Okay, I'll start with replantation for digital amputation. This is the clinical problem. Every case is completely different, and what you see here is that the initial surgery may take years of reconstructive surgery to deliver an optimal form and function. What makes it difficult? It's usually an emergency case late at night. It's a complex injury pattern, as I've shown in all of those pictures. Everyone's different. There are high expectations for the patient. These are long procedures that are technically challenging, and failure will be obvious. A black finger is hard to hide. What are the pitfalls of replantation? Well, sometimes you have unreasonable patient expectations. The patient may expect the amputated digit to be just like new. Many times you can have inadequate exposure and debridement, and this is something we'll harp on, that we should have good exposure. People stay in the zone of injury and then suffer as a result of that. There's poor setup and positioning, and finally, surgeon impatience and fatigue leads to shortcuts that you pay for dearly. We know these complications. A dying finger needs immediate take-back, a dead finger needs a completion amputation, and there's also an unstable finger, a stiff finger, and a worthless finger after much work. Okay, so this is my definition of microsurgical health. It's late at night, maybe 2 a.m., and you have an 8 a.m. clinic. You know you have 30 patients stacked up until noon, and there's multiple digits involved. As Joe Upton said, nothing happens good late at night. You're six hours into the case. You're sewing tiny veins in an awkward position. You're in the zone of injury. The tourniquet's let down, and blood is everywhere. You look in the microscope, and this is what you see. You're in microsurgical hell. We've all been there. So I'm going to give you some tricks to stay on top and head upwards. Here are the key anatomic points. One, remember that the digital nerves lie volar to the arteries, so it's an easy dissection to identify those nerves and then the arteries. The dorsal veins can be gently mobilized off the skin and off the extensor tendon to a nice plane. Bones may be shortened. The flexor tendon repair determines the eventual outcome, so take time with that. And then finally, the volar wrist veins are a good source of vein grafts as you need them. Remember, consent is essential. When I tell my patients in the emergency room, I tell them that replantation is an unnatural act, and we'll do everything we can to try to save that finger, but we may need completion amputation. Okay, so this is my surgical order for replantation. It's a little different than what's in the textbook sometimes, but you follow along. Yes, we tag in vessels and nerves. We debride. We shorten the bone. We fix the extensor tendons. We slow down. We fix the flexor tendons. Then we fix the nerves, the digital nerves, but then we do something a little different. We anastomose the veins while the tourniquet is still up, and then we anastomose the arteries. And I'll tell you why we do that. So we do the veins before the arteries. We anastomose the veins before the arteries while the tourniquet is still up. Why? Because it's a bloodless field still. I told you about microsurgical hell when you're trying to sew those little veins with three or four stitches, and there's bleeding everywhere. There's back pressure because all that blood has come back through the arterial system that you've already revascularized. So I find that it's easier to sew those fine veins in a clean field with the tourniquet still up. And then the beautiful part is you just close the skin, you turn the hand over, you do the arteries, and you're done. Of the papers I've written, this one seems to give the readers the most pleasure because it's a practical approach to replantation. First I'll take you step by step. So to explore and tag the vessels and nerves, a simple trick here is use different size hemoclips. Use a medium hemoclip for the nerve and a small hemoclip for the vessels. It makes it easy when you're under a microscope as those vessels and nerves have retracted into that fat to be able to match medium to medium, small to small. It's a simple little thing, but it saves you a little bit of trouble identifying under the microscope. Second, use a tally sheet. In this four-digit revascularization, you can see different structures are cut on each finger. So if you have a nice little tally sheet like this, it's simply the card that when you turn your gown and tie up, you save that little card, you mark it neatly like this, you itemize everything, and then you go structure by structure, and you go across those fingers, you fix all the flexor tendons, fix all the nerves, fix all the arteries, and then you have that, you take it off the field, you dictate from that, and then it's in the operative record because I guarantee you when that patient comes back ten days later to your clinic, you won't remember what you did for each finger if you don't have this carefully documented. To breathe widely and leave the zone of injury. We want to take shortcuts and just do a primary anastomosis, but many times you're better off doing a vein graft and taking a minute to, ten minutes, twenty minutes to do a vein graft and extra anastomosis than to stay in a zone of injury. So pick B always. Open and fix the bone as we know, this may obviate the need for a graft, and it may make that dorsal skin easier to close. Here's a little trick for protecting the nerves and arteries and veins you've just carefully identified. Take an S mark, cut a small piece, cut a tiny little hole in this, and then drape the bone over it, and then you have more room when you use your sagittal saw to shorten or a K-wire driver, etc. Our president, Neil Jones, showed me this trick in fellowship. 90-90 intraosseous wire fixation is great for replantation. Don't take the shortcut of just firing your K-wire through three joints to get that finger on because that'll slow down your post-operative rehabilitation for the flexor tendon. So this is a simple way of doing it for one joint and not crossing two to three different joints. Repair the extensor tendon. This is the quick part with two horizontal mattress sutures, and then you slow down. The feeling is you want to rush and do the flexor tendon to get to the good stuff, the arteries and the nerves under the microscope, but slow down because it's your flexor tendon repair that's going to determine your ultimate result, and I don't really care what kind you do. Something that you're comfortable with. This is what we do, the epitendinous first, but just make sure you slow down and take care to do that flexor tendon. Then you bring in the operating microscope. You repair the nerves here. You've matched the medium clip to the medium clip so you can easily repair the nerve. This is the easy part for us. And then instead of the arteries, repair the veins. Again, I'm harping on this because it's changed my practice. Repair the veins first. You're still in a bloodless field. You can identify everything. You can lengthen them. And then you actually close the dorsal skin with a couple of chromic sutures, and then you flip the hand over, let the tourniquet down at this point. Ensure good inflow. The point of this picture from scleroderma is to show that if you don't get good inflow at the point of the amputation, keep going more proximal. Until you have that blood spurting out, you don't have good inflow. And if you repair an artery, an asthmatic artery, and there's no good inflow to begin with, guess what? When you take the clamps off, you still probably won't have good inflow. And let me stop for a specific case of thumb amputation as shown here. We've all seen this common injury. And we know from anatomy that the ulnar digital artery is about three times as large as the radial digital artery. So we're always going to go to the ulnar digital artery in the thumb. And guess what? In order to access that in the thumb amputation, that hand has to be hypersupinated in a very awkward position. We've all been there trying to put four or five stitches in a distal anastomosis for a thumb replantation. So we stop doing that because we don't want to struggle. Instead, we proceed directly to vein grafting. Well, what does that mean? That means you actually take the part, you're on the back table, you take a vein from the foot, and you take a nice harvested vein, and you actually skewer that thumb part onto a stack of blue towels with the ulnar digital artery up. And you do that distal anastomosis in a very preserved and good position. And then you roll that vein graft up carefully. Then you do your bone fixation, et cetera, et cetera. You use an S-mark drape so it protects that vein graft. And then the last phase is to just do that nice anastomosis to the radial artery snuff box. We do this routinely straight off the bat. We don't even consider doing that ulnar digital artery deep repair because this makes it so much easier. I think if you spend half an hour to do this vein graft, you're better than doing two hours of redoing your anastomosis and then six hours of taking it back. Skin coverage is simply chromic sutures. Make sure you leave areas open. If you have an area there that you're worried about closing because you've just done a vein graft, then just simply put a skin graft on top of the vein graft. That's a very well vascularized bed for a skin graft. Pulse oximetry is all we use for monitoring. If the nurse says there's a waveform and it's 96% or above, you know you're good. This is a three-digit amputation in a child with three different pulse oximeters with all good readings. And lastly, good microsurgical technique is critical. And you want to do micro like this, without blood, without struggling, face up. So my final key points are avoid microsurgical hell. Get out of the zone of injury. Slow down when repairing the flexor tendons. Do the veins before letting the tourniquet down. Just try it. I think you'll really like it. Ensure great arterial inflow. And importantly, if you do the good surgery, it allows good early therapy. Thank you, and especially thank you to our kind radiologists who are always so helpful with the diagnosis. Thank you.

replantation

digital amputation

challenges

surgeons

surgical order