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Indications

Indications for replantation after trauma


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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
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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
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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
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time to replantation

warm ischemia time < 6 hours

cold ischemia time < 12 hours

distal to carpus (digit)

warm ischemia time < 12 hours

cold ischemia time < 24 hours

general operative sequence of replantation (beavfns)


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bone fixation +/- shortening (after irrigation and debridement of soft-tissue and bone)

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extensor tendon repair

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artery repair(repair second after bone if ischemic time is >3-4 hours)

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venous anastomoses

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flexor tendon repair

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nerve repair

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skin +/- fasciotomy

finger order

proximal to carpus

thumb, long, ring, small, index

for multiple amputations structure-by-structure sequence is most efficient

Postoperative Care
Environment

digit-by-digit sequence takes the most time

keep patient in warm room (80F)

avoid caffeine, chocolate, and nicotine

Replant monitoring
o

skin temperature most reliable

pulse oximetry

< 94% indicates potential vascular compromise

Anticoagulation
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adequate hydration

medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)

Arterial Insufficiency
o

concerning changes include a > 2 drop in skin temp in less than one hour or a temperature

treat with

release constricting bandages

place extremity in dependent position

consider heparinization

consider stellate ganglion blockade

early surgical exploration if previous measures unsuccessful

thrombosis secondary to vasospasm is most common cause of early replant failure

Venous congestion
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treatment

elevate extremity

leech application

Complications

releases Hirudin (powerful anticoagulant)

Aeromonos hydrophila infection can occur (prophylax with Bactrim or ciprofloxac

heparin soaked pledgets if leeches not available

Replantation failure
o

Stiffness
o

replanted digits have 50% of total motion

tenolysis is most common secondary surgery

Myonecrosis
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most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm

greater concern in major limb replantation than in digit replantation

Myoglobinuria
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caused by muscle necrosis in larger replants (forearm and arm)

can lead to renal failure and be fatal

Reperfusion injury
o

mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine

allopurinol is the best adjunctive therapy agent to decrease xanthine production

Infection

Cold intolerance

Indikasi untuk replantation setelah trauma


o indikasi utama
jempol di tingkat manapun
beberapa digit
melalui telapak tangan
tingkat pergelangan tangan atau proksimal pergelangan
hampir semua bagian pada anak-anak
o indikasi relatif
digit individu distal penyisipan superfisialis fleksor digitorum [FDS] (Zona I)
cincin avulsion
melalui atau di atas siku
Kontraindikasi replantation
o kontraindikasi utama
gangguan pembuluh darah yang parah
hancur tungkai atau crush injury

segmental amputasi
berkepanjangan waktu iskemia dengan konten otot besar (> 6 jam)
o kontraindikasi relatif
satu digit proksimal ke FDS penyisipan (Zona II)
pasien medis tidak stabil
menonaktifkan penyakit jiwa
kontaminasi jaringan
waktu iskemia yang berkepanjangan tanpa konten otot (> 12 jam)

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