re implantation and micro surgical techniques
DESCRIPTION
overview of replantaion surgery for digit amputation and basic of microsurgeryTRANSCRIPT
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Reimplantation and Reimplantation and microsurgical microsurgical
techniquestechniques
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Reimplantation
Definition: Preserve and surgically reattach amputated extremity/digit
Aim: Restoration of function and cosmesis
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Historical
Malt(1962): Massachusetts first reimplantation of severed arm
Chen (1962) Shanghai, China first hand reimplantation
Emerging microsurgical technology Kleinert (1966), revacularised thumb Komatsui(1968), thumb reimplantation
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Factors related to outcome
Level of amputation: proximal v distal Mechanism of injury: Guillotine v crush Contamination of wound Age of patient Ischaemia time Delay to theatre Smoking/caffeine/diabetes Patient motivation/expectations/compliance
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Level of amputation
Transhumeral, elbow, mid forearm most favourable outcome
Distal tip amputations fare worse
Thumb attempt at reimplantation/toe transfer
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Level of amputation
Multiple digit loss-aim to have at least pincer grasp(thumb-index/middle)
Aim for power grip (ring/small)
May require autogenous salvage harvest from amputated extremity
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Mechanism of injury
Sharp, clean, guillotine amputations most favourable outcome
Avulsions, crush injuries worse
Compounded by thermal, chemical injury
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Age related factors
Children best outcome:though technical difficulty operatively.
Improved healing potential, better neuroplasticitySpontaneous neurotisation. Faivre(2003). France
Outcome less favourable with age/concomitant disease
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Ischaemia time
Warm ischaemia time < 6hrs, but reports up to 20 hours Increased risk of systemic complications,
dependant on muscle mass, myonecrosis
Cold ischaemia temp, cooling to 40
Reports up to 30 hours preservation
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Transportation
Physiological saline Moist swab Sterile container
preferable Placed on ice/water-
temp ~40
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Digit functions
Thumb-post in pincer grasp
Index-with thumb, prehensile function
Ring and small-grip Loss index
tolerated,middle compensates
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Indications-summary
Thumb amputations Multiple digits Any digit in child Wrist/forearm amputations Amputation distal to FDS insertion
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Contraindications
Crushed, avulsed extremities/digits Amputations at multiple levels Amputations distal to DIPJ Arteriosclerotic disease Severely injured patients Mentally unstable patients
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Surgical strategy
Wound debridement Identification and tagging of structures Shortening and Stabilisation of bone Flexor tendon repair Arterial anastomosis Nerve repair Extensor tendon repair Venous anastomosis Skin coverage/closure
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Microsurgical techniques
Developed for the repair/anastomosis of small BV and nerves
Transfer of composite tissue grafts Loupe magnification –x5 Microscope-x16-40 Microsurgical instrumentation Microsurgical skill/experience
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Immediate post op care
Well padded dressing, tips exposed Elevation Warm environment Analgesia Thrombolysis Regular 30 min circulatory assessment initially No tobacco smoke/caffeine
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Vascular monitoring
Colour- Turgor Capillary refill Pulse oximetry Fluorescein – dermal fluroscanning
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Failing replant-vascular compromise
Vasospasm- treat underlying cause
Arterial insufficiency:pale cold digit, treat with vascular recon
Venous engorgement-most common, either vascular recon or venous drainage.
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Rehabilitation
Individualise to patient 5 anatomical ‘systems’ involved(skin,tendon,
nerve, vascular and bone) Splintage-dorsal blocking- after anticoagulation-
usually -day 5 post op Early protective motion and exercise 3/52-
Silvermann regime:J Hand Surg2:2 Apr-Jun 1989
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Chen grading of recovery
Grade I- >60% recovery function. Gd4/5 above motor/sensory recovery.Full work
Grade 2->40% recovery motor/sensory grade ¾ above. Suitable work
Grade 3->30% recovery, Activities of daily living
Grade 4-no useful function of replanted limb
• Chen et al: World J Surg 2-513 (1978)
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Results
Survival: variable results above elbow 60-80%, forearm, 40-60%. Digit: 80% adults
Function- Chen grading. 68% excellent/good outcome Largest study: Waikakul et al, Thailand
– 1018 replantations in 552 patients.(336m/186f)– Minimum 2 year FU– 92% ‘successful’ outcome– 69%- Chen I/II grades. 7% in gradeIV– Poor prognosis with type injury, smoking,prolonged
ischaemia• Injury 2000 Jan;31 (1):33-40
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Composite free tissue transfer from foot
Foot versatile donor for tissue transfer Sural nerve nerve graft EDB /neurovascular pedicle First and second toe transfers Dorsalis pedis cutaneous/nv transfer First web space neurovascular transfer Other techniques(toe wrap,trimmed toe
transfer,twisted two toes, free vascular joint transfer)
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Toe to thumb transfer
Most studies less than 10 patients
Tsubokawa et al (2003) Longest FU 10-22 yrs 80% grip strength
achieved Main problems: extension
lag, flexion contracture, early OA– J Hand Surg(Am).2003
May:28(3):443-7
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Toe wrap technique
Harvesting of distal great toe with neurovascular pedicle and transfer
Harpf et al (2002) 5 male patients, no
complications. 2pd 8-15mm. 79% grip strength, 90% pinch grip– Harpf et al :Handchir
Mikrochir Plast. Chir.2002 Mar:34(2):95-102
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Toe wrap technique-cont.
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Free vascularised toe joint transfer to hand
Kimori et al: Hiroshima Hand and Microsurgery centre
12 patients Age range 7-47 Post op FU: 9-48 months Av ROM: PIPJ: 590 – MCPJ:540
No donor foot problem– J Hand Surg (Br).2001 Aug:26(4):314-20
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Rehabilitation cont
Sensory relearning
Improvement of prehensile and power grip strength
Aim to get patient to working capacity again
Psychological counselling
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Summary
Reimplantation successful procedure Careful pre-op assessment and case
selection required Outcome influenced many factors Importance of rehabilitation Aim to preserve function and cosmesis
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Thank you