Replantation : things you should know

Indications

Indications for replantation after trauma  primary indications thumb at any level  multiple digits  through the palm wrist level or proximal to wrist  almost all parts in children relative indications individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I)  ring avulsion through or above elbow Contraindications to replantation primary contraindications severe vascular disorder mangled limb or crush injury  segmental amputation  prolonged ischemia time with large muscle content (>6 hours) relative contraindications single digit proximal to FDS insertion (Zone II)  medically unstable patient disabling psychiatric illness tissue contamination prolonged ischemia time with no muscle content (>12 hours)

Treatment

Transport of amputated tissue indications any salvageable tissue should be transported with the patient to hospital modality keep amputated tissue wrapped in moist gauze in lactate ringers solution place in sealed plastic bag and place in ice water (avoid direct ice or dry ice) wrap, cover and compress stump with moistened gauze Operative time to replantation proximal to carpus warm ischemia time < 6 hours cold ischemia time < 12 hours distal to carpus (digit) warm ischemia time < 12 hours cold ischemia time < 24 hours

ORDER  OF  REPlantation

 After  all  structures  have  been  thoroughly  cleansed,  débrided, and  identified,  repair  is  begun.  As  indicated  in  the  discussion that  follows,  certain  conditions  or  circumstances  dictate  a variation  in  the  order  of  repair.  The  following  is  our  usual order  of  repair  of  damaged  structures.  Discussions  of  digit, hand,  and  arm  replantations  are  included.

1.  Shorten  and  internally  fix  bone.
2.  Repair  extensor  tendons.
3.  Repair  flexor  tendons  (2  and  3  may  be  reversed,  or  flexor tendon  repair  may  be  delayed).
4.  Repair  arteries.
5.  Repair  nerves.
6.  Repair  veins.
7.  Close  or  cover  wound.

If  time  permits,  we  often  repair  the  veins  immediately after  extensor  tendon  repair.  This  minimizes  repositioning  of the  hand  and  allows  for  venous  anastomosis  in  a  bloodless f ield.  It  also  may  minimize  venous  congestion.  Also,  if  time permits,  it  is  easier  to  repair  the  nerve  just  before  repairing the  artery.