Digit Replantation


Article Author:
Ryan Rebowe


Article Editor:
Shruti Tannan


Editors In Chief:
Ron Feller
Grant Goold
Kyle Cohen


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/10/2019 12:17:30 PM

Introduction

The focus of replantation of any part of the upper extremity is maximizing functional outcome rather than simple survival of the amputated part. Functional outcomes are dependent on anatomical characteristics of the injury as well as patient-specific factors. Anatomical considerations include the level of amputation and the degree injury to the arterial intima and other soft tissue structures. Other considerations must be given to patient factors such as age, occupation, and cultural significance attributed to the hands.[1][2][3][4]

Anatomy

The level of amputation is stated as related to the zone of flexor tendon injury. Zones of flexor tendon injury are labeled in relation to insertion of the flexor digitorum profundus, the level of the digital pulley system, and the location of the carpal tunnel. Zone 1 injuries comprise those injuries in which the transection occurs distal to the origin of the flexor digitorum superficialis tendon. Zone 2 injuries lie between the distal insertion of the flexor digitorum superficialis and the A1 pulley, located just proximal to the metacarpophalangeal joint. Zone 3 flexor tendon injuries and amputations occur between the A1 pulley and the distal edge of the carpal tunnel. Injuries through the carpal tunnel are referred to as Zone 4 injuries. Zone 5 amputations and flexor tendon injuries occur proximal to the carpal tunnel.

Zone I amputations involve only the flexor digitorum profundus tendon, leaving motion intact at the proximal interphalangeal joint (PIP). Amputations at this level portend a favorable outcome, however, if the amputation occurs at the distal aspect of the middle phalanx or past the distal interphalangeal joint (DIP) the small diameter of the digital vessels may preclude replant. Amputations at this level have classically had a very poor outcome due to the inability of the repair to pass between the complex digital pulley system. However, Zone 2 amputations are not absolute contraindications to replantation and should still be considered in the properly selected patient. In general, outcomes of replantation in Zones 3 to 5 depend on other patient and injury factors, such as ischemia time, mechanism of amputation and patient comorbidities, then on the level of amputation.[5][6][7]

Indications

General indications for upper extremity replantation are thumb amputation, multiple digit amputation, mid-palm (transmetacarpal) amputation, single-digit amputations distal to the insertion of the flexor digitorum superficialis tendon (Zone 1), sharp amputations at the hand, forearm, or elbow level, and any amputation in a child. Any patient that is transferred to a Level 1 trauma center or replant capable facility should be done after consultation with the hand surgeon at that facility to ensure the transfer is appropriate.[5]

Contraindications

General contraindications are severe crush or avulsion injuries, multiple level injuries, single finger amputation proximal to the insertion of the flexor digitorum superficialis tendon (proximal to Zone 1), prolonged ischemia time, and mentally or physically unstable patients. Patients with absolute contraindications to replantation do not need emergent transfer to a replant capable facility if their wounds can otherwise be managed at the facility of initial presentation.

Equipment

Digit replantation requires the use of an operating microscope as well as appropriate microsurgical instruments and suture. If this equipment is not readily available at the treating facility, the patient may need transfer to a facility with the proper resources.

Personnel

Any surgeon trained in microsurgical technique and hand replantation may perform digit replantation. This includes any attending orthopedic or plastic surgeon. However,  this procedure requires specialized equipment and personnel that are familiar with that equipment. These resources may not be available at all institutions. Orthopedic, plastic, or general surgeons with the Certificate of Added Qualifications (CAQ) in hand surgery are the best resources for performing replantation or referring to facilities where replantation is possible. 

Preparation

Handling of Amputated Extremity Parts

Transportation of the amputated part is paramount in preserving viability. The most widely utilized and effective method of preservation is wrapping the amputated extremity in gauze moistened with a physiologic solution (normal saline or lactated ringers), placing the wrapped amputated part in a plastic bag, then placing this plastic bag on ice. Alternatively, the part may be immersed in a physiologic solution in one bag which is then placed on ice. Amputated extremity parts should never be placed directly on ice, as this may cause frostbite or other soft tissue injuries to the amputated part. Such injury may preclude replantation altogether or compromise the achievable functional result of replantation.

Ischemia Time 

Timing is critical in replantation surgery. The amount of muscle in the amputated part determines the amount of ischemia time each part will tolerate. Digits contain no muscle, and the bone and soft tissue present in each digit have a relatively low metabolic rate and formation of toxic byproducts of ischemia. Therefore, digits amputated in Zone 1 and Zone 2 may tolerate up to 12 hours of warm ischemia time and up to 24 hours of cold ischemia time. In general, muscle makes up a substantial portion of the soft tissue in Zone 3 to 5 amputations. Extremities amputated at this level will tolerate no more than six hours of warm ischemia time or 12 hours of cold ischemia time. Because of this, vascular shunting to the amputated part may be necessary for forearm or elbow amputations before surgical repair may be initiated.

Technique

Sequence of Repair

When possible, the amputated part should be taken to the operating room before the patient for thorough debridement and examination under the microscope. The quality of the tissue, specifically the nerves and blood vessels, are examined before committing to the replantation. Identifiable structures should be tagged with suture or microclips. The first step in replantation is bone shortening and fixation. Bone should be shortened enough to take all tension off of the subsequent soft tissue repairs. In the pediatric population, any bony shortening should take care not to sacrifice the physis. Bony fixation is followed by extensor tendon then flexor tendon repair. Arterial repair should then be undertaken. No matter what the level of amputation, anastomosing intact and healthy arterial intima on each side of the repair is paramount to success. If this requires excessive debridement, vein grafts must be taken. Ample vein grafts are typically available from the ipsilateral extremity in the cephalic or basilic vein. However lower extremity vein grafts may be necessary. Nerve repair is then completed followed by vein repair. Lastly, soft tissue coverage of the repair is completed.[2][8][9][10]

In short:

  1. Bone
  2. Extensor Tendon
  3. Flexor Tendon
  4. Artery
  5. Nerve
  6. Vein
  7. Soft tissue

Complications

Complications of flexor tendon injury can include bleeding, infection, replant failure, and finger stiffness. Venous congestion of the finger is a common problem as anastomosis of damaged dorsal veins is often difficult. Various strategies to prevent or treat venous congestion exist, including removal of the nail plate, fishmouth incisions over the fingertip with heparin pledget application, or application of leeches. Any patient begun on leech therapy should also be placed on Ciprofloxacin therapy to prevent infection from Aeromonas hydrophilia.

Clinical Significance

If performed by an experienced hand and microsurgeon, viability rates of replants should be at least 80% following replantation. Motion at the affected joints depends on the level of amputation, mechanism of amputation, and compliance with postoperative therapy. Patients should be advised before surgery that the motion in replanted digits averages only approximately 50% of normal. Furthermore, patients undergoing replantation average ten days in the hospital and approximately seven months of time off of work. In general, the best results come from replantation of the thumb, hand, distal forearm, and fingers distal to the insertion of the flexor digitorum superficialis (Zone 1).

Enhancing Healthcare Team Outcomes

Digit reimplantation requires a multidisciplinary team that includes a hand surgeon, plastic surgeon, emergency department physician, and specialty trained nurses. Once the digit is reimplanted, close monitoring is required to ensure that there is no ischemia or infection. Following the surgery, patients require prolonged physical therapy to regain joint function and strength. While digit reimplantation does have success, the procedure does not work in everyone. [11][12][13]


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Digit Replantation - Questions

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A 22 year old welder with no past medical history is brought to the emergency department following a sharp amputation of his dominant right hand following an altercation. The amputated part was placed in saline soaked gauze, placed in a bag, and then the bag was placed on ice. The injury was sustained one hour ago. Plain film inspection of the hand and amputated part reveal amputation through the distal shaft of the middle phalanx. Physical exam reveals intact flexor digitorum superficialis. After inspection of the amputated part under the operating microscope, a decision is made to attempt replantation. What is the first repair that must be performed in the surgical sequence of replantation?



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A 15 year old boy with no past medical history is brought to the emergency department following sharp amputation of the dominant right thumb while hunting. The injury occurred 30 minutes prior to presenting to the emergency department. The amputated finger is in good condition and is with the patient. What is the best way to preserve the finger until replantation can be attempted?



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A 24 year old landscaper with no previous medical history presents to the emergency department for evaluation two hours following an injury to his non-dominant left hand. He reportedly amputated his index, long, and ring fingers sharply with a large machete. Physical examination and plain films of the affected hand reveals complete transverse amputation of the left hand index, long, and ring fingers through the mid portion of their proximal phalanges. At the time of injury, the amputated parts were placed in saline soaked gauze, placed in a bag, and then that bag was placed on ice. Which of the following factors is likely to contribute to a poor outcome of replanted digits in this patient?



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A 74 year old retired investment banker with hypertension, COPD, and stage III chronic kidney disease is brought to your emergency department by his son following an accident in his tool shed. The previous night, roughly 13 hours prior, he amputated his ring finger on his non-dominant left hand when he injured it with a skill saw. The examination at the emergency department reveals an amputation at the level of the proximal interphalangeal (PIP) joint with multi level soft tissue injury extending into the palm. Anteroposterior, lateral, and oblique plain films of the hand reveal a severely comminuted fracture through the head of the proximal phalanx and the base of the middle phalanx. The patient's son would like to know if you can salvage the amputated digit. Which of the following is the best next course of action?



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A 15 year old male with no medical problems presents to the emergency department for evaluation 2 hours after an amputation of his dominant right hand thumb and index finger. The amputated parts are transported to the emergency department after being wrapped in saline soaked gauze, placed in a bag, and the bag placed on ice. The patient reports that the fingers were crushed in a large farming machine when amputated. Physical exam, plain films of the hand, and plain films of the finger reveal an amputation just distal to the metacarpophalangeal joint of the thumb and at the distal aspect of the index finger middle phalanx. Flexor digitorum superficialis tendon of the index finger is intact on physical exam. A decision is made to attempt digit replantation. Which of the following is a relative contraindication to successful replantation in this patient?



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Digit Replantation - References

References

Shaterian A,Sayadi LR,Tiourin E,Gardner DJ,Evans GRD,Leis A, Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis. Hand (New York, N.Y.). 2019 Apr 2;     [PubMed]
Prsic A,Friedrich JB, Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit. Hand clinics. 2019 May;     [PubMed]
Cho HE,Kotsis SV,Chung KC, Outcomes Following Replantation/Revascularization in the Hand. Hand clinics. 2019 May;     [PubMed]
Lee DC,Kim JS,Roh SY,Lee KJ,Kim YW, Flap Coverage of Dysvascular Digits Including Venous Flow-Through Flaps. Hand clinics. 2019 May;     [PubMed]
Pet MA,Ko JH, Indications for Replantation and Revascularization in the Hand. Hand clinics. 2019 May;     [PubMed]
Long C,Suarez PA,Hernandez-Boussard T,Curtin C, Disparities in Access to Care Following Traumatic Digit Amputation. Hand (New York, N.Y.). 2019 Jan 31;     [PubMed]
Johnson SP,Drolet BC, Revascularization and Replantation in the Hand: Presurgical Preparation and Patient Transfer. Hand clinics. 2019 May;     [PubMed]
Milone MT,Klifto CS,Lee ZH,Thanik V,Hacquebord JH, Relationships Between Vein Repairs, Postoperative Transfusions, and Survival in Single Digit Replantation. Hand (New York, N.Y.). 2019 Feb 14;     [PubMed]
Shaterian A,Rajaii R,Kanack M,Evans GRD,Leis A, Predictors of Digit Survival following Replantation: Quantitative Review and Meta-Analysis. Journal of hand and microsurgery. 2018 Aug;     [PubMed]
Tang JB,Wang ZT,Chen J,Wong J, A Global View of Digital Replantation and Revascularization. Clinics in plastic surgery. 2017 Apr;     [PubMed]
Lee ZH,Cohen JM,Daar D,Anzai L,Hacquebord J,Thanik V, Quantifying outcomes for leech therapy in digit revascularization and replantation. The Journal of hand surgery, European volume. 2019 May;     [PubMed]
Cavadas PC,Rubí C,Thione A,Pérez-Espadero A, Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes. The Journal of hand surgery. 2018 Jul;     [PubMed]
Ngaage LM,Oni G,Buntic R,Malata CM,Buncke G, Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes. Journal of reconstructive microsurgery. 2018 May;     [PubMed]

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