Reimplantation and

microsurgical
techniques
 Reimplantation
Definition: Preserve and
surgically reattach
amputated
extremity/digit

Aim: Restoration of
function and cosmesis
 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
 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
 Level of amputation
 Transhumeral, elbow,
mid forearm most
favourable outcome
 Distal tip amputations
fare worse
 Thumb attempt at
reimplantation/toe
transfer
 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
 Mechanism of injury
 Sharp, clean, guillotine
amputations most
favourable outcome

 Avulsions, crush injuries

worse

 Compounded by thermal,
chemical injury
 Age related factors
Children best outcome:though technical difficulty
operatively.

Improved healing potential, better neuroplasticity

Spontaneous neurotisation. Faivre(2003). France

Outcome less favourable with age/concomitant

disease
 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
 Transportation
 Physiological saline
 Moist swab
 Sterile container
preferable
 Placed on ice/water-
temp ~40
 Digit functions
 Thumb-post in pincer
grasp
 Index-with thumb,
prehensile function
 Ring and small-grip
 Loss index
tolerated,middle
compensates
 Indications-summary
 Thumb amputations
 Multiple digits
 Any digit in child
 Wrist/forearm amputations
 Amputation distal to FDS insertion
 Contraindications
 Crushed, avulsed extremities/digits
 Amputations at multiple levels
 Amputations distal to DIPJ
 Arteriosclerotic disease
 Severely injured patients
 Mentally unstable patients
 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
 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
 Immediate post op care
 Well padded dressing, tips exposed
 Elevation
 Warm environment
 Analgesia
 Thrombolysis
 Regular 30 min circulatory assessment initially
 No tobacco smoke/caffeine
 Vascular monitoring
 Colour-
 Turgor
 Capillary refill
 Pulse oximetry
 Fluorescein – dermal fluroscanning
 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.
 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
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)

 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
 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)
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
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
Toe wrap technique-cont.
 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
 Rehabilitation cont
 Sensory relearning

 Improvement of prehensile and power grip

strength

 Aim to get patient to working capacity again

 Psychological counselling
 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
Thank you