose life may be jeopardized if you proceed with replantation because they are unstable otherwise. Single digits proximal to the sublimus tendon, so zone two single digits is the number one contraindication or relative contraindication to replantation. Atherosclerotic vessels are considered to be a relative contraindications. I've done plenty of atherosclerotic vessels, and I haven't found any difficulty in doing replants in those patients. Mentally unstable patients and prolonged ischemia time. So let's get a show of hands. This is a transcarpal amputation at the proximal row. Just by a show of hands, who would think that this is an indication for replantation? So about half the audience. Well, based on my previous slide, it's an indication for amputation. However, when you look at this image, how many still think that it's an indication for replantation? And I see maybe no hands. And the reason that it's not an indication for replantation because this is an avulsion injury. You can see that the tendons are avulsed from the musculotendinous junction. You can see the nerves are avulsed. So this is not an indication for replantation. Similar to this patient who had his thumb avulsed, what you see on the right hand image are the tendons that are avulsed from the musculotendinous junction. And the other things which is called the whisker sign are the digital arteries and digital nerves. If you look closely, you'll also see the ribbon sign. That's when the vessel looks like a corkscrew. This is not an indication for replantation. And similar to the osteoplastic experience that Warren talked about and then Jamie followed up on, I embarked on discussion of the reconstructive options with him. Replantation was not an option that night. We agreed to proceed with second stage to toe transfer once he has recovered. However, he had a large soft tissue defect. The soft tissue defect initially needs to be recovered. So it needs to be covered. And the best coverage for that is a reversed radial forearm flap. And the reason that this is by far the best reconstructive option to temporize prior to toe transfer is that you're actually bringing the radial artery right to where you're going to do your toe transfer anastomosis. So it's really like cheating. He elected later on not to proceed with toe transfer. So again, based on the osteoplastic principles that we talked about, his first metacarpal was lengthened. The radial forearm was debulked. And the first web space was deepened with a Z-plasty. And this was his functional outcome, which was useful for him. So in preparation for replantation, one needs to get a form of consent. You really need to document a length of operation, failure rate, length of hospital stay, length of rehabilitation, and the realistic expectation of return sensation, motion, and return to work. Lately, unfortunately, I wrote a chapter on replantation and have become the target of attorneys. Not looking not for me, but they are looking to sue physicians that didn't do replantations on one of their patients. So I'm getting a request at least once a month now. So it's really important to document your thought processes on why or why not you proceeded with replantation and why, when you've proceeded with replantation, if it was not successful. Again, they're looking for excuses of why this wasn't replanted. The body part that's been amputated needs to be x-rayed, as does the proximal segment. Patients need to receive antibiotics, tetanus prophylaxis. And oftentimes, there has been not so insignificant amount of bleeding. So they should be warmed and rehydrated. I'd like to get an axillary block with an indwelling catheter. This takes off the sympathetic tone during your operation and also takes away the sympathetic tone in the post-operative setting and keeps the patient more comfortable. A Foley catheter needs to be applied, and these can be long operations. Because of that, it's really important when it behooves you to pad the patient yourself. I've had, unfortunately, two patients that have resulted in have had alopecia because the anesthesiologist didn't pad their scalp well enough during this prolonged operation. Preservation of the body part is really, really critical. I like the cold cloth method. And basically, this means you take the amputated segment, wrap it in a Moisten 4x4 or a lap pad, then place it in a watertight plastic bag, and that goes over ice. It's really critical not to submerge the replanted segment. And what you'll do is after a few times, if you do these enough, and if you haven't paid attention to it, when you look back, you'll see that the scrub nurse has put this directly on ice or directly submerged it in the ice. And then that gets a crystal injury, and it becomes really difficult to do that replantation. So I take personal responsibility for the amputated segment. I wrap it myself, and I indicate to the scrub nurses how to manage this and not to put it on their ice. What about the ischemia period? What is the indications and contraindications regarding the ischemia period? So warm ischemia period is considered six hours for proximal amputations and 12 hours for digits. The longest reported warm ischemia time has been 42 hours in digits. For cold ischemia time has been 12 hours is considered for the proximal segments and for the distal segment, sorry, and 24 hours for digits. Fuchan Wei reported a 94 hour cold ischemia time for digits and that were successful. I was trained by a European surgeon, and his thought process was if the amputation came in the middle of the night, the replantation wouldn't happen in the middle of the night. He would take it, put it in the refrigerator, and they would come in the next morning and do the replantation. They were successful, but for medical legal purposes, I don't think I would be comfortable in doing that in this environment. So the surgical technique, and this is a test question, it begins by generally locating and tagging the structures, debridement, shortening and fixation of the bone, repair of the tendons. You can start with the extensors or the flexors first. Then there's the vascular anastomosis, following by coaptation of the nerves, skin coverage, and then post-operative care. So basically, you're beginning from bottom up. You're doing the gross maneuver procedure, which is the bony fixation and the tendon repairs first, and then you move to the delicate neurovascular repairs. The two-team approach, if possible, is important. If you have the manpower to do that. So we have this thing at my institution, and I call it the mandatory anesthesia screw-around time. So once you know you're coming to the OR, it usually takes them, I don't know what they're doing for several hours before they can get them into the operating room. I actually usually come back to the operating room first before the patient even gets there. And on the back table, I prepare the segment. So once the patient comes in, half of the operation is done, all I have to do is I reattach it. And an aid that I found to be very useful on the back table prior to performing the actual surgery is this tongue stabilizer. So if you place the amputated segment, such as this thumb, onto a thumb stabilizer, you suture it, it gives you a nice platform and it doesn't go back and forth. You can bring the operative microscope in, and you can do your dissection under a bloodless field prior to the patient coming to the operating room. So the surgical technique usually proceeds by structures if it's a single replant, a single-digit replant. But if it's a multiple-digit replant, you go by structure by structure, not digit by digit. So if it's a five-finger replant, you wanna do the flexor tendons, you wanna do all bone fixations first, then the flexor tendons, then the extensor tendons. That keeps it, allows you to go faster. And I use a tally sheet. And the little scrub card you have in your gown, I usually take that and I make this tally sheet based on what I need to do. And I check off every structure as it goes along. And we've repaired it. These sometimes become long operations and you become tired. And oftentimes you can forget what you've done already, particularly in multiple-digit replants. And if you check it off, it really keeps you aligned on what's not been done and what needs to be done. The operation begins by debridement. This is a patient that required immediate or urgent revascularization. And I found that the pulse lavage is a useful tool for this. It can clean off the debris and then the revascularization can proceed. For exposures, mid-axial incisions are really the number one thing. The bruner incisions that we're used to for exposure of the other usual hand anatomy is not appropriate for replantations. The mid-lateral exposures really produce a nice view of the extensor tendons on the back, the dorsal veins on the back, and then on the palmar side, the nerve vascular structures. One of the first things that I do is I tag all the structures. I use microclips on the vessels. I use mini, sorry, I use small clips which are larger on the nerves. And then I put half-modified Kessler suture on the tendons. This actually helps you when you are dealt with a patient such as this. Multiple amputations, multiple fractures, a lot that needs to be done. This is a prolonged operation that cannot be done under a single tourniquet run. And once you put down that tourniquet, it can become a bloody mess. And although it sounds ridiculous at this time, it becomes really difficult sometimes to tell the difference between a nerve and a vessel. So if you've put the appropriate tags on, it allows you to find the structures faster. This case taught me a lesson, and I'll never forget to do that from here forward. Also in preparation, as soon as the patient comes to the operating room, I put on the tourniquet. I elevate the tourniquet without exsanguinating. And I mark the veins. You can see the veins marked. And in the top image, you see that there's a Y vein that's marked in the appropriate direction of flow. If you need these vein graphs, they're already marked for you. You don't have to go searching for it. And if you can find a Y vein in the top image that it's in the direction of flow will take away the need for doing one anastomosis. So you don't have to do that single anastomosis if you've done the Y vein. I actually like to do, if I'm thinking that this patient needs a vein graph, I'll do the vein graph first. So I'll do this on the back table under a bloodless field. You can see that in this image, a vein graph was placed on the thumb because I knew this was going to be a very difficult anastomosis. For the thumb, you're going to be standing on your head to try to do the operation. And if you do this, you can plug it into another vessel. And I'll show you about this a little bit later on. So the first line of fixation after debridement is osseous shortening. It's really important. You want to shorten about five to 10 millimeters to allow the anastomosis to be performed without tension. Veins under tension, arteries under tension, and nerves under tension is a death blow, particularly the vessels. That's almost a guarantee for failure. So appropriate tensioning gives the advantage of not having to vein graph, which saves time. And if a joint is involved that's not salvageable, I actually go ahead and fuse it, such as in this case. The soft tissue dissections are important when you're doing your osseous fixation. If anybody's ever experienced a K-wire wrapping around the digital vessels or the nerves, some people are shaking their heads, and you never want to see that. So if you put an Esmark tissue protector such as this, just put a little slit in the Esmark, pull it over the bones. This actually keeps all the soft tissues out of your way, and you can do your bony fixations without interference of the soft tissues. The methods of bony fixation varies. You can use single K-wires. I don't advocate that. Double intramedullary K-wires are certainly better because it prevents rotation. 90-90 interosseous wires can be used cross K-wires, intramedullary screws, or plate fixation. Plate fixation oftentimes is not possible for digit replants because it requires significant amount of soft tissue stripping. So my preferred techniques are one of the above. The 90-90 interosseous wire, that gives you a nice, rigid, stable construct that's fairly quick to do with little, if any, soft tissue dissection. The other one that's very quick to do, is as well as the Graham-Lister technique, such as this, which is a single crossed K-wire and an interosseous wire to provide a compression. And as I indicated, if a joint is involved that's not salvageable, go ahead and fuse it right off the bat. For major replants, you need major plates. And this was a case that major plate was not used. That arc is not the elbow. That arc is the mid-forearm because the wrong plate was used. This was a recon plate that was used. It bent, and unfortunately the patient ended up with a single bone forearm salvage of this procedure. You fix the bones, next comes the extensor tendons. In repairing the extensor tendons, it's important to pay attention to the lateral bands as this provides distal interphalangeal joint extension. Then come the flexor system. So I like to do the extensors first, then I move on to the flexors. And I would put before you that one of the key elements of replantation is your flexor tendon repair. Initially, you are judging the replant success as if the replant survives, right? If the vascularity is maintained. Later on, you're gonna judge your replant success by how much motion they have and how much sensation they have. And oftentimes, we don't pay enough attention to the repair of the extensor tendons or we try to do this very quickly. So we discussed the repair of the flexor tendons first. We've already discussed them today. Whatever technique you choose, do it well. I like the epitendinous suture first, followed by the modified Kessler suture and a core suture. For cases that the flexor tendons are too damaged, particularly with the saw blades. As you know, the saw blades have offset teeth and they have the carbide tips. The purpose of those is to shatter. They oftentimes destroy the tendons. And if I can't repair the tendons well, I actually go ahead and excise them and put a silicone rod in and I come back as a second stage to procedure and repair them later on. Next comes the arterial repair. And the important pearl, if I have to give you any, is when you're doing your arterial repair, bring the microscope in, place it on high-powered magnification, and begin serial resection of the intima. You want to resect back until the intima looks absolutely pristine. Otherwise, there's a chance for failure. And once you do your repair, you want no tension whatsoever. If there is any tension, I have a very, very low threshold of vein grafting. And the vein graft, such as this case that I showed you earlier, can be done earlier. It can, on the right-hand side, be plugged in directly into the anatomic snuff box. It's a quicker operation. You can place the vein grafts in the middle finger here as an interposition vein graft. Or you can do your repair based on what vessel is available to you, and the size and the caliber and the quality of it. So you can do an arterial shift procedure if one of the vessels does not meet the appropriate diameter and also health of a good vessel in asthmosis. This was used in such a case. One of the sides was not quite useful. We repaired it a few times and the vessel kept on going down. So I performed an arterial shift. It went from the ulnar side to the radial side, and that actually worked for the patient. For major replants of proximal limbs, it's important to revascularize first. So you're changing the order. You're not getting bony fixation first. So for major replants, particularly if they've been around six hours or more, you want to go ahead and revascularize first. And the way you revascularize them is by placing a vascular shunt. Carotid shunts can be used for this with vascular keeps that are placed. So in doing this, and this could be a test question, you want to do the shunt first and leave the veins open to drain while you get your osseous fixation done. And during this process where you've left the veins open to drain, obviously the toxic metabolites are coming out of the blood and you're having a fair amount of blood loss. So this has to be coordinated with your anesthesiologist to know that, to recess at the patient prior to performing the vascular shunt procedure. Then comes the nerve repair. You want to repair the nerves preferentially primarily, and you want to avoid tension. Objective way to see if there's too much tension or not is just by placing a single 8-0 or 9-0 nylon suture, as you can see in the bottom image. If you are able to place that suture in your epineurium and the nerve doesn't fall apart, doesn't pull apart, it's not under too much tension. If it is under too much tension, you can certainly use nerve grafts. The medial antebrachial cutaneous, lateral antebrachial cutaneous nerve grafts are excellent. And really one of my favorites is the posterior interosseous nerve in the dorsal aspect of the wrist. This is a perfect nerve graft for a digit replant. It's the exact size as the digital nerve. For larger ones, such as in the forearm, the sural nerve can be used. And if that's not possible, you can use some form of conduit. Initially, the vein conduits were described. I'm not a big fan of the vein conduits. I find that they collapse. I like the nerve tubes better, and I certainly like allograft that I use in the event that there's too much undue tension. Next comes the venous anastomosis. I like to do the venous anastomosis first, if possible. I think the venous anastomosis is the most difficult part of replantation, and it's the most problematic part of replant survival. This is, I think, potentially a test question. The most common reason why replants fail is because of venous congestion or adequate venous outflow. The veins have slower flow, so they have increased clots. They have thinner walls, so they're more difficult to repair and they have lower pressure within them, so they're really susceptible to compression. For every artery that I use, sorry, revascularize, I try to do two veins, and if possible, I do the veins first. This case, I did two vein grafts prior to the arteries, and the reason that you wanna try to do that first, if possible, is that it's a bloodless field, and you can do this very simply. If you can't see the veins, you can actually do the artery first, and sometimes the distal veins plump up to a point that you can see them. What happens if there are no veins, or the veins can't be repaired? A couple things can be done. One is an AV loop, so you repair the artery, and if there is no vein in the distal segment, you can connect one of the digital arteries into a dorsal vein in the proximal segment. The patient may feel a little thrilled, and there may be a tiny brui, but these actually do very well. You can try volar veins. I found difficult time doing volar veins. I found them to be too diminutive in size to try to do those as a replant. Or you can take off the nail plate, scrape up the nail bed, and keep putting heparin-soaked sponges on there to have the vessel drain, sorry, to have the digit and the drain. You can try intrapulp heparin. Some people place a stab of an 11 blade in the pulp and put 5,000 units of heparin in the pulp, or you can begin with a leaching. One of my partners, Roy Meals, advocates in taking off a small, full thickness part of the distal pulp and placing the skin graft, sorry, and placing the heparin-soaked sponges on top of that and not harming a perfectly good nail bed. So what about leaches? I think for replantation, this is your test arena. They've been asking these on self-assessment questions every year. The leaches carry a gram-negative rod in their saliva called the erymonas hydrophilum, and this can result in an infection rate of up to one-third of the patients. So test question becomes, what do you prophylax them with? The third-generation cephalosporin is the answer. And some people, for resistant species, you can try ceftriaxone. So third-generation cephalosporin for leach prophylaxis, and if that fails, cephalosporin. How do you get the leaches to attach? Well, there's the Azari SuperDuper high-tech leach guidance system. Of course, I'm joking, but this works. I'll never forget having to put leaches on and having a difficult time having them attach, and the ICU nurse is spending a lot of time in trying to put these on. So I found this little system to be very helpful. It's a three-cc syringe, a two-by-two gauze stuffed in it, and a Xeriform. I found that leaches don't like Xeriform. They want to go away from Xeriform. So the leach is put in there, and you put a drop of D50 on where you want it to attach, and they usually attach right away, and you don't have to go through a prolonged process of having them attach. So I actually teach the patients how to do this themselves. They do it. The nurses can do what they need to do, and it gives them a buy-in for their own care. They actually wash it. When it becomes congested, they'll put their own leach back on. Skin closure is really important. You've done this unbelievable microvascular procedure that's taken a long time to do, and then you want to do what we call a quote-unquote plastics closure at the end. Well, that's a death blow. You want to close your incisions really loosely, a few stitches here and there, and if there's any form of tension, you want to have it covered. You can cover it with skin flaps, skin grafts, or allograft. So these are two examples. The top right and left images are a piece of skin graft that were placed on for a wound that I found that had too much tension, and the bottom image is actually allograft, not a skin graft. Very thin allograft can be used. These incorporate beautifully and actually constrict in time, and you can hardly see it. This is a larger piece of allograft, and if you look at the dorsum of the hand, you'll see a large vein that the allograft was placed on. Jamie, I did this case with you. I don't know if you remember it. Finally, when the operation is done, you place your nerve block in. It continues for the next couple days. You want to put Xeriform on, and if you're putting the Xeriform on, don't do it circumferentially. Put it in strips. You want a bulky dressing and a splint, usually a volar splint for digit replants or a thumb-spica splint for thumb replants. Postoperative pain relief, as indicated, is with the axillary block. They should get appropriate analgesia. The hand should be elevated. I place them in a warming blanket. I don't like the room to be warmed too much. I think it's uncomfortable for the patient, but a warming blanket does the job. They have bed rest for the first few days, and then if there's any issues, you want to re-explore them early. The way you monitor the flaps with temperature, color, turgor, and Doppler signals, I find that to be a little bit confusing, particularly for the nurses that have to do it, so the better way of doing this is by placing a pulse oximeter. The pulse oximeter, you get an arterial waveform. If you get that waveform, you know the artery's working, and also you'll get a saturation that tells you whether the vein is working. If the pulse ox falls below 92%, you see that there is a vein compromise, and in fact, the patient, for my case, just leaves the operating room with two pulse oxes, one on the replanted digit, and another one on an adjacent digit, so the nurse, all they have to do is just compare the two pulse oxes, and if there's any discrepancy, they know something is changing. Anticoagulation, there is minimal empiric data as to what is beneficial. Most surgeons advocate something that may make us feel better. I personally like aspirin, and I give that at the time of the vascular anastomosis. Others don't. Complications earlier on are usually arterial within the first few days. Within the first zero to three days is usually an arterial injury or compromise. It can be because of positioning cast problems, blood clot formation or blood cast formation, or vasospasm, so keeping the extremity warm is important. If there's any issues, re-explore them early. Also venous outflow happens usually a little bit later on. That's also because of positioning and also tightness around the edematous digit. If there's any issues, you can begin topical heparin, leeches, or early exploration. So how long, if you have to leech, or if you have to bleed the patient, how long do you need to do that? There's only one study that addresses that, and it's somewhere around seven or eight days. It's hard to tell, but crush injuries typically take a little bit longer, and sharp amputations typically take less, but around seven or eight days is the time of the bleeding that you need to do before neovascularization occurs. Early complications include a compartment syndrome, metabolic disturbances and infection, and the late complications are virtually everything that you know about, including ruptures, poor sensation, and cold intolerance. A test question is, when would you advise the patient that the cold intolerance resolves? Well, it's typically around two years that they begin feeling better with a cold intolerance. I borrowed this from Nick Vetter because I love this image. It's a single-digit amputation in zone two, and they come in, please, doc, you have to do this, I need this digit, and you've done the digit, and the digit survives, but it's a triumph technology over coercion. This was a similar patient that, this is the image, probably around nine months after replantation, very useless hand, you can see the quadrigia effect in full force here. Ray resection, and this is what he is able to do just a few weeks after the operation. This is about a month after the operation. So, best outcomes are for thumbs, hands at the wrist, and single digits distal to the FDS. Zone two replants in a single digit oftentimes does not result in good functionality. These are demanding operations, yet gratifying, and I thank you for staying here this afternoon and your attention.

replantation

indications

surgical technique

post-operative care

thumb

reconstructive option

complications