Indian Journal of Plastic Surgery
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REVIEW ARTICLE
Year : 2013  |  Volume : 46  |  Issue : 2  |  Page : 256-264
 

Unfavorable results in replantation


Department of Plastic Surgery, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication21-Sep-2013

Correspondence Address:
Abraham G Thomas
Professor of Plastic Surgery, Christian Medical College, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0358.118602

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 » Abstract 

Reattachment of amputated parts of the body (Replantation) has become a reality since the first arm replant was carried out six decades ago. Failures were not uncommon in the beginning, leading on to the analysis of the problem and refinements in technique. Improvements in sutures, instrumentation and better microscopes further helped the surgeons to do replantation with better finesse and functional results. Evaluation of results and particularly failure and long term results help the younger surgeons to learn from the difficulties faced earlier to do better in the future. An attempt is made to list various aspects of replantation experienced by the author during the past 30 years, particularly in reference to unfavorable results, which had been occasionally total failure, or a partial failure, with poor function and cosmesis due to infection. An insensate limb with poor function is the result of inadequate or improper nerve coaptation or infection destroying the whole repair. It is apt to mention that infection is mostly the result of poor vascularity due to devitalized tissue. Difficulties arise often in identifying the viable tissue, particularly while debriding in the distal amputated part since there is no bleeding. Experience counts in this, specifically to identify the viable muscle. The factors that may lead to complications are listed with remarks to avoid them.


Keywords: Replantation, failed repalnts; insensate replant


How to cite this article:
Thomas AG. Unfavorable results in replantation. Indian J Plast Surg 2013;46:256-64

How to cite this URL:
Thomas AG. Unfavorable results in replantation. Indian J Plast Surg [serial online] 2013 [cited 2019 Apr 20];46:256-64. Available from: http://www.ijps.org/text.asp?2013/46/2/256/118602



 » Introduction Top


Twentieth-century witnessed rapid changes in many surgical fields, thanks to better anesthesia, antibiotics and innovations in instrumentation and sutures. Reconstructive surgery benefitted from the introduction of microscope as the surgeons discovered that magnification helps in seeing better and also helps in repairing the structures with finesse, till then unknown.

As a result of all these, evolved the arm replant in 1962 by Malt and McKhann [1] and later in 1965 by digital reimplantation by Komatsu and Tamai. [2] The success and failure which were based on the restoration of the part or total failure, and recovery of function or delay, or absence of it, were the hard facts the patients and surgeons realized, mistakes and complications were analyzed and this led to various improvements in technique to get better outcome. Replantation of other parts soon followed.


 » Review Top


We have to realize the importance of microscope and sutures, which made replantation a reality and the refinements of these two over the years, which has made it possible for us to see much better and also suture with least trauma to the vessels. The knowledge of the pathophysiology of injury and the physiology of blood flow helped to reduce the failure rate. Anatomy got more attention, specifically about vascular anatomy, and the knowledge of myocutaneous flaps and vascular territories further prompted one to look into the anatomical structure of the small blood vessel. Microvascular anastomosis is nothing but the coaptation of two blood vessels in its best form, with the least of trauma and tension.

The initial glamour of putting back amputated digits or limbs faded away when the function was unsatisfactory and in fact resulted in more of a burden for the recipient. The cause and nature of injury, the effect of changes of temperature on the devascularized part, reperfusion changes that may result in the body, [3],[4] all added to refinements and perfecting the technique of reimplantation.

Kleinert [5] and Tamai [6] have listed in detail the long-term results and analysis of replants, which holds true even today.

In ideal conditions, a perfect result is expected, [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6] although there are instances where nothing can be done [Figure 7] and [Figure 8]. However, when the segments are long enough, it is possible to use one or two of them for thumb and an opposable digit [Figure 9].
Figure 1: Finger replant in child

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Figure 2: Finger replant in child - result a year later

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Figure 3: Hand replant in child and result 5 years later

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Figure 4: Hand replant in child and result 5 years later

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Figure 5: Hand replant in child and result 5 years later

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Figure 6: Thumb replant in an Adult

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Figure 7: Amputation of Multiple digits - replantation not possible

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Figure 8: Amputation of Multiple digits - replantation not possible

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Figure 9: Amutation of finger long enough to replant -priorty for thumb and few opposable digits

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Even after shortening, acceptable aesthetic results are possible [Figure 10], [Figure 11] and [Figure 12]. Further, it is also true in major crush injuries where shortening was needed [Figure 13] and [Figure 14], that a good functional and aesthetic result are obtained.
Figure 10: Shortened limb in an Adult

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Figure 11: Below shoulder amputation in a child

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Figure 12: Shortened limb in a Child but adapts well with satisfactory function

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Figure 13: Major crush amputation in young Adult

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Figure 14: Major crush amputation in young Adult - shortened , Debridement done to live bleeding tissue proximally and muscles without maceration or crush distally, with satisfactory function

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Major crush amputation in young Adult - shortened. Debridement done to live bleeding tissue proximally and muscles with maceration or brush distally with satisfactory function.

That brings to the fore, what are ideal or not so ideal conditions and the unfavorable results.

Amputation or loss of body part is an unfortunate incident, some due to sharp objects, others due to blunt objects or associated with crush or avulsion injuries.

Amputation due to sharp objects is guillotine. After proper evaluation of the parts under good light and magnification and minimal debridement to rid of ragged or devitalized tissue, suturing and anastomosis will give good results. However, with crush, minimal or major or avulsion injuries the parts have received trauma to destroy considerable amount of tissue which will have to be debrided.

From the surgical principles it is amply true that body will not accept any dead or devitalized tissue.

It is here the decision to replant or not replant that is crucial, based on severity of injury, ischemia time or other associated injuries.

Debridement will definitely lead to shortening, which is acceptable as long as function is kept as the goal, especially in upper limb. Aesthetic result is important when we encounter scalp, face or parts of it. Patients perception of the result varies, especially in India and the decision to replant or not has to be also based on patient's desire and need.

So what are the unfavorable results?

  • Total failure - this can be due to poor decision or due to poor technique on the part of the surgeon or rarely due to associated problems related to blood coagulability
  • Anatomical restoration, but poor function due to muscle atrophy as a result of ischemia, due to poor nerve coaptation or joint dysfunction or due to infection, resulting in scarring
  • Anatomical restoration but no function or sensation. This is one of the worst problems a patient will have to live with, as an anesthetic limb will be more of a burden.
The above can be avoided or decreased by having;

  • An organized team approach to replantation. This will speed up the procedure. Reduce ischemia time by proper and quick bone fixation and use of appropriate vascular clamps to prevent damage to vessels
  • Proper assessment of the parts and adequate debridement to bleeding live tissue on the proximal part and debriding loose crushed tissue on the distal part or muscles without maceration and showing pink color
  • Meticulous nerve coaptation. It is advised to repair the nerves after vascular anastomosis. I have always preferred to bring the end of the nerves together, before vascular anastomosis and then suture the nerves subsequently without fear of prolonging the ischemia period
  • Adequate postoperative monitoring, splintage, and physiotherapy
  • Vocational rehabilitation, if necessary.
The indicators for poorer outcome are [7]

  • Major crush or avulsion injury
  • Ward ischemia of more than 5 h or
  • Cold ischemia of more than 12 h
  • Multiple levels of injury
  • Nerve avulsion or crush
  • Associated major trauma
  • Poor patient compliance.

 » Organisation of a Team Top


Replantation is done well only if the whole procedure is well planned and executed sequentially to give optimum results. Stray attempts can lead to frustration for the surgeon, as the success and functional recovery may not be as expected for the time and effort spent.

A good hospital set up, with operation theatre (OT) and blood bank, surgeons, nurses, technicians, attendants, therapists and social workers, are all part of this and the period from the emergency room to discharge of the patient and therapy thereafter is part of the whole protocol of management. Replantation should be undertaken only if the team approach can be followed.

It is essential that at least two doctors are part of this team, as the work starts from emergency room to theatre simultaneously if the decision has been taken to replant.

Bench dissection of the amputated part is undertaken in the OT, while the patient is prepared for surgery. This gives a chance to decide whether the part can be replanted or not, is shortening necessary, whether a graft is necessary. Many a time an error in judgment during this vital procedure leads to disastrous results. Bench dissection also reduces the operating time when the patient is anesthetized. If there is a delay in surgery and vascular anastomosis, it is advisable to keep the amputated part cooled by ice, or in the fridge itself in a sterile container.

Any patient, who has suffered a traumatic amputation from whatever cause, will definitely look forward to have his limb or body part reattached to the body. The patient and the relatives will go to any extent to have this facility available. The onus of deciding to do reattachment or not, depends on the surgeon and his team, also weighing into consideration the pros and cons of reattachment. This includes well discussed criteria like ischemia time, cause of injury, nature of the wound, the trauma to the other parts of the body and general condition of the patient, and definitely the vocation and socio-economic factors. I would also add that reattachment surgery is a very demanding surgical procedure which needs the wholehearted commitment and perseverance of the surgeon and his team. The willingness to perform the replantation, irrespective of personal difficulties, is an important factor for the commitment of a surgeon.

Indications and contraindications for replantation have been discussed many times in all the literature and are available for review. [8],[9]

  • Preservation technique and transportation [Figure 15].
    Figure 15: The Crushed ice should not come into direct contact with the amputated segment to prevent absorption of water which may damage the cells. Ideal preservation for transportation is in a polythene cover placed in a thermacol containing ice

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The crushed ice should not come into direct contact with the amputated segment to prevent absorption of water which may damage the cells.

Ideal preservation for transportation

  • The amputated part is covered with an wet gauze or cloth soaked in saline and placed in a thermacol containing ice. Under no instance should water or ice be in direct contact with the part. Unfortunately, many possible replants could not be done as parts were brought in cold water or ice
  • Identification of crushed or devitalized tissue: very often, in the urgency to do a replantation, the surgeon may not appreciate the vascularity of all the tissues. It is important that only viable tissue be preserved; failing which one can guarantee infection and subsequent failure of the entire replanted part [Figure 16].
    Figure 16: Fingers inadequately shortened and debrided, leading on to gangrene and total loss

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Fingers inadequately shortened and debrided, leading on to gangrene and total loss

  • There are examples of this which I have come across in my personal experience, mainly because of inability to identify it at the time of re-plantation. The fear of shortening the limb also adds to this. Some examples of this are shown in the figures [Figure 17]
    Figure 17: Inadequately debrided and shortened, limb and digit lead to loss of tissue infection and poor function. (a): Inadequately debrided and shortened, limb and digit lead to loss of tissue, infection and poor function

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Inadequately debrided and shortened, limb and digit lead to loss of tissue, infection and poor function. Where the limb ultimately survived but required additional procedures. Very often the function suffers as a result of this

  • Shortening: Decisions to shorten the limb to get rid of the devitalized tissue is very important. This error in judgment can lead to ''gaps'' in the replanted part, leading to ultimate disruption of the vessels or nerves and futur
  • Bone fixation in re-plantation: Speed is essential to delay further ischemia to tissues and appropriate use of bony stabilization should be determined in the beginning. It is necessary that too much of stripping of the bone and dissection of the muscles be avoided and plates or K-wires may be used as necessary
  • I would always suggest that one or two arteries and at least two veins be identified and dissected free before fixing the bone. It has been my practice that I do at least one artery and one or two veins before I release the vascular clamps on the vessels. The anastomoses, needless to say, have to be perfect, without tension, well placed, with least trauma or leak. Use grafts in avulsion injuries [Figure 18] or when there is tension in avulsed digit replanted with vascular (vein) graft to bridge the gap deficiency in vessel which had to be debrided to rid of damaged intima, usually seen in avulsed injury
    Figure 18: Avulsed digit

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Re-anastomosing the blood vessels and also the nerves. Tension free anastomosis is necessary to give pulsatile flow to the distal extremity. Similarly, nerves should be co-opted as a primary procedure, whenever feasible, to get the best functional results [Figure 19]
Figure 19: Avulsed digit as in figure 18 replanted with vascular (vein) graft to bridge the gap in vessel which had to be debrided to rid off damaged intima.

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  • Identification of the nerves and proper coaptation should be done always as a primary procedure. The only exception for delay is severe avulsion injury if general condition of the patient which warrants delay. An anesthetic limb without any function will be a burden for a patient in activities of daily living and hence all attempts are made to repair the nerves [Figure 20]
    Figure 20: Poor nerve function and stiff hand

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  • Tension free closure of the skin is important to prevent dehiscence or contracture, use additional flaps if necessary at the time of replantation [Figure 21] and [Figure 22]. In partial amputation, the decision to attach adequate veins should be taken in case of ''reverse flaps,'' especially in the extremities to prevent flap loss [Figure 23] and [Figure 24].
    Figure 21: Avulsion amputation - reattached and additional cover provided by groin flap primarily

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    Figure 22: Avulsion amputation - reattached and additional cover provided by groin flap primarily

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    Figure 23: Distal hand near total amputation

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    Figure 24: Distal hand near total amputation - veins not anastomosed leading to gangrene of digits Distally based flaps may need venous anastomosis to prevent congestion

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Distal hand near total amputation - veins not anastomosed leading to gangrene of digits.

Distally based flaps may need venous anastomoses to prevent congestion

  • Adequate splinting helps prevent disruption of the reattached portion of the body. This also involves a splint which allows early mobilization of joints to get the best functional results
  • Physiotherapy, counseling and vocational training [Figure 25]. In an extremity, surgery contributes to only 50% of the procedure and the other major factor is the therapy to make the limb functional. The patient and the relatives should be made to understand this and there can be no excuse for delay in timely physiotherapy.
    Figure 25: Physiotherapy is essential for return of function in Adults and Children - Children adapt well to toys, blocks, and modeling clay

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Physiotherapy is essential for return of function in Adults and Children - children adapt well to toys, blocks, and modeling clay.

In lower limb, if shortening is minimal, replant or revascularization should be considered, which will be better than a prosthesis, as long as sensation is preserved [Figure 26] and [Figure 27].
Figure 26: Near total leg amputation

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Figure 27: Near total leg amputation. Revascularized with minimal shortening

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In scalp replantation, although it is an avulsion injury, with careful dissection and planning, it should be possible to save many an avulsed scalp. We have found that when veins are not available for outflow, the opposite artery could be anastomosed to a vein for the blood to flow out with satisfactory results [Figure 28].
Figure 28: Scalp reattached. No suitable vein available in the avulsed segment. Opposite artery attached to vein with survival

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Replantation of a digit, limb, or body part should be undertaken whenever feasible, as there is no substitute for one's own body part. Life threatening injuries should be weighed against reimplantation when called for. Replantation needs dedication, perseverance, and commitment on the part of the surgical team and motivation from the patient. The problems or complications listed are realized and prevent such untoward results for the future and any unavoidable complication should be a lesson for better technique.

In short, factors to prevent unfavorable results are



 
 » References Top

1.Komatsu S, Tamai S. Successful replantation of a completely cut off thumb. Case report. Plast Reconstr Surg 1968:42:374.  Back to cited text no. 1
    
2.Maft RA, McKhann CF. Replantation of severed arms. JAMA 1964;189:716-22.  Back to cited text no. 2
    
3.Waikakul S, Vanadurongwan V, Unnanuntana A. Prognostic factors for major limb reimplantation at both immediate and long term follow up. J Bone Joint Surg Br 1998;80:1024-30.  Back to cited text no. 3
[PUBMED]    
4.Wood MB, Cooney WP. Above elbow reimplantation functional results. J Hand Surg Am 1986;11:682-7.  Back to cited text no. 4
    
5.Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma 1998;20:390-8.  Back to cited text no. 5
    
6.Tamai S. Twenty years' experience of limb replantation. Review of 293 upper extremity replants. J Hand Surg Am 1982;7:549-56.  Back to cited text no. 6
[PUBMED]    
7.Medling BD, Bueno RA, Russell RC, Neumeister MW. Replantation outcomes. Clin Plastic Surg 2007;34:178.  Back to cited text no. 7
    
8.Van Beek AL, Kutz JE, Zook EG. Importance of Ribbon Sign, indicating unsuitability of the vessel. Plast Reconst Surg 1978;61:32-5.  Back to cited text no. 8
[PUBMED]    
9.Wilson CS, Alpert BS, Bunke HJ, Gordon L. Replantation of the upper extremity, "Red line Sign". Clin Plast Surg 1983;10:88.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28]


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