Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

FIGURE 83.6 Various fixation methods of phalangeal bone fractures in digital replantation. A. Cross K-wire fixation for
arthrodesis of the interphalangeal joint. B. Single longitudinal K-wire fixation. C. Intraosseous 90-90 wiring technique. D.
Miniplate fixation with screws. E. Double-screw fixation. F. Cross K-wire fixation. G. Intraosseous wiring and additional K-wire
fixation. H. Implant arthroplasty for metacarpophalangeal joint reconstruction.
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Tendon Repair
Before extensor tendon repair, dorsal periosteum should be sutured with 5-0 absorbable sutures when
possible. Repaired periosteum can provide a smooth gliding surface for the tendons and also will cover
any exposed wires or metal plates following bone fixation. In zone 1 and zone 2 injuries, extensor repairs
are performed with running 5-0 nonabsorbable sutures. For zone 3 or 4 extensor tendon repairs, a
modified 4-0 Kessler suture is used with 5-0 or 6-0 running epitendinous suture. A Silfverskiöld cross-
stitch epitendinous repair may be useful. In amputations at the proximal phalanx, repair of the lateral
bands of the extensor tendon is essential to achieve appropriate extension of the distal joints.
Depending on the surgeon’s preference, for flexor tendon repair, a four-strand or more core suture
technique with 4-0 nonabsorbable suture is sufficiently strong to provide early rehabilitation. Repairing
the proximal FDP to distal FDS tendon is an available option to get flexion in cases of significant injury to
the substance of the distal FDP. However, in zone 2 injuries, repair of only the FDP tendon may be
undertaken to avoid adhesions between the FDS and FDP tendon suture lines. Currently, repairing the
FDS tendon is not mandatory because it simplifies surgery and makes postoperative finger motion easier.
Venting the sheath or pulley for a total of 1.5 cm in the areas close to the amputation level should be done
to allow smooth gliding of the repaired tendon (Figure 83.7).
FIGURE 83.7 A. After resection of flexor digitorum sublimis, flexor digitorum profundus is retracted with 4-0 Prolene suture. B.
Distal half of the A2 pulley is vented to allow smooth gliding of the repaired tendon. C. Flexor digitorum profundus tendon is
repaired with Tang method.
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Vessel Repair
The order of vessel repair depends on the amputation level, delayed ischemic time, and also the
surgeons’ preferences. In most digital replantations, performing arterial repair first decreases ischemic
time and allows the dorsal veins to fill, aiding in the identification of small and friable veins. Even in
cases of more proximal amputation containing more muscle, and in cases where considerable time has
passed since amputation, arterial anastomosis should precede vein repair.
Adequate resection of the proximal vessel is verified by checking for blood spurt strength from the cut
end. Gentle dilation and irrigation of the cut ends of the artery helps to clear the field of thrombogenic
material. Irrigation with heparinized solution at a concentration of 100 units/mL should be under
80 mm Hg of pressure, sufficient to remove clots and avoid damage to the endothelium. Weak spurting
and persistent spasm indicates a damaged proximal artery and the artery should be resected back further
until pulsatile flow is obtained.
If the digital arteries can be approximated under minimal tension using a microvascular clamp, direct
end-to-end anastomosis is performed using interrupted 9-0 or 10-0 nylon sutures or 11-0 sutures for very
distal replantation. In cases of excessive tension or a definite segmental gap between the proximal and
distal ends of the artery, interposition vein graft or shifting artery from the undamaged adjacent artery of
the same or another finger is necessary (Figure 83.8A). The use of vein grafts is not as time consuming as
much as commonly thought and is a straightforward and reliable technique. Rather than struggling to
shorten the bones substantially and to repair the vessels under tension, it is more expedient to harvest the
vein graft early in the operation and bypass the crushed vessels. Depending on the amputation level,
selection of donor sites of the vein graft is important to minimize the discrepancy of diameter between the
vein graft and the artery. Vein grafts can be easily obtained from the volar aspect of the proximal
phalanx, thenar area, and the volar wrist (most readily available source) depending on the length and
vessel diameter. To match the arterial defect, measuring the length of vein graft in situ before division is
probably the best way to avoid making it too short or long.
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FIGURE 83.8 A. Techniques of bridging segmental defects in the digital arteries. B. Dividing venous branches will allow
mobilization and primary repair of veins (black line, ligation or clipping; dotted line, cut the vein).
If the digit or hand does not become pink even after arterial microanastomosis, there are several possible
reasons besides technical errors. Arterial thrombosis or spasm is caused by tension on the anastomosis or
excessive handling of the intima. Several factors besides vessel condition can affect blood flow to the
amputated part including the patient’s temperature, the patient’s hydration status, systolic blood
pressure, and any more proximal arterial injuries.
Maintaining venous drainage is the key to successful replantation because venous insufficiency is the
most common cause of replantation failure. 17 It is preferable to repair both digital arteries and as many
veins as possible for successful replantation. The vein which is actively draining the most blood should be
chosen. In a middle or proximal phalangeal replantation, anastomosis of one artery and two veins is
sufficient. If two arteries have been repaired, two or more veins should be repaired. To increase the
number of anastomosed veins, it may be necessary to mobilize or harvest adjacent branches of the vein
(Figure 83.8B). The digital dorsal venous plexus is conventionally considered as a reliable source for
venous repairs. The volar skin of the digit is a useful site for vein repair because it is less likely to be
avulsed during injury and in amputations with tissue loss, and the size discrepancy is less for volar veins
than for dorsal veins. It also does not require changes in hand position and it is indicated when primary
repair of dorsal veins can be difficult due to tightness ensuing from arthrodesis of the underlying joint in
flexion.
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Nerve Repair
Nerve regeneration is the most important prognostic factor in final functional recovery after replantation.
In most replants, nerve repair is not difficult because of the amount of bone shortening. Only two to four
epineurial stitches of 9-0 or 10-0 monofilament suture are enough to get approximation of the fascicles.
To prevent neuroma formation in replantation, nerve repair should be performed without tension. A
short defect of the nondominant digital nerve is reconstructed with a vein conduit. This is appropriate for
defects of less than 1 to 2 cm in length. Nerve conduits consisting of collagen or polyglycolide can also be
used. When a nerve graft is required, a terminal branch of the posterior intraosseous nerve or medial
antebrachial cutaneous nerve of the forearm is easily harvested from the ipsilateral side. In multiple-digit
amputations, nerve grafts may be taken from the discarded digits. In avulsion injuries or digital nerve
injuries of different levels, radial to ulnar or reversed cross-pattern digital nerve repair should be
considered. In case of long nerve defect or uncertainty regarding the extent of intraneural injury, it is
better to delay primary nerve grafting for later reconstruction. The ends of the avulsed or crushed nerve
should be marked with 6-0 nylon sutures for easy identification.
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Skin Closure
During skin closure, be sure not to create any pressure over the repaired vessels. Just one tight stitch can
result in venous congestion. When there is an open wound, small split-thickness skin grafts can be
applied, even directly over arterial or venous anastomosis or vein grafts. Soft tissue defect may require a
Z-pasty, local flap, or a venous flap to cover tendons as well as the artery or veins. If at any time during
skin closure the fingertip loses its pinkish color or becomes dusky, then excessive tension is
compromising either arterial inflow or venous outflow. Sutures must be removed and a split-thickness
skin graft or artificial skin used to cover the defect. Dressings should be loose and the extremity
immobilized in a long-arm splint then elevated.
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Postoperative Management
Monitoring
Postoperative monitoring of replantation is essential for successful replantation because early recognition
of vascular compromise provides the best chance for flap salvage. Patients should be admitted to a warm
room and be well hydrated and comfortable to avoid peripheral vasospasm. Circulation status can be
assessed by aid of technical devices such as pulse oximeter, implantable venous Doppler probe, digital
thermometry, and the laser Doppler. A temperature drop of 1.8 to 3°C or an absolute temperature of less
than 30°C mandates immediate re-exploration of the arterial and venous anastomosis. 18 A continuous
pulse oximeter can monitor the pulse rate and the oxygen saturation within the digit. Loss of the pulse
rate indicates arterial occlusion, whereas a fall in the oxygen saturation below 90% usually indicates
venous occlusion. However, intensive monitoring of capillary refill, temperature, and the color of
replanted digits by experienced nursing staff is the most reliable (Table 83.1). This should be checked
hourly for the first 48 hours, every 2 hours for the next 2 days, and then every 4 hours for the next 3 days
because the highest risk of postoperative thrombosis is in the first 72 hours after surgery. Arterial thrombi
usually result from platelet aggregation and present on day 1, whereas venous thrombi result from fibrin
clotting and usually present by day 2 or 3.
TABLE 83.1
Monitoring of Circulation in Replanted Digit
Normal
Arterial Occlusion
Venous Insufficiency
Color
Pink
Pale or white pink
Dark pink or purple
Capillary refilling
Fast
Very slow
Very fast
Temperature
Warm
Cold
Warm-cool
Turgor
Full
Hollow
Swollen
Bleeding
Bright red
Minimal, only serum
Dark red or purple
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Anticoagulation Therapy
Perioperative anticoagulation therapy varies according to the circumstances of the replant and preference
of the surgeons. The most common agents are aspirin, heparin, and low-molecular-weight dextran.
Aspirin inhibits the platelet enzyme cyclooxygenase and impedes arachidonic acid breakdown through
thromboxane and prostacyclin. Preoperative administration of aspirin decreases microvascular
thrombosis formation. Heparin possesses properties of prevention of both platelet-induced arterial
thrombi and coagulation-induced venous thrombi and vasodilatory effect, but it causes hematoma
formation and induces thrombocytopenia. The use of intravenous heparin does not correlate with higher
success rates of replantation but it may be indicated in cases of intimal damage by crush and avulsion
injuries, intraoperative thrombus, or following successful thrombolysis and arteriosclerotic changes.
Dextran 40 is a group of synthesized polysaccharides which interfere with the formation of fibrin clot and
to prevent the aggregation of red thrombi. This has a low risk of postoperative bleeding and hematoma
formation but in rare cases has the serious consequence of pulmonary edema due to fluid overload.
Regimen of anticoagulation for replantation is recommended as follows. 19 Preoperative loading dose of
1.4 mg/kg (100 mg in the 70-kg adult) of enteric-coated aspirin is started and followed by the same dosage
per day for 2 weeks. Before the release of microvascular clamps, heparin bolus of 50 to 100 U/kg is
intravenously injected. Intraoperatively, dextran 40 is administered at a dose of 0.4 mL/kg/h, 
 and the
dosage is cut in half on postoperative days 3 and 4 and weaned off on postoperative day 5. In cases of
suspicious perfusion failure, intravenous bolus injection of heparin of about 100 to 160 U/kg 
 is
recommended.
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Rehabilitation
Rehabilitation after replantation surgery is unique in that all tendons, bone, joint, and neurovascular
structures are involved. An initial period of immobilization is followed by passive and active
mobilization with particular emphasis on maintaining the range of motion of the noninjured digits. For
an even digital replantation, the splint is applied in a protective position with the wrist neutral, MP joint
flexion at 60 to 90 degrees, and IP joint extension. In this position, both tendon systems are protected, the
length of the collateral ligament length is preserved, and flexion contracture of the PIP joints can be
avoided. A thermoplastic protective splint is fabricated as soon as the anticoagulants are discontinued,
usually on the fifth to seventh postoperative day, to allow ease of wound care and exercises in the
mobilization phase.
Two stages of supervised exercises, known as early protected motion (EPM), are designed to prevent joint
stiffness and to minimize adhesions after digital replantation. 20 EPM I begins at approximately 5 to
14 days after replantation and consists of gentle wrist flexion and simultaneous finger extension by virtue
of the tenodesis effect. EPM II begins at 7 to 14 days and consists of the intrinsic minus (hook) and the
intrinsic plus (table) position, respectively. The hook position provides the most differential gliding
between the FDS and FDP tendons; the table position maintains intrinsic muscle function. After the first
3 weeks, patients are encouraged to participate in a graduated program of active, active-assisted, and
protected passive stretching and range-of-motion exercises supplemented by appropriate dynamic and
static bracing and splinting. For either digits or thumb replantations, wrist extension beyond neutral,
blocking exercises, and tendon gliding exercises are introduced at 4 to 5 weeks. At 5 to 6 weeks,
composite motion and functional activities are introduced. Blocking splints and dynamic splints can also
be added when the protective splint is discontinued at 6 weeks. Strengthening begins at 6 to 8 weeks.
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Replantation for Specific Level of Amputation
Distal Digital Replantation
Regarding replantation distal to the DIPJ level of amputation, multiple classification systems have been
proposed (Figure 83.9). 21 Revision amputation was perceived to be the better choice, given the minimal
functional loss and reduced expense compared with replantation. However, systematic review and
retrospective studies indicate that high success rates and good functional outcomes and cosmetic results
followed distal digital replantation when compared with revision amputation. 23,32 Although it can be
technically demanding because of the diminutive size of the distal arteries, successful replantation
restores an almost normal appearance and satisfactory sensibility if the digital nerves can be
approximated (Figure 83.10). This level of amputation should be included as a formal indication of
replantation surgery. 22,23
FIGURE 83.9 Amputation level of distal part of digits proposed by Sebastin and Chung, Ishikawa, and Tamai. DIPJ, distal
interphalangeal joint; FDP, flexor digitorum profundus; FDS, flexor digitorum sublimus.
FIGURE 83.10 A. Guillotine-type amputation of the long finger at sub-zone II of Ishikawa classification (zone 1A of Sebastin
and Chung, zone I of Tamai) and ring finger at sub-zone I by Ishikawa classification. B. Anastomosis included two bifurcating
central artery repairs at the long finger and one bifurcating artery repair at the ring finger. Immediately after operation. External
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bleeding with heparin and medical leech application for 5 days. C. Twelve months after operation.
This procedure can usually be performed safely and comfortably as outpatient surgery, often under local
anesthetic block or under brachial plexus block. 23 It usually takes less than 2 hours for bone fixation with
0.028 or 0.035 K-wires through distal phalangeal bone, one digital artery and/or one vein repair, and
where possible two digital nerves and nail plate and skin sutures. Finding a suitable vein at this level is
challenging, and venous insufficiency is the most compromising cause of replantation failure. At the DIP
joint level, the vein goes distally and the larger vessels are palmar; proximal to the DIP joint, the dorsal
veins tend to predominate. At the level of the eponychium, 63% of fingers have a vein of 0.8 mm or
larger. Distal venous arch on the lateral nail fold area is reliable to find and to anastomose. This runs
around the lateral nail wall and distal pulp forms an arch over the distal phalanx that surrounds the nail
proximally. Occasionally after release of the tourniquet, a small vein can be identified dorsally just
proximal to the nail fold and a single venous anastomosis performed.
In cases of impossible vein repair, there are suggested methods of salvage procedures with external
bleeding with a fish mouth incision or removal of the nail bed, medical leeches, continuous
administration of heparinized saline, or creation of an arteriovenous anastomosis between the other distal
digital artery and a proximal vein. The external bleeding method for one digit needs blood transfusions of
1.2 to 1.8 units on average and with success rate typically higher than 85%, including adequate sensory
recovery. 24,25 If there is postoperative congestion on the day or days immediately after the primary
vascular anastomosis, dilated venules usually become larger and can easily be anastomosed. Delayed
venous drainage results in a high success rate in distal phalangeal replantation. 26 To support adequate
venous drainage, external bleeding with topical heparinized saline solution with hyperbaric oxygen
therapy with venous anastomosis can surely overcome venous congestion.
Leeches are effective at treating venous outflow problems in failing replants (Figure 83.11). The leech
saliva contains the effective anticoagulant “hirudin” that acts as a regional anticoagulation of the part. If
the venous congestion happens 2 or 3 days after the initial surgery, re-exploration may harm the
neovascularization of the replanted parts. When the leech is placed on the failing digit, it bites the digit,
then sucks a small amount of blood, and ultimately falls off the digit within 10 to 40 minutes of beginning
its meal of blood. Leeches are generally applied on an as-needed basis but can be used up to every
6 hours and are slowly weaned at approximately 5 days until venous circulation should be re-established.
The most feared complication of leech use, however, is an infection from the bacterium Aeromonas
hydrophila. The incidence of this infection ranges from 2.4% to 20%, with clinical presentations ranging
from cellulitis or abscess to extensive soft-tissue infections causing tissue loss and systemic sepsis. 27
Routine antimicrobial prophylaxis with a fluoroquinolone should be used for cases of leech therapy.
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FIGURE 83.11 Medicinal leech on the distal digital replantation. It improves oxygenation and enhanced bleeding in venous
congestion.
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Pediatric Replantation
Replantation should be considered for all amputated parts in children. Crush by door hinge and avulsion
injuries from bicycle chain or mechanical sports equipment are common mechanisms for amputation in
children and should not be considered contraindications for replantation. The preponderance of this
mechanism of injury results in lower survival rate than in adults. Furthermore, replantation in young
children may be more technically demanding because of the small caliber of the vessels and the
propensity for vasospasm, but the digit will continue to grow and the results of the tendon and nerve
repairs are much better than in an adult. Replantation should consist of minimal bone shortening to
preserve epiphyseal plates and simple bone fixation with longitudinal K-wires. Postoperatively, use of
sedation to maintain calmness and encourage somnolence can be helpful to prevent vasospasm in
children. Recovery of sensibility in the replanted digit is nearly as good as for isolated digital nerve
repair. The success rates of pediatric digital replantation have been reported to be as high as 95% to 97%,
28,29 but proximal replantation is less favorable than digital replantation, with a reported success rate of
77% for complete amputations and 80% for revascularization procedures. 30 One long-term study shows
that continued skeletal growth occurred and the digit attained 81% to 90% of normal longitudinal length
at maturity unless significant damage to the epiphyseal plate is apparent 29 (Figure 83.12). Patient and
parent satisfaction is high when replantation is successful, with uniform approval of the extensive effort
required.
FIGURE 83.12 A. In this 40-month-old child, belt injury resulted in incomplete amputation of the left long finger. It was a
Salter-Harris type II epiphyseal fracture of the base of proximal phalanx. B. Bone fixation with two crossed Kirschner wires. C,
D. After 6 years of revascularization, the length and joint motion of the replanted digit were found to be nearly normal. E. Six
years postoperatively.
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Thumb Replantation
Thumb replantation should be considered for any traumatically amputated thumb regardless of the type
of injury or level of amputation. After successful replantation of the thumb, there is no significant
correlation between the level or type of injury and the grip/pinch strength. Compared with the
contralateral unaffected hand, grip strength and key pinch strength are 70% to 92% and 68% to 81%,
respectively. 31,32 Most patients with traumatic thumb amputation who received replantation are able to
return to their previous occupation and are able to perform the activities of daily living. However, a low
level of sensory recovery is one of the most critical points which is directly related to crush or avulsion
injuries as well as low compliance and insufficient sensory reeducation.
Operative technique of the thumb is a little different from digital replantation. Regarding bone
management, shortening of an amputated thumb should be kept to a minimum and an arthrodesis is
more generously accepted in cases of amputation around the IP or MCP joint. The thumb with IP fusion
can still have useful motion through the MCP joint and carpometacarpal joint without repairing flexor
pollicis longus (FPL) and extensor pollicis longus (EPL). Even a thumb with MCP joint fusion maintains
the role of post for opposition with digits.
The ulnar digital artery is the dominant artery in the thumb and is most reliable for arterial anastomosis
resulting in successful replantation. Proximally, the princeps pollicis artery can provide sufficient blood
flow from the dorsum if no palmar arteries are suitable for repair. If possible, primary arterial repair is
easiest by anastomosis of the severed ends of both digital arteries after bone shortening. If not,
interposition of short or long vein grafts is employed from the volar aspect of the wrist or forearm.
Microscopic focus on the ulnar artery at different levels is annoying because it requires extreme arm
pronation or supination. This can be avoided by either repairing the ulnar digital artery before the bone
fixation or using an arterial interposition graft (see Figure 83.8A). It may be easier to anastomose
interpositional vein grafts to the terminal branch of the ulnar digital artery and largest vein in a supine
position before performing osteosynthesis. The proximal anastomosis can be performed dorsally and
proximal to the area of injury.
Thumb avulsions are common industrial injuries by conveyor belt or rotating machines, traditionally by
rodeo roping and sports activities like water skiing tow ropes and riding a mechanical bull and team
roping. When the FPL and EPL tendons have been avulsed from their musculotendinous junction,
treatment options are tendon resection, reattachment to muscle, tendon transfer, side-to-side repair, or
insertion of tendon spacer. If these could be reconstructed primarily as a one-stage procedure, the costs
would be lower, the patients would return to their work earlier, and the technical difficulties encountered
in secondary reconstructions would also be eliminated. Reattachment of the FPL tendon to its muscle
belly and direct repair of the EPL is preferred as the most promising technique in the recovery of function
(Figure 83.13).
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FIGURE 83.13 A. Avulsion amputation of the left thumb and incomplete amputation of the index. B. After muscle portions of
the avulsed flexor and extensor tendons were clearly debrided, both extensor and flexor tendons were reattached to the viable
muscle belly by interweaving suture at the dorsal and volar proximal forearm. C. Vein graft about 8 cm in length was harvested
from the volar aspect of the ipsilateral wrist. D. Arterial reconstruction with interpositional vein graft between princeps pollicis
artery and ulnar digital artery. E. Postoperative appearance about 12 months demonstrating active motion of the
interphalangeal joint.
The mean survival of replantation of thumb avulsion injuries is 68% (26% to 100%). 33-35 This variability
may in part explain the different success rates in the reports of replantation of the thumb resulting from
different causes of avulsion.
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Replantation for Ring Avulsion Amputation
A ring avulsion injury is sustained by a sudden and strong traction force as pulling a ring from a finger.
These injuries are usually caused by crushing, shearing, and avulsing the soft tissue envelope which
results in severe macroscopic and microscopic damage to the digital neurovascular bundle along with
tendon rupture, and even bone fractures. 36 Ring avulsion amputation is regarded as a denuded finger
necessitating a tubed pedicle flap or primary ray amputation.
Optimal management will vary depending on the pattern of injury, status of the amputated part, and
functional requirements and expectation of individual patients. Several classification systems have
evolved that are useful to recommend anticipated treatment and to predict possible outcomes (Table
83.2). 37-39 Class II injuries are often incorrectly diagnosed as a skin laceration at the emergency room
because there is intact tendon and no skeletal injury. If there is inadequate perfusion of the distal digit as
evidenced by no capillary refill, poor pulp turgor, coldness, and pallor, immediate care including
irrigation and debridement of the wound as well as microsurgical repair of artery or vein and both digital
nerves should be performed. Because bone shortening is not available for intact bone, short vein graft is
often needed for reconstruction of vessel whether there is damage to the digital arteries, veins, or both.
Prognosis of the replanted digits in class II injuries show a better range of motion, sensibility, strength,
and appearance when compared with class III injuries which include skeletal injuries.
TABLE 83.2
Modified Classification System of Finger Avulsion Injury Based on Urbaniak Classification
Class
Description
I
Avulsion injuries with adequate circulation
II
Incomplete avulsion injuries with inadequate arterial or venous circulation, without skeletal injury
IIa
Arterial circulation inadequate only
IIv
Venous circulation inadequate only
IIav
Arterial and venous circulation inadequate
III
Incomplete avulsion injuries with inadequate arterial or venous circulation, with fracture or joint injury present
IIIa
Arterial circulation inadequate only
IIIv
Venous circulation inadequate only
IIIav
Arterial and venous circulation inadequate
IV
Avulsion injuries with complete degloving or amputation
IVp
Complete avulsion injuries with amputation proximal to flexor digitorum superficialis insertion
IVd
Complete avulsion injuries with amputation distal to flexor digitorum superficialis insertion
A class IVd injury is considered as a candidate for replantation, but in patients with an IVp injury,
amputation or ray amputation should be considered, as these patients are likely to have poor hand
function. Proximal dorsal or volar skin flap of the survived digit tends to be necrosed by direct injury and
insufficient circulation. Additional flap coverage is often necessary for the late necrosis (Figure 83.14).
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FIGURE 83.14 A 53-year-old woman sustained left ring finger avulsion amputation by henhouse chicken wire. The proximal
interphalangeal jointwas intact, but both the digital artery and nerve were avulsed, for class IVd. The ulnar digital artery was
anastomosed with vein graft about 1.2 cm from the volar aspect of the proximal interphalangeal joint, and the proximal radial
digital nerve was transposed to the distal ulnar digital nerve. A. Four weeks after the operation, the volar soft tissue was
necrotic. B. After debridement of the necrotic tissue, about 7 cm × 3 cm radial artery superficial palmar branch flap is harvested
from the ipsilateral thenar area to cover the whole volar aspect of the ring finger. Donor site was closed primarily. C, D. Five
years postoperatively.
Ring avulsion injuries have traditionally been considered as having low success rates and unsatisfactory
functional results. However, systemic review proves the 78% of mean survival rate, protective sensation,
and acceptable functional outcomes. 35 Completely amputated ring avulsion injuries with an intact PIP
joint and FDS are thus worthwhile replantation procedures.
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Multiple-Digit Replantation
Compared with single-digit or double-digit replantation, there are many considerations in replantation
operations for three or more digits to avoid systemic or more serious general complications. In terms of
prolonged ischemic time, it is preferable to use a digit-by-digit replantation sequence rather than
structure-by-structure replantation. However, to reduce operation time, a structure-by-structure sequence
is more efficient because prolonged cold ischemic time at this level of amputation does not affect the
survival rate and final functional results of the replanted digits. 11 Because of the importance of the
pinching and grasping functions of the hand, a good replantation order is the thumb first followed by the
middle finger, the ring finger, index finger, and the small finger last. By bone shortening at the
phalangeal bone, any graft for vessel or nerve should be avoided. Maintenance of digital length is not a
positive factor for the final functional result. However, in cases of guillotine-type injury, direct bone
fixation and primary repair of the tendon, nerve, and vessel is possible without any shortening or even
any extended incision. A no-incision technique can certainly decrease total operation time as well as
improve wound healing and regeneration (Figure 83.15).
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FIGURE 83.15 A. A 63-year-old man with a sharp cutting injury on the right hand. The right index and small finger were
amputated at the base of distal phalangeal bone, and long and ring finger were amputated at the middle phalanx. B. Immediate
after replantation by structure-by-structure technique. C. Postoperative radiograph. D. At 25 months of follow-up, the patient
had nearly full flexion of the proximal interphalangeal joint and radiograph.
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However, in case of multiple-digit amputations including nonreplantable thumb, the least damaged digit
should be replanted in place of the mutilated thumb (Figure 83.16). Transpositional replantation is aimed
to achieve basic pinch, tripod pinch, and even most importantly, opposition grip. Amputated long digit is
always used to replace an unreplantable thumb with simultaneous reconstruction of opposition with
tendon repair or transfer. In cases of multiple-digit amputations with the thumb intact, the effort is made
to replant the digits toward the ulnar side of the hand, so the width of the palm span is preserved and the
power grip of the hand can be increased. 40 In cases of bilateral multiple-digit amputations or bilateral
multiple-
 digit and hand amputations, the replantation effort is directed at increasing the dexterity of the
dominant hand or restoring basic hand function by transposing digits or hand from relatively less injured
part of digits or hand. Cross-hand replantation or cross-arm replantation is aimed to save at least one
hand or one limb used for pinch and grasping.
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FIGURE 83.16 A, B. Illustrations depicting the transposition of the amputated digits. C. After a devastating crushed
amputation injury by press machine, all three fingers seemed irreplantable. D. Amputated part of the right index finger was
transposed to the thumb and distal phalanx of the thumb to the long finger. E. Immediate postoperative view. F. Thirteen
months after the second ray amputation.
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Adequate radical debridement is required to achieve immediate replantation in cases where amputation
is combined with extensive soft tissue loss or contamination, or where the immediate replantation on the
orthotic position seems impossible due to associated severe injuries or with an unstable patient. Even if it
performs, it would be functionally or aesthetically inadequate. The amputated part of the upper extremity
may be rapidly ectopically banked to the thoracodorsal artery of the axilla or contralateral radial artery of
the forearm. This creative and useful concept serves as an important limb-saving technique for the
reconstructive hand surgeon in select clinical settings.
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Transmetacarpal Replantation
Functional results after this level of replantation have been mainly attributed to poor recovery of intrinsic
muscle function, which is due to direct injury to the intrinsic muscle, ischemia, or postoperative scarring.
41 Because replantation at this level is not technically difficult, primary survival rate is reported at a high
of 86%. 41
Regarding operative technique, at least 1 cm of bony shortening is recommended to prevent secondary
intrinsic tightness in the fingers. Bone fixation is recommended with longitudinal K-wires in children and
minicompression plates in adults. Care must be taken during bony fixation to prevent malrotation of an
individual digit because rotation at this level translates into a greater functional deficit than a similar one
in the digit. At least three or four dorsal veins should be anastomosed, approximately two veins for each
artery. Hemostasis is particularly important at this level where branches of the deep metacarpal arteries
may bleed profusely. It should be identified both in the distal amputated part and in the amputation
stump and ligated to prevent postoperative hemorrhage causing a hematoma after revascularization is
completed. The distal portions of devitalized and denervated interosseous muscles should be completely
debrided, which can allow the intrinsic tendons to tenodese in an intrinsic-plus position.
A postoperative protocol should be initiated 72 hours after replantation consisting of early protective
active mobilization with anticlaw splinting. This helps prevention of intrinsic minus deformity, provides
a more serviceable grasping hand, and improves final functional results. 42 Recovery of sensibility is poor
but protective sensory recovery can be expected in most cases; , cold intolerance remains a permanent
problem in half of the patients in cold weather areas. Intrinsic muscle function and pinch and grip
strengths are weak or absent in most patients (Figure 83.17).
FIGURE 83.17 A. A 46-year-old woman sustained a local crushed-type amputation to her nondominant hand. All digits
including thumb were amputated through the metacarpal bone. The intrinsic muscles were extensively debrided, and plate and
screw fixation of the shortened metacarpals was followed by extensor and flexor tendon repair. Princeps pollicis artery and the
second and third common digital arteries were microanatomosed and three dorsal veins were repaired. B, C. Fourteen years
later.
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Major Limb Replantation
Major limb amputations are defined when they occur through or proximal to the radiocarpal joint and
include transections at the level of the wrist, forearm, elbow, humerus, or shoulder. In more proximal
amputation, there is a high possibility of significant associated injuries such as rib fractures, hemothorax,
cervical spine injury, or traction injury of the brachial plexus so the patient should be checked thoroughly
by the emergency specialist. These may be life-threatening conditions which may preclude replantation of
upper extremity amputation.
There are very different considerations on both preparations and operative techniques compared with
digital replantation. 43 First of all, if the total ischemic time extends beyond 8 hours, the operator should
think over the replantation attempt once again. From the time of a patient’s arrival at the emergency
room to restore arterial blood flow to the amputated part, it will take at least 2 hours. Because the most
common complication of major limb replantation is infection, debridement is a very critical step in
preventing infection and is more radical at the muscles of the distal part. Acutely spreading infection
immediately after operation may give rise to ruptured vessels or multiple organ system failure resulting
in life-threatening complications. During the whole phase of operation, a hypothermic condition should
be maintained by placing the amputated part on ice bags. Temporary vascular stent is used to avoid
ischemic risk by connection arterial inflow from the proximal vessel to the amputated part. This can be
performed before bone fixation if the duration from amputation to arrival in the operating room is longer
than 4 to 6 hours. Hypothermic perfusion with the University of Wisconsin solution may allow longer
periods of preservation, which could enable surgeons to take more precise and confirmed preparation
procedures before arterial anastomosis.
Replantation at transcarpal and radiocarpal level of amputation is technically much easier but there are
different options for joint management. In cases of amputation at the level of the intercarpal joint or
radiocarpal joint with intact distal articular surface, proximal row carpectomy is a useful procedure to
preserve joint motion of the wrist. An overall shortening effect of 2 to 3 cm by proximal row carpectomy
can facilitate radical debridement of the soft tissue as well as direct repair of the vessels and nerves
without any graft. Multiple K-wires are used for transarticular fixation for 6 to 8 weeks. The remnant of
the joint capsule of the wrist and extensor retinaculum should be robustly repaired. In cases of extensive
bone fractures around the radiocarpal joint, partial or total carpectomy and primary arthrodesis of the
wrist is recommended. This is indicated especially if the radiocarpal joint is destroyed or in a young,
working man. And, if the level of amputation is just proximal to the distal articular surface of the radius,
shortening osteotomy of the radius and Darrach resection of the distal ulna are preferred.
At the wrist and proximal forearm, aggressive bone shortening up to 2.5 to 5 cm of both radius and ulna
or 6 to 8 cm in length of either of the humeri is essential to make functional restoration possible. 43 The
sequence of repair from this point on is from deep to superficial. Motor units of tendons are repaired with
braided nonabsorbable sutures using a locking four-strand technique. If no motors are available, the
tendons after resection of the muscle portion are left in the floor of the wound.
Regarding vessel repair, two main arteries and their venae comitantes as well as two subcutaneous veins
at least should be repaired. Venae comitantes of radial and ulnar artery seem small compared with
subcutaneous vein but are capable of draining a significant quantity of blood. Once arterial flow is
established, the vein should be allowed to bleed for 5 minutes. Before this critical time, the
anesthesiologist should be on standby and supply blood and sufficient fluid to the patient. Acute blood
loss may cause transient hypovolemic shock necessitating prompt management. If the ischemic time is
over 6 hours and/or there is a considerable muscle mass, the venous blood causes metabolic acidosis,
hyperkalemia, cryoglobulinemia, and possibly reperfusion injury. With intensive monitoring of
electrocardiogram, sodium bicarbonate is slowly given intravenously over a period of 5 minutes prior to
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clamp release. Reperfusion injury by reactive oxygen species into systemic circulation causes direct cell
damage and produces inflammatory mediators, complements activation, and aids leukocyte adhesion.
This cascade increases vascular permeability and can cause cell death despite revascularization. Even to
decrease or prevent reperfusion injury, the conditioning maneuvers at the onset of reperfusion are
simple, safe, and at least relatively harmless. A postconditioning maneuver should include brief
alternative episode or episodes of nonocclusion/reocclusion on the feeding artery. Remote
postconditioning is composed with brief alternative episode or episodes of ischemia and reperfusion on
one of the nonoperative extremities.
Grouped fascicular primary nerve repair using 9-0 nylon sutures without tension can achieve optimal
nerve regeneration which determines final functional results and ultimate use of the hand. Where the
nerves are avulsed or segmentally defected, cross nerve suture between proximal radial to distal median
repair or proximal ulnar to distal median is an alternative method for providing protective sensation of
radial digits. If not, the nerve ends must be tagged with 4-0 nylon sutures at an easily accessible plane for
later nerve grafting.
By significant bone shortening, primary skin repair is possible. Skin flap should be placed on the vessel
anastomosis sites. If the skin graft is on the repaired vessel, there is a risk of delayed rupture. In cases of
large soft-tissue defect possibly exposing vital structures or plate, tentative coverage with artificial skin or
thin-split skin graft should be replaced by flap surgery as soon as possible depending on the general
condition of the patient.
Major upper extremity replantation is successful in 77% to 93% of cases, depending on the level and
mechanism of injury. 44 Better functional outcomes have been reported for distal and sharp injuries. 44 The
functional outcomes of proximal amputations often caused by higher energy injury mechanisms are less
predictable due to greater tissue damage and longer distances for muscle reinnervation. For improvement
of the survived limb replantation, secondary surgical managements of the remaining functional deficits
are mandatory. Tenolysis is the most common secondary procedure performed for amputations of the
distal forearm to wrist. Free functioning muscle transfer is the most common secondary surgeries for
amputations between the elbow and mid-forearm (Figure 83.18) and soft-tissue coverage is the most
common secondary procedure in case of upper arm replantation.
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FIGURE 83.18 A. A 43-year-old man sustained elbow amputation by belt injury. All nerves were avulsed from the upper arm.
B. Elbow joint was fixed with a temporary K-wire with external fixator. C. Six months later, sural nerve grafts were used to
reconstruct ulnar and median nerve. D. Functioning gracilis muscle was transferred to reconstruct elbow flexion. E. Fifteen
years after the operation, functional result was grade III by Chen’s criteria.
Technical innovations and refinement of the indications for major replantation of limb amputations have
resulted in a predictably high rate of successful revascularization. Replantation surgery produces
superior functional results compared with revision amputation and a prosthesis. 45
Regarding rehabilitation for more proximal level of replantation at palm, wrist, and forearm, prevention
of intrinsic minus deformity, maintaining full passive range of motion at uninjured joints distal to the
amputation level, and daily use of the replanted digit is essential to get satisfactory functional restoration.
As the intrinsic minus posture is difficult to correct once it becomes fixed, daytime exercise with a
dynamic crane outrigger splint with an MP joint extension block and night anticlaw splint are mandatory
(Figure 83.19). Even though active motion of the digits is not recovered after replantation, the status of
full passive motion of the digits leaves the possibility of functional improvement by later reconstruction
with tendon transfer or free functioning muscle transfer.
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FIGURE 83.19 Active and resisted exercise of the joint with the orthoplast dynamic splint. This can prevent claw deformity of
the digits as well as adduction contracture of the thumb.
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Secondary Problems and Outcomes
The long-term patency of the microanastomosed digital arteries after successful replantation varies. In
spite of successful replantation, the pulsation of Doppler and angiography reveals occlusion of the
arteries in 37% of vessels after an average of 15 postoperative days. 46 Therefore, early wound healing of
the soft tissue is critical for neovascularization of the replanted finger. In crush amputation cases,
neovascularization of the replanted part occurs slowly. In these cases, replantation failures may happen
after 1 week to 10 days postoperatively. Radical debridement of the soft tissue, as well as apposition
between fresh tissues, is essential upon completion of the case. In cases of soft-tissue defects following
replantation, local or free flaps are necessary.
The worst complication in the early postoperative period is replantation failure. Failed distal replants can
be allowed to mummify and be left in situ to act as a dressing for the underlying stump. In children, in
young women, and in multiple-digit amputation, preservation of middle phalangeal bone length at the
time of revision amputation is important to preserve hand competence and prevent objects from slipping
through the hand. Later, secondary reconstruction with toe-to-hand transfer is possible only where at
least 1 cm of the middle phalangeal bone remains.
In practice, secondary operation after digital replantation is almost a necessity for the improvement of
both function and appearance of the digits. About 30% to 50% of replantation cases show problems
related to bony healing. 16 Nonunion rates range from 10% to 30% with K-wire fixation having the highest
nonunion rates. Malunion rates are about 20% with screw fixation being associated with the highest rates
of malunion. Intraosseous wires alone have been found to have the lowest nonunion and complication
rates. In cases of rotational deformity or nonunion, secondary revision with corrective osteotomy and
internal fixation with or without bone graft are needed.
Stiffness of the MCP, PIP, and DIP joints remains a problem due to edema and swelling in the replanted
digit. The surgeon should avoid using longitudinal K-wires to transfix joints. It is important to encourage
an active and passive range of motion exercises of the joints of adjacent noninjured digits, otherwise these
too can become stiff. To improve joint motion, artificial joint insertion or toe joint transfer is another
option depending on the condition of the tissues surrounding the joint.
The indications for flexor or extensor tendon tenolysis of the replanted digits are almost the same as the
general indications for tenolysis following isolated flexor tendon injury. These include significant
discrepancy between passive and active flexion of the digital joints after a substantial period of more than
6 months. This allows sufficient time for wound healing and maximum rehabilitation therapy. The result
of tenolysis after digital replantation is a useful and safe procedure to achieve improvement in the active
flexion of the digit. After tenolysis, secondary tendon rupture or subsequent bone fracture may happen
due to aggressive rehabilitation. Secondary tenolyses or two-stage flexor tendon grafting may
significantly increase the total active range of motion of a replanted digit. In extensor tenolysis, any
hardware used in bone fixation should be removed at the same time. An intrinsic reconstruction and
dorsal arthrolysis and capsulotomy are worthwhile when active and passive flexions are present. Certain
procedures such as tenolysis, capsulotomy, and arthrolysis are performed together because all these
procedures need no immobilization.
Factors that influence digital sensibility following replantation include patient’s age, level and
mechanism of injury, digital blood flow, cold intolerance, and postoperative sensory reeducation.
However, there is no significant relationship between the return of sensibility and the length of ischemia
time. Thermoregulation following digital replantation is likely to be a complex interaction among
vascular, neural, metabolic, and possibly hormonal mechanisms. Cold intolerance after replantation is a
significant problem, but the exact mechanism of cold intolerance following digital nerve injury is
unknown and clearly, greater than 80% of patients have moderate to severe cold intolerance following
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digital replantation. In most series, this disabling phenomenon abates somewhat after a period of 2 years
but may persist. 6,47 This means that cold intolerance results from a disorder in vasoregulation and not
from arterial insufficiency of the digit. Postoperative sensory reeducation and daily use of the replanted
digits will continue to improve digital sensibility as well as cold intolerance following replantation.
Chen’s classic criteria for the evaluation of function after replantation 48 are ideal for assessing
multisystem injuries and are general enough to allow comparison of results within complex injury
groups. Viable upper extremity replantation without return of sensation does not represent a functional
success.
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Questions
1. Which is mostly related with overnight delay in replantation, with preservation of the amputated
part at 4 to 6°C?
a. Correlated with lower overall viability of the replant
b. Resulted in no differences in survival rate
c. Caused hypothermic damage to the replanted finger with later loss
d. Resulted in increased surgeon fatigue
2. Which of the following patients presenting with an amputation would be most appropriate to
consider for replantation?
a. A 63-year-old diabetic suffering a crushing amputation of the index finger
b. A 5-year-old boy with a sharp amputation of the little finger
c. A 35-year-old woman with an avulsion amputation of the forearm with 6 hours of warm
ischemia
d. A 73-year-old man with an amputation of the arm through the mid-humerus
3. What is the appropriate antibiotic prophylaxis against Aeromonas hydrophila infection?
a. Penicillin
b. Fluoroquinolone
c. Cefazolin
d. Clindamycin
4. The most common complication of major limb replantation is:
a. bleeding
b. bony nonunion
c. infection
d. adult respiratory distress syndrome
5. A 22-year-old welder with no medical history is brought to the emergency department following a
sharp amputation of his dominant right hand following an altercation. Plain film inspection of the
hand and amputated part reveals amputation through the distal shaft of the middle phalanx.
Physical examination reveals intact FDS. After inspection of the amputated part under the operating
microscope, a decision is made to attempt replantation. What is the first step that must be performed
in the surgical sequence of replantation?
a. Bone shortening and fixation
b. Flexor tendon repair
c. Arterial anastomosis
d. Venous anastomosis
6. A 15-year-old boy with no medical history is brought to the emergency department following
sharp amputation of the dominant right thumb while hunting. What is the best way to preserve the
finger until replantation can be attempted?
a. Place the finger directly on ice
b. Allow the finger to soak in a bath of physiologic solution at room temperature
c. Wrap the finger in saline-soaked gauze, place the gauze in a watertight bag, and place the bag
on water and ice mixture
d. Place the finger in a dry container and place directly in the tissue freezer
1. Answer: b. The survival rate of digital replantation in the overnight-delayed replantation group
was 93.4% and in the immediate replantation group was 91.2%. This difference was not statistically
significant.
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2. Answer: b. All indications for replantation must take into account the status of the amputated part
(sharp amputation versus crush) and the patient (healthy versus systemic illnesses). The degree of
tissue injury may argue against replantation, even in the case of a clear indication, such as thumb
amputation. Although single-finger replantations are generally not performed, replantation beyond
the level of the sublimis tendon insertion (zone 1) usually results in good function. Multiple finger
amputations present reconstructive difficulties that may be difficult to correct without replantation of
one or all of the amputated digits. Any hand amputation from zone 2 (distally) to zone 4 (proximally)
offers the chance of reasonable function after replantation, usually superior to available prostheses. It
is generally believed that replantation should be attempted with almost any part in a child. In
children, success rates (in terms of viability) are lower, but the functional results are better. Although
there have been several reports of successful lower limb replantation, this area remains controversial.
The available lower extremity prostheses make amputation less of a functional problem in the leg
than in the upper extremity. The leg contains larger masses of muscle (which tolerate ischemia
poorly) and without adequate sensory recovery, the foot is at risk for soft-tissue breakdown.
Replantation and revascularization of the foot, lower leg, or both in children may give gratifying
results, however.
3. Answer: b. If there is total obstruction of venous outflow, near-continuous leeching will be
necessary for at least 5 or 6 days, and the patient may suffer significant blood loss (in the 2 to 6 unit
range). This blood loss represents the primary potential complication of leech therapy, but they also
have the potential to cause infection. Aeromonas hydrophila is a saprophytic organism in the leech’s
gut, which, although not a primary pathogen in humans, can cause significant infection. One review
article found that infection occurred in 7% to 20% of cases of leech application for venous outflow
problems and was associated with a decrease in salvage of the involved tissue. Infection is
uncommon in tissue with adequate arterial supply, however, and their use should be avoided if the
viability of the tissue is questionable. To minimize the risk of infection, the patient should be covered
with appropriate antibiotic therapy during the period of leech application. Studies of leech flora
suggest that a fluoroquinolone is appropriate prophylaxis in most cases.
4. Answer: c. Attempting to replant a forearm or arm with a prolonged warm ischemic period can
lead to severe metabolic problems and potentially death of the patient. Debridement of nonviable
tissue is paramount, and this process leads to the problem of soft-tissue coverage in many of these
patients. Although uncommon in digital replantation, infection, and even systemic sepsis, is the
number one complication in major limb replants. For this reason, major limb replantation is not to be
undertaken without a serious commitment to the endeavor.
5. Answer: a. 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.
6. Answer: c. 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.
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References
Malt, RA, McKhann, C. Replantation of a severed arm. JAMA. 1964;189:716-722.
Kleinert, HE, Kasdan, ML, Romero, JL. Small blood vessel anastomosis for salvage of severely injured upper extremity. J Bone Jt Surg Am.
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Komatsu, S, Tamai, S. Successful replantation of a completely cut off thumb: case report. Plast Reconstr Surg. 1968;42:374-377.
Chen, ZW, Meyer, VE, Kleinert, HE, et al. Present indications and contraindications for replantation as reflected by long-term functional
results. Orthop Clin North Am. 1981;12:849-897.
Scott, FA, Howar, JW, Boswick, JA Jr. Recovery of function following replantation and revascularization of amputated hand parts. J Trauma.
1981;21:204-214.
Jones, JM, Schenck, RR, Chesney, RB. Digital replantation and amputation-
 comparison of function. J Hand Surg Am. 1982;7:183-189.
El-Diwany, M, Odobescu, A, Bélanger-Douet, M, et al. Replantation vs revision amputation in single digit zone II amputations. J Plast
Reconstr Aesthet Surg. 2015;68:859-863.
Zhu, H, Bao, B, Zheng, X. A comparison of functional outcomes and therapeutic costs: single-digit replantation versus revision amputation.
Plast Reconstr Surg. 2018;141:244e-249e.A retrospective review of 1023 single-digit amputations was performed over a 3-year period. Replantation of
thumb, index, long, and ring fingers showed extra benefit compared with revision amputation.
Meyer, TM. Psychological aspects of mutilating hand injuries. Hand Clin. 2003:19:41-49.
Nishizuka, T, Shauver, MJ, Zhong, L, et al. A comparative study of attitudes regarding digit replantation in the United States and Japan. J
Hand Surg Am. 2015;40:1646-1656.
Woo, SH, Cheon, HJ, Kim, YW, et al. Delayed and suspended replantation for complete amputation of digits and hands. J Hand Surg Am.
2015;40:883-889.A retrospective review of 28 cases of delayed and suspended digital replantations was performed. It shows similar survival rates and
functional results compared with those involving immediate replantation. This justifies having the option to delay and suspend replantation.
Godina, M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285-292.
Nishikawa, H, Manek, S, Barnett, S, et al. Pathology of warm ischemia and reperfusion injury in adipomusculocutaneous flaps. Int. J. Exp.
Pathol. 1993;74: 35-44.
Kwon, GD, Ahn, BM, Lee, JS, et al. The effect of patient age on the success rate of digital replantation. Plast Reconstr Surg. 2017;139:420-426.
Zimmerman, NB, Weiland, AJ. Ninety-ninety intraosseous wiring for internal fixation of the digital skeleton. Orthopedics. 1989;12:99-103.
Whitney, TM, Lineaweaver, WC, Buncke, HJ, et al. Clinical results of bony fixation methods in digital replantation, J Hand Surg Am.
1990;15:328-334.
Zumiotti, A, Ferreira, MC. Replantation of digits: factors influencing survival and functional results. Microsurgery. 1994;15:18-21.
Khouri, RK, Shaw, WW. Monitoring of free flaps with surface-temperature recordings: is it reliable? Plast Reconstr Surg. 1992;89:495-499.
Conrad, MH, Adams, WP. Pharmacologic optimization of microsurgery in the new millennium. Plast Reconstr Surg. 2001;108:2088-2096.
Silverman, PM, Willette-Green, V, Petrill, J. Early protective motion in digital revascularization and replantation. J Hand Ther. 1989;2:84-101.
Ishikawa, K, Ogawa, Y, Soeda, H, et al. A new classification of the amputation level for the distal part of the fingers. J Jpn Soc Microsurg.
1990;3:54-62.
Hattori, Y, Doi, K, Ikeda, K, et al. A retrospective study of functional outcomes after successful replantation versus amputation closure for
single fingertip amputations. J Hand Surg Am. 2006;31:811-818.
Scheker, LR, Becker, GW. Distal finger replantation. J Hand Surg Am. 2011;36:521-528.
Buntic, RF, Brooks, D. Standardized protocol for artery-only fingertip replantation. J Hand Surg Am. 2010;35:1491-1496.
Erken, HY, Takka, S, Akmaz, I. Artery-only fingertip replantations using a controlled nailbed bleeding protocol. J Hand Surg Am.
2013;38:2173-2179.
Koshima, I, Yamashita, S, Sugiyama, N, et al. Successful delayed venous drainage in 16 consecutive distal phalangeal replantations. Plast
Reconstr Surg. 2005;115:149-154.
Lineaweaver, WC, Hill, MK, Buncke, GM, et al. Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap
surgery. Ann Plast Surg. 1992;29:238-244.
Baker, GL1, Kleinert, JM. Digit replantation in infants and young children: determinants of survival. Plast Reconstr Surg. 1994;94:139-145.
Cheng, GL, Pan, DD, Zhang, NP, et al. Digital replantation in children: a long-term follow-up study. J Hand Surg Am. 1998;23:635-646.
Beris, AE, Soucacos, PN, Malizos, KN, et al. Major limb replantation in children. Microsurgery. 1994;15:474-478.
Unglaub, F, Demir, E, Von Reim, R, et al. Long-term functional and subjective results of thumb replantation. Microsurgery. 2006;26:552-556.
Chen, HC, Tang, YB. Replantation of the thumb, especially avulsion. Hand Clin. 2001;17:433-445.
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Am. 2010;35:1485-1490.
Bieber, E, Wood, MB, Cooney, WP, et al. Thumb avulsion: results of replantation/revascularization. J Hand Surg Am. 1987;12:786-790.
Sears, ED, Chung, KC. Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes. J Hand Surg Am.
2011;36:686-694.A systemic review of ring avulsion amputation was performed. It demonstrates that functional outcomes of sensibility and range of
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Kupfer, DM, Eaton, C, Swanson, S, et al. Ring avulsion injuries: a biomechanical study. J Hand Surg Am. 1999;24:1249-1253.
Urbaniak, JR, Evans, JP, Bright, DS. Microvascular management of ring avulsion injuries. J Hand Surg Am. 1981;6:25-30.
Kay, S, Werntz, J, Wolff, TW. Ring avulsion injuries: classification and prognosis. J Hand Surg Am. 1989;14:204-213.
Adani, R, Pataia, E, Tarallo, L, et al. Results of replantation of 33 ring avulsion amputations. J Hand Surg Am. 2013;38:947-956.
Soucacos, PN, Beris, AE, Malizos, KN, et al. Transpositional microsurgery in multiple digital amputations. Microsurgery. 1994;15:469-473.
Paavilainen, P, Nietosvaara, Y, Tikkinen, KA, et al. Long-term results of transmetacarpal replantation. J Plast Reconstr Aesthet Surg.
2007;60:704-709.
Scheker, LR, Chesher, SP, Netscher, DT, et al. Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm
replantation. J Hand Surg Br. 1995;20:584-590.
Sabapathy, SR, Venkatramani, H, Bharathi, RR, et al. Technical considerations and functional outcome of 22 major replantations. J Hand Surg
Eur. 2007;32:488-501.Twenty-two consecutive major limb replantations carried out over a 5-year period were assessed. Surgical technique, risk factors,
and outcome are discussed. The technical details believed to be important for success are outlined. With decreasing numbers of such injuries in most
countries, this paper may help surgeons faced with an occasional patient with a major amputation to make the right decisions.
Larson, JV, Kung, TA, Cederna, PS, et al. Clinical factors associated with replantation after traumatic major upper extremity amputation.
Plast Reconstr Surg. 2013;132:911-919.
Pet, MA, Morrpetison, SD, Mack, JS, et al. Comparison of patient-reported outcomes after traumatic upper extremity amputation:
replantation versus prosthetic rehabilitation. Injury. 2016;47:2783-2788.
Lee, CH, Han, SK, Dhong, ES, et al. The fate of microanastomosed digital arteries after successful replantation. Plast Reconstr Surg.
2005;116:805-810.
Waikakul, S, Sakkarnkosol, S, Vanadurongwan, V, et al. Results of 1018 digital replantations in 552 patients. Injury. 2000;31:33-40.
Chen, CW, Qian, YQ, Yu, ZJ. Extremity replantation. World J Surg. 1978;2:513-524.The pioneer of replantation surgery in the world discusses
traditional surgical techniques and different methods of replantation. Final evaluation of replantation using “Chen’s criteria,” which are still very
useful and reliable, is included.
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C H A P T E R 8 4
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Thumb Reconstruction
Patrick L. Reavey and Neil F. Jones
Key Points
The thumb is responsible for 40% of the overall hand function; therefore, reconstruction of this digit
is essential to restore adequate length as well as sensate and durable soft tissue.
The minimum length for acceptable thumb function is at the interphalangeal joint. Complex injuries
at or distal to the IP joint may not require extensive reconstruction.
Isolated soft tissue defects of the thumb can be reconstructed with either local/regional or
microsurgical flaps though selection of sensate flaps is essential.
Thumbs with inadequate length (proximal to the IP joint) require bony and soft tissue reconstruction
and in these cases, microsurgical techniques utilizing a toe-transfer procedure provide superior
outcomes.
In complex hand injuries involving the thumb, replantation of the thumb is an absolute priority;
heterotopic replantation and/or pollicization of injured digits should be considered. Secondary
reconstruction can be accomplished by conventional techniques of distraction lengthening or
pollicization of an injured finger or a normal finger and probably now better by microsurgical toe-to-
thumb transfer.
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Anatomy and Biomechanics
The thumb is unique in humans due to the position of the thumb axis at the trapeziometacarpal (TM)
joint, which is pronated and flexed with respect to the other metacarpals. This position allows for
circumduction and opposition of the thumb and the versatility of the thumb to participate in prehension.
The thumb contributes 40% of hand function but takes on a much more significant role in mutilating
trauma when other digits are missing or stiff. 1
Opposition is necessary for the majority of essential thumb function. Opposition is the result of the
abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis flexing and
rotating the TM and metacarpophalangeal (MP) joints simultaneously. The abductor pollicis brevis
inserts on the radial sesamoid and radial base of the proximal phalanx. It is the main contributor of
opposition and every effort should be made to preserve this function during reconstruction. In proximal
transmetacarpal thumb injuries, the opponens pollicis, which inserts on the volar-radial aspect of the
thumb metacarpal, may still provide some opposition function at the TM joint. 2 However, secondary
opposition transfer may be required after reconstruction to maximize thumb function in proximal
injuries.
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Patient Evaluation
All patients require a comprehensive evaluation. A detailed medical history, including tobacco use, is
important as medical comorbidities may preclude long microsurgical procedures in some patients.
Handedness, occupation, and any prior injuries or limited function help to determine the goals of
reconstruction. Details on the mechanism and timing of injury are crucial in the evaluation of patients
presenting at the time of injury or for primary reconstruction. Additional medical records, especially
time-of-injury radiologic examinations and prior operative reports, are important for planning in patients
presenting for secondary reconstruction.
A complete hand examination should be performed to determine the extent of soft tissue loss, vascular
and neurologic status, tendon lacerations, and bone, joint, or ligamentous injuries to the thumb and all
digits. In regards to the thumb, specific attention should be paid to the geometry (e.g., dorsal, volar,
transverse, oblique) and location of soft tissue loss (e.g., pulp, radial, or ulnar) as well as the quality of
remaining tissue adjacent to the injury. The level of amputation or bony injury should be noted relative to
soft tissue component and involvement or injury to the first webspace should be noted. Standard
anteroposterior and lateral radiographs of the hand or digits should be obtained. Additional views (i.e.,
Roberts view for evaluation of the TM joint) can be ordered as needed for proximal or carpal injuries.
Advanced imaging (computerized axial tomography, magnetic resonance imaging) is not indicated in the
evaluation of acute injuries but may be helpful in patients presenting with complicated injuries for
secondary reconstruction.
A shared medical-decision making approach is essential to the conversation between the patient and
surgeon about the reconstructive options. The patient should be asked what the goals and expectations of
reconstruction are. The surgeon should discuss the expected outcomes of any reconstructive options,
including details on expected thumb and hand function, the need and extent of postoperative therapy,
overall recovery time, donor site morbidity, and the appearance of the reconstructed thumb. Patients may
decide to undergo a suboptimal functional reconstruction due to the cultural, social, occupational, or
financial impact of that option (i.e., choosing not to undergo great toe-transfer due to the inability to wear
sandals postoperatively).
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Reconstructive Goals
An optimal thumb reconstruction should restore thumb length, mobility, stability, strength, sensibility,
and aesthetics. 3 It is difficult to achieve all of these in every patient so it is important to remember that
the overall goal of thumb reconstruction is to maximize hand function; this requires that the thumb
participates in prehension. The goals of reconstruction can then be simplified into three key objectives:
creating a thumb with adequate length, with optimal mobility and/or position for opposition, and with a
sensate, painless tip.
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Length
The minimum required length for a functional thumb is at the level of the IP joint. An amputation at this
level decreases the function of the thumb by 50%; however, the thumb is still able to oppose the other
digits and function in prehension. Thumb amputations at or distal to the IP joint do not necessarily
require additional length or bony reconstruction. Amputations proximal to the IP joint of the thumb will
require a surgical approach that restores a functional length similar to that of a normal thumb or a
minimum at the level of the IP joint.
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Mobility/Position
The thumb is normally pronated 80° relative to the other digits with additional pronation occurring
during opposition to allow tip pinch. In injuries distal to the MP joint, the majority of thumb mobility will
be maintained, and the goals of length and sensibility will take precedence. In injuries proximal to the MP
joint, the function of any remaining thenar musculature must be assessed and a decrease in thumb
mobility is expected. Secondary opposition transfers may be required to maximize the function. Thumb
injuries without a functional TM joint require a reconstructive procedure to create a neo-TM joint (e.g.,
pollicization) or the creation of immobile post that may still serve to restore some hand function.
Attention should also be paid to injuries involving the first webspace as contracture in this area will limit
thumb opposition and require additional reconstructive procedures.
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Sensate and Painless Tip
An optimal thumb has good sensation and preferably stereognosis. At a minimum, the ulnar aspect of the
thumb tip/pulp should have sensibility as this is the portion most often involved in pinch and
prehension. Additionally, the tip of the thumb should have durable and adequate soft tissue for pain-free
use. Restoration of adequate soft tissue and sensibility may be performed in staged procedures; however,
the end goal must be to restore as close to normal sensibility as possible.
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Thumb Replantation
Replantation of a native thumb will nearly always achieve better outcomes when compared to secondary
reconstruction techniques. As such, every effort should be made to replant amputated thumbs including
those with relative contraindications to replantation such as crush and avulsion injuries. Distal digital
replantations require a supermicrosurgical expertise but have excellent results and survival. 4 Surgeons
not facile with these techniques should give consideration to referring distal thumb amputations to a
regional center where this care is available prior to performing a revision amputation or planning
secondary reconstructive procedures.
Mangled hand injuries involving the thumb are some of the most complicated cases for hand surgeons. A
systematic approach is required to achieve optimal outcomes. First priority should be given to the
replantation/reconstruction of the thumb. When the amputated thumb is not salvageable, other injured
digits should be evaluated for heterotopic replantation to the thumb position. Spare parts from
nonsalvageable digits should also be considered for maximizing the outcome of thumb reconstruction in
more limited injuries (Figure 84.1).
FIGURE 84.1 Avulsion amputation of the index finger and thumb. A. The proximal phalanx of the thumb is intact but without
soft tissue coverage. B. The amputated thumb had a multilevel injury, with better preservation of the index finger. C, D.
Neurotized fillet of the index finger flap transferred to salvage the remaining thumb. E, F. Postoperative outcome at 3 months.
Severe mutilating hand injuries involving the proximal amputation of all digits, such as in the metacarpal
hand, require a thoughtful approach to the initial operation and the plan for secondary procedures.
Microsurgical techniques allow for the reconstruction of a hand with a functional thumb or thumb analog
and a minimum of a second opposable finger or unit. 5,6
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Thumb Reconstruction
When replantation is unsuccessful or cannot be performed, thumb reconstruction can still achieve good
results. Several classification schemes have been proposed to guide the reconstructive approach to thumb
injuries. 1,3,7 We find that a modified version of Lister’s scheme is most useful for guiding decision making
(Table 84.1). This scheme focuses on the two main issues that need to be addressed in reconstructing a
thumb—length and soft tissue coverage. The mobility and position of the thumb are often most impacted
by the level of the initial injury and proximal injuries may require secondary procedures to maximize
function.
TABLE 84.1
Thumb Injury Classification and Reconstructive Approach
Type of Injury
Reconstructive
Need
Considerations
Options a
Bone
Soft
Tissue
Soft-tissue deficit with acceptable length
(amputation at or distal to the IP joint)
+/−
+
Reconstructive techniques to reestablish the
normal thumb length preferred
First webspace deepening may improve
functional length in distal proximal phalanx
injuries
Local
or
regional flaps
Osteoplastic
reconstruction
Free
toe-pulp
flap
Partial trimmed-
toe transfer
Amputation distal to the MP joint but
inadequate length
+
+
Bone and soft tissue reconstruction must
restore minimal functional length
Reconstructive techniques to reestablish
normal thumb length preferred
Great or second
toe transfer
Trimmed
toe
transfer
Wrap-around
toe-flap
Osteoplastic
reconstruction
Distraction
lengthening
.
Amputation proximal to the MP joint but
preserved TM joint
++
++
Opponens pollicis function on remaining
metacarpal should be assessed
APB function should be restored if possible
First
webspace
injuries
may
require
additional soft tissue reconstruction
Second
toe
transfer
Osteoplastic
reconstruction
Distraction
lengthening
Pollicization/on-
top-plasty
Amputation with destruction of the TM
joint
+++
+++
Pollicization standard option for the TM
joint and thumb reconstruction
Creation
of
stable
post
must
ensure
appropriate position
First webspace will likely require additional
soft tissue reconstruction
Pollicization
Second-toe
transfer
with
TM fusion
aOptions in bold indicate the first-line reconstructive options when appropriate.
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Soft Tissue Deficit With Acceptable Length (at or Distal to the IP Joint)
These injuries require only the restoration of a soft tissue envelope to maintain the remaining thumb
length. Dorsal soft tissue loss can be adequately covered by any soft tissue procedure because there is no
need for normal sensibility in this area. Wounds of the volar pulp with adequate remaining soft tissue
and no exposed bone can achieve excellent functional and cosmetic outcomes with good wound care.
Significant volar soft tissue loss with exposed bone or tendons require sensate and durable
reconstruction. Local, regional, and microvascular flaps can all be considered; the best option is selected
after considering the patient’s needs.
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Local and Regional Flaps
Moberg Flap
The Moberg flap is a bipedicle neurovascular advancement flap from the proximal volar thumb. 8 Because
this flap advances in line with the longitudinal neurovascular pedicle, it has a limited range and is only
indicated for defects less than 1.5 cm. A proximal transverse incision at the MCP flexion crease, leaving
the neurovascular bundles intact, provides greater advancement up to 2 cm but requires a skin graft in
the donor site. 9 V-Y or bilateral Z-plasty modifications at the proximal incision yield a similar
advancement without the need for a skin graft. 10,11 Although this flap has the advantage of using the
native glabrous skin and normal sensibility, IP joint flexion is frequently required to get complete distal
coverage and patients may be left with a residual IP joint contracture.
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First Dorsal Metacarpal Artery (FDMA) Flap
The FDMA flap (Foucher or kite flap) is a regional flap based on the FDMA supply to the dorsal aspect of
the index finger. 12 The flap can include all of the dorsal skin and soft tissue between the MCP and PIP
joints of the index finger. The proximal soft tissue pedicle includes dorsal veins and branches of the
superficial radial nerve, making it a sensate flap. A key aspect in the flap dissection is to preserve the
paratenon over the index finger extensor tendon for a subsequent skin graft to the donor site. After
dissecting the pedicle back to the origin of the FDMA, it can then be transposed to the thumb tip either by
tunneling under the remaining thumb skin or dividing the bridge during inset. Including a proximal skin
paddle in the flap design to inset along the thumb is helpful in avoiding compression of the pedicle
(Figure 84.2). This flap is reliable and provides a significant amount of tissue for large defects. The static
two-point discrimination (s2PD) of the dorsal index finger is 12 to 15 mm and this sensibility is
maintained in the standard flap design. 12-14 Patients may have double-sensitivity, experiencing sensation in
the dorsal index finger when using the thumb; however, some patients are able to cortically reorient over
time. 14,15 An alternative is to divide the radial nerve branches proximally and perform a neurorrhaphy to
the proper digital nerves of the thumb to restore normal cortical function and this may improve s2PD to
8 mm. 13 With careful dissection of the pedicle, the flap can be mobilized to reach the tip of the native
volar thumb 16 ; however, this often requires IP joint flexion or thumb adduction. 13 An additional
limitation of this flap is the conspicuous donor site.
FIGURE 84.2 A. Thumb amputation immediately distal to the IP joint. An FDMA flap dissected with proximal skin extension
(B) and wide soft tissue pedicle preserving paratenon (C). An inset of a flap to tip of thumb without tunneling (D) and good tip
coverage (E).
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Cross-Finger Flap
A cross-finger flap from the dorsal aspect of the index finger is another option for distal thumb coverage.
The flap is designed over the proximal phalanx of the index finger and raised in the standard fashion
with the donor site covered by a full thickness skin graft. 17 A flap from the dorsal middle phalanx of the
index or long finger has also been reported. 18 After the initial inset, the patient is brought back to the
operating room for flap division after 2 to 3 weeks. Reported sensory recovery is variable and ranges
between poor (>12 mm s2PD) and normal (<6 mm s2PD) sensation, and can take more than a year for the
final outcome. 18 Several modifications of the flap to improve sensibility are described; branches of
superficial radial nerve can be isolated during proximal flap dissection and pedicled during flap inset 19
or these nerves can be divided and neurorrhaphy performed to the digital nerves of the thumb. 20 Though
this flap has the advantage of being easily executed, the donor site morbidity, need for two operations,
and potential index finger and thumb stiffness due to prolonged immobilization 21 limit the routine use of
this technique.
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Heterodigital Neurovascular Island Pedicle (Littler) Flap
The Littler flap 22 is a flap transferred from the ulnar aspect of the middle finger or radial aspect of the
ring finger to the thumb tip. The flap is harvested from the hemipulp of the respective finger and
transferred on the neurovascular pedicle after dissection through the palm. The donor site is covered with
a skin graft. Due to the inclusion of the donor digital nerve, most patients have s2PD <8 mm but suffer
from double-sensitivity. 14,23 Cortical reorientation is rare and can take more than 18 months. 23 Division of
the nerve and coaptation to the thumb digital nerves result in minimal loss in s2PD (<10 mm) but better
cortical integration. 24,25 Due to the issues with donor site morbidity, significant dissection in the palm,
and poor cortical reorientation, routine use of this flap should be limited to use in combination with other
methods for subtotal thumb reconstruction as discussed later.
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Microsurgical Soft Tissue Reconstruction
Microsurgical reconstruction of distal thumb soft tissue defects has the advantage of transferring sensate
soft tissue to the thumb while limiting morbidity to the already injured hand. The most common method
is the free toe-pulp flap taken from the lateral great toe, though the second toe is an alternative donor site.
26,27 With standard microsurgical techniques, the success of these flaps is greater than 95% and static 2PD
<5 mm can be achieved. 27 Partial great and second toe flaps can be customized with skin, skin and bone,
and portions of the nail matrix 28 adhering to plastic reconstructive principles of replacing like-with-like
and maximizing the function and aesthetic appearance of the thumb. Details of flap options anatomy,
dissection, and donor site considerations are discussed in the section on toe-transfers.
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