DIGITAL REPLANTATION

    What is the goal of digital replantation?

Equivalent or improved function when compared to revision amputation and prosthesis.

    What are the current indications for digital replantation?

•  Thumb

•  Multiple digits

•  Single digit distal to sublimis

•  Hand at the wrist or forearm (sharp amputation)

•  Any level amputation in a child

    What is the appropriate preoperative workup for a patient with an amputated digit?

•  Evaluate and stabilize the patient using ATLS protocol.

•  Do not complete partial amputations until fully examined in operating room.

•  Wrap amputated part in moist gauze and place in plastic bag, then place on ice. Avoid direct contact with ice which can result in irreversible damage to microvascular system.

•  Administer intravenous antibiotics, and tetanus prophylaxis.

•  Radiographs of the involved hand and the amputated part.

•  Appropriate preoperative counseling and consent (include possible nerve/vein/skin graft as well as possible amputation).

    What is the order for a single digit replant?

BEFANV:

•  Bone

•  Extensors

•  Flexors

•  Arteries

•  Nerves

•  Veins

    What is the order for multiple digit replantations—digit by digit or structure by structure?

Structure by structure, systemically repairing as above.

    What are the potential advantages to skeletal shortening in digital replantation?

•  May enable more secure bone fixation

•  May minimize the need for vessel or nerve grafting

    What are the options for skeletal stabilization in digit replantation?

•  Kirschner wires

•  90–90 wiring

•  Miniplates and screw

•  Intramedullary bone pegs

    What are the functional deficits associated with ray amputation of the index finger?

Loss of power grip and key pinch.

    What is the lumbrical plus deformity?

The FDP tendon and lumbrical muscle migrate proximally after division of the tendon in trauma. With flexion, tension is exerted on the lumbrical via the radial lateral band causing paradoxical extension of the PIP during flexion of the MP joint.

    Treatment?

Division of the lumbrical insertion.

    What is the most common cause of digital replantation failure?

Arterial insufficiency.

    What is the treatment of arterial insufficiency after digital replantation?

1.  If any concern about arterial patency RETURN to OR

2.  Loosen dressings

3.  Heparin

4.  Anti-vasospastic medications (Thorazine)

5.  Sympathetic blocks

    What is the treatment of venous congestion after digital replantation?

1.  Removal of dressings

2.  Leech therapy

3.  Heparin

4.  Nail bed bleeding with heparin-soaked sponges

5.  Revision of the venous anastomosis

    Which tissue is most sensitive to warm ischemia?

Skeletal muscle.

    What is the maximal cold ischemia time reported for digital replantation?

30 to 40 hours.

    When should prophylactic fasciotomies be performed in upper extremity replantation?

With any replantation proximal to the wrist prophylactic fasciotomies should be performed because of the increased amount of skeletal muscle present.

    What is the quadriga effect?

Weakness in flexion of fingers secondary to excess pull of one FDP tendon of the amputated finger.

    What is the maximum nerve gap for use of a neural tube (PGA)?

2.5 cm.

    What nerves are available for use as donors for nerve grafting?

•  Posterior interosseous nerve

•  Sural nerve

•  Superficial radial nerve

•  Superficial peroneal nerve

    What is the treatment of choice for a tip amputation through the nail bed without bone exposure?

Local dressing changes (i.e., healing by secondary intention).

    What is a good option for a failed thumb replantation at the MCP level?

Revision amputation followed by toe-to-thumb transfer at a later date.

    What donor vessel is the toe-to-thumb transfer based on?

First dorsal metatarsal artery from dorsalis pedis artery or plantar digital artery from lateral plantar artery.

    What is a good option for a thumb-tip amputation with exposed bone?

Moberg flap.

    How much advancement can be obtained from a Moberg flap?

1.5 cm.

    What are contraindications to digital replantation?

•  Severe concomitant injuries

•  Severely crushed or mangled

•  Multilevel amputations

•  Significant comorbidities

•  Prolonged warm ischemia time

•  Mentally unstable/self-mutilation

•  Single finger proximal to FDS insertion

    How many arteries and veins are needed for a digital replantation?

One artery and one vein (two are preferred).

    Is an artery only digital replantation possible?

Yes. Leeching and/or bleeding of the nail bed can be used to relieve venous congestion.

    How many places can you find a digital vein?

Two. Dorsal and volar.

    What is the concern in avulsion amputation versus guillotine amputation?

Zone of injury is much greater in avulsion injuries.

    What is the red stripe sign?

A red streak along the artery indicating severe intimal injury along the length of the vessel.

    What is the best method for treating the zone of injury of an artery or vein in cases of crush or avulsion injuries?

Resection of compromised vessel and vein grafting.

    Where can veins be reliably found on the hand dorsum?

Proximal to each web space.

    What vascular pattern exists in a finger that was crushed and has the appearance of venous congestion and slow capillary refill?

Loss of proper digital artery inflow, intact venous flow.

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