Abstract book - ESPRAS

As regard the level of amputation, scapulothoracic amputation with brachial
plexus root avulsions represented the only real absolute contra-indication to
replantation. Amputations through the arm to the wrist have the potential for
recovery of useful functions, and should be attempted in selected cases after
careful evaluation. The same evaluation and case selection is recommended
for single digit and distal digital amputations.
There is general agreement on the absolute indication for replantation of the
thumb, mid-palm, wrist, and forearm level in children so long as the part is
not severely crushed.
Microsurgical repair of the tiny vessels of infants makes the operation
technically difficult; on the other hand, functional return after replantation
of digits in small children is often quite good. In the elderly, useful
functional recovery cannot be expected with any reliability, thus any
attempt at replantation in elderly patients should be carefully weighed
against the potential systemic insult from the anesthesia and operation.
Clean, minimally crushed amputations yield the best results after replantation.
Avulsion injuries, severely contaminated wounds, and amputations with
multiple levels of injury are poor choices for replantation. Microsurgical repair
in cases where the entire finger has been degloved does not result in good
function.
Kleinert vi believes that 12 hours or more of warm ischemia is a relative
contraindication to digital replantation. Prompt cooling of the amputated digit
to 4°C prolongs the acceptable ischemic period to over 24 hours, with a good
chance of complete survival and full functional return.
Regarding the patient selection, his/her occupation, economic and social
status, nationality, mental health and cooperativeness must all be taken
into account when deciding whether to attempt replantation or not.
When performing a replantation, one must be particularly careful to place
the anastomoses outside the zone of injury and to incorporate only
undamaged vessel ends. Excessive shortening of replanted parts results in
muscle-tendon imbalance and dysfunction.
The operative sequence varies according to the clinical situation and
surgeon's preference. A common approach involves the following steps:
- preoperative patient evaluation and preparation
- identification of structures in amputated part
- identification of structures in the amputation stump
- bone shortening (minimal) and bony fixation
- muscle-tendon unit repair
- nerve repair
- arterial repair (with or without recirculation)
- venous repair
- skin closure or soft tissue coverage
There are as many different standards for evaluating functional recovery
after replantation (for sensation, motor outcomes, assessment to cold
intolerance and all the indicators of complications) as there are reporting
surgeons vii .
For failed replants or for extremities that cannot be replanted at the time of
injury, function can be partially restored by toe-to-finger or toe-to-thumb
transplant. Leung viii and Frykman ix describe the technique and functional
results of these transfers.
Transplantation of composite tissue allografts, such as a hand, offers
immense potential in reconstructive surgery. Thus far, six human hand
transplants have been performed with various degrees of success. A