MICROSURGICAL REPLANTATION OF DIGITS AND UPPER LIMB AMPUTATIONS

1. Replantation of a total amputation of the hand
2. Replantation of a total amputation of the distal forearm
3. Replantation and management of a frozen total thumb amputation
4. Replantation of a total amputation of the distal thumb in zone III
5. Replantation of a very distal digital amputation of the fourth finger
6. Replantation and management of mutli-digits and multi-levels digits amputations


CASE I
Replantation of a total amputation of the hand



This 27-year-old male patient has been victim of a total amputaiton of his right hand with a circular saw. The amputation crosses through the distal radio-ulnar complex. The hand was recuperated and hibernated to limit tissue and particularly muscles suffering from the ischemia.
The patient was admitted 4 hours after the accident. The upper limb stump and teh amputated hand were debrided and the bones were shortened for 1 cm to have a clean section and to avoid any traction on the tendons and vessels sutures.
The radial fracture bone was fixed with a T shaped Plate and the ulna fracture bone was secured with a straight shaped plate. All the flexor and extensor tendons were identified and repaired. The radial, ulnar and median nerves were sutured under magnification. Finally the radial artery, the ulnar artery, the lateral dorsal and medial dorsal veins were debrided and largely irrigated with heparine and saline water. They were directly anastomosed.
The replantation procedure took 4 hours long and the hand was automatically revascularized. The patient was admitted in the intensive care unit for one week where the hand was closely keeped watch.



The result after two-year follow-up with restoration of a complete flexion and extension of the digits. The pulp sensibility recuperates a very satisfiying degre of discimination.
The patient retrieves a normal life and returns to his previous work.

CASE II
Replantation of a total amputation of the distal forearm



This 55-year-old patient has been victim of a total amputation of his left hand at the level of the distal quarter of the forearm. The patient was admitted 5 hours after the accident. The X-Ray of the forearm showed an oblique amputation of the forearm bones.



A trasversal osteotomy of the distal radius and ulna extremities was done to obtain a sharp amputation and bone surfaces suitable for osteosynthesis. The radius ostosynthesis was done using an anterior radial plate while the ulna fracture was left free of any fixation liberation the prono-suppination movements. The distal radio-ulnar joint was fixed with a transversal screw. The hand was replanted as usual with large debridement and tendons, nerves, skin and vessels repair.



The results after two-year of follow-up and adpated physiotherapy. The patient retrieves a full range of digit flexion with a partial anteposition of the first ray.




CASE III
Replantation of a frozen total thumb amputation




This 69-year-old patient was wictim of a total amputation of his right thumb with a circular saw. The amputation crosses the trapezo-metacarpal joint lifting all the muscles of the thenar region.
During the transfer of the patient, the thumb was putted between two freezing plates which generated a complete freezing of the thumb tissues. At patient admission, the thumb has a hard consistency.
Regarding the importance of this digit for the hand function we decided to try a thumb revascularization in spite of the important risks of fail. We started the operation by warming the thumb until we obtained a normal tissue consistency.
We did the replantation as usual with bone, tendons, muscles, nerves and vessels repair. After tourniquet release the thumb showed a normal blood irrigation for only few minutes with rapid arterial ischemia. This signs the “No Reflow Phenomenon” which was hardly predictable. The vascular anastomosis revision shows free vessels anastomoses without any thrombi.
We started then a direct intra-arterial fibrinolysis as follows :
- A flash of 50.000 UI Urokinase, 36 cc Lidocaine 1% and 40 mg Enoxaparine Followed by an electric seringue infusion :
- for the fisrt six hours with 150.000 UI Urokinase, 36 cc Lidocaine 1% and 40 mg Enoxaparine at 6 cc / h speed. - for the next 24 hours, the Urokinase is interrupted but the Lidocaine 1% and Enoxaparine are maintained with 72 cc and 80 mg respectively and administrated at a 3 cc / hour speed. This last combination is renewed and least for ten days and more until the neo arterioles and venules are established enough to ensure an efficient irrigation of the replanted digit.
OUFQUIR A., BAKHACH J., PANCONI B., GUIMBERTEAU J.C., BAUDET J. Salvage of digits replantations by direct arterial antithrombotic infusion. Annals of Plastic & Aesthetic Surgery., 51, 6 : 471-481, 2006.



The patient was admitted in the Intensive Care Unit and observed hourly. The thumb was protected under a warm light to favourate tissue blood irrigation.
The thumb experienced an epidermolysis over all its length but still remained well vascularized. At the fiveteenth day post-replantation we stopped the intra-arterial perfusion and we replaced the anti-thrombotic treatment by an oral anti-coagulant drugs for two months.



After 14-month follow-up the patient recovers a stable first ray and a functionnal pinch. This intra-arterial anti-thrombotic protocol was the only way to save this amputates digit from the necrosis.




CASE IV
Replantation of an distal thumb amputation



This 32-year-old patient has experienced a crush traumatism of his right first ray and presented a total amputation of the distal thumb in zone III which corresponds to the base of the nail bed.



The amputated thumb is revascularized by a direct anastomoses of the central artery of the pulp through a dorsal approach. At this amputation level there no possibility to accomplish veins anastomosis. The blood outflow is ensured by slowly and continuous bleeding through a distal pulp scarification.



At the seventh day post replantation the thumb shows a good blood irrigation with a normal skin color.



The result at one-year follow-up with a good integration of the replanted thumb, a recovery of a satisfying pulp sensation and normal mobility of the thumb.




CASE V
Replantation of a very distal digit amputation



This amputation concerned a young boy who was repairing his motorbike. He experienced a very distal pulp amputation of his left fourth finger with the motorbike chain. The amputated digit which normally shall be hibernated at 4°C until its replantation was directly putted in contact with the ice and bathed in water for four hours.



The amputated digit was debrided and replanted with an arterial anastomoses on the central artery of the pulp which measured 0.6 mm. Ten minutes after tourniquet release the replanted digit showed a lack of irrigation due to a “Non Reflow Phenomenon”. An arterial catheter was introduced in the radial artery and the fibrinolytic protocol was started. This protocol is composed by :
- A flash of 50.000 UI Urokinase, 36 cc Lidocaine 1% and 40 mg Enoxaparine
Followed by an electric seringue infusion :
- for the fisrt six hours with 150.000 UI Urokinase, 36 cc Lidocaine 1% and 40 mg Enoxaparine at 6 cc / h speed. - for the next 24 hours, the Urokinase is interrupted but the Lidocaine 1% and Enoxaparine are maintained with 72 cc and 80 mg respectively and administrated at a 3 cc / hour speed. This last combination is renewed and least for ten days and more until the neo arterioles and venules are established enough to ensure an efficient irrigation of the replanted digit.
OUFQUIR A., BAKHACH J., PANCONI B., GUIMBERTEAU J.C., BAUDET J. Salvage of digits replantations by direct arterial antithrombotic infusion. Annals of Plastic & Aesthetic Surgery., 51, 6 : 471-481, 2006.
The principal aim of this intra-arterial fibrinolytic protocol is to dissolve all the blood clots which can be formed in the arteriolar network at the sites where the vessels endotheluim are injured. It maintaines an efficient arterial blood flow until the endothelial sheath retrieved a complete healing and a normal organisation.



The result after nine-month follow-up with restoration of the digit length. The scar is little constricted but the pulp recovered an effecient sensibility. The mobility of the DIP joint was not altered as well as the regrowth of the nail system.