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Plastic Surgery - HAND > Chapter 43 - Replantation > Flashcards

Chapter 43 - Replantation Flashcards

1
Q

What is the goal of digital replantation?

A

Equivalent or improved function when compared to revision amputation and prosthesis

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2
Q

What are the current indications for digital replantation?

A

Thumb, multiple digits, single digits distal to FDS insertion, hand at wrist or forearm (sharp), any amputation in a child

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3
Q

What is the appropriate workup for a patient with amputated digit?

A

ATLS, Do not complete amputation until fully evaluated in OR, wrap part in moist gauze and in plastic bag, place plastic bag in ice. IV antibiotics, Tetanus. Xrays. Consent for possible nerve/vein graft and amp as well as replant.

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4
Q

What is the order for replantation steps?

A

Bone, Extensors, Flexors, Arteries, Nerves, Veins

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5
Q

What is the order for multiple digit replantations?

A

Structure by structure (all bones, then all tendons, then all arteries, then all nerves, then veins)

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6
Q

What are the potential advantages in skeletal shortening in digital replantations?

A

May enable more secure bone fixation, may minimize need for vessel or nerve grafting

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7
Q

What are the options for skeletal stabilization in digital replantation?

A

K wires, 90-90 wiring, miniplates and screws, intramedullary bone pegs

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8
Q

What are the functional deficits associated with ray amputations of the index finger?

A

Loss of power grip and key pinch

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9
Q

What is the lumbrical plus deformity?

A

FDP tendon and lumbrical muscle migrate proximally after division of the tendon in trauma. With flexion , tension is exerted on the lumbrical via the radial lateral band causing paradoxical extension of the PIP during flexion of the MP joint

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10
Q

What is the treatment for lumbrical plus deformity?

A

Division of the lumbrical insertion

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11
Q

What is the most common cause of digital replantation failure?

A

Arterial insufficiency

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12
Q

What is the treatment of arterial insufficiency after digital replantation?

A
  1. If any concern about arterial insufficiency, return to OR
  2. Loosen dressings
  3. Heparin
  4. Antivasospastic meds (thorazine)
  5. Sympathetic blocks
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13
Q

What is the treatment for venous congestion after digital replantation?

A
  1. Removal of dressings
  2. Leeches
  3. Heparin
  4. Nail bed bleeding with heparin-soaked sponges
  5. Revision of venous anastamosis
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14
Q

Which tissue is most sensitive to warm ischemia

A

Skeletal muscle

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15
Q

What is the maximum cold ischemia time reported for digital ischemia?

A

30-40 hours

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16
Q

When should prophylactic fasciotomies be performed in upper extremity replantation?

A

With any replantation proximal to the wrist (because of increased skeletal muscle present)

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17
Q

What is the quadriga effect?

A

Weakness in flexion of the fingers secondary to excess pull of one FDP tendon of the amputated finger

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18
Q

What is the maximum nerve gap for use of a neural tube (PGA)?

A

2.5cm

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19
Q

What nerves are available for donor grafting?

A

Posterior interosseous, sural, superficial radial, superficial peroneal

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20
Q

What is the treatment of choice for a tip amputation through the nail bed without bone exposed?

A

Local dressing changes (healing by secondary intention)

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21
Q

What is a good option for failed thumb replantation at the MCP level?

A

Revision amputation followed by toe to thumb transfer at a later date

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22
Q

What donor vessel is the toe-to-thumb transfer based on?

A

First dorsal metatarsal artery from the dorsalis pedis artery or plantar digital artery from the lateral plantar artery

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23
Q

What is a good option for a thumb-tip amputation with exposed bone?

A

Moberg flap

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24
Q

How much advancement can be obtained from a Moberg flap?

A

1.5cm

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25
What are contraindications to digital replantation?
Severe concomitent injuries, severely crushed or mangled part, multilevel amputations, significant comorbidities (relative), prolonged warm ischemia time, Mentally instable/self-mutiliation (relative), single finger proximal to FDS insertion
26
How many arteries and veins are needed for a digital replantation?
One artery and one vein (two is preferred if possible)
27
Is an artery-only digital replantation possible?
Yes. Leeching and/or bleeding of the nail bed can be used to relieve venous congestion
28
How many places can you find a digital vein?
Two. Dorsal and volar.
29
What is the concern in avulsion amputation vs guillotine amputation?
Zone of injury is much greater in avulsion injuries
30
What is the red stripe sign?
A red streak along an artery indicating severe intimal injury along the length of the vessel
31
What is the best method for treating the zone of injury of an artery or vein in the case of crush or avulsion injuries?
Resection of the compromised vessel and vein grafting
32
Where can veins be found on the hand dorsum?
Proximal to each webspace
33
What vascular pattern exists in a finger that was crushed and has the appearance of venous congestion and low capillary refill?
Loss of proper digital artery inflow, intact venous flow
34
Eight months post digital replantation, what operation would you offer the patient with minimal active or passive ROM?
Extensor tenolysis and open capsulotomy
35
What operation would you offer s/p digital replantation with minimal active ROM but good passive ROM?
Flexor tenolysis
36
What is the greatest danger in digital reoperation after replantation?
Injury to the neurovascular bundle embedded in the scar
37
What is fluorimetry?
a method of monitoring tissue perfusion by injecting fluorescein dye intravenously and using a fluorometer to quantitatively measure rise and fall of fluorescein in tissue
38
What if there is a two to threefold rise but no fall in the number on fluorimetry?
Signs of venous congestion
39
What if the absolute number (on fluorimetry) is very low and remains low, but the digit clinically looks viable?
Thick skin or heavily contaminated skin can alter the numbers
40
When is the highest likelihood of a thrombotic event at the microanastomosis?
Within 24-48 hours
41
At the microanatomosis, what is the most prominent cell layer on day 3?
Platelets
42
At the microanatomosis, what is the most prominent cell layer on day 4-14?
Pseudointima
43
At the microanatomosis, what is the most prominent cell layer on days 14+?
Intima
44
One year status post replantation at the PIPJ level with severe arthritis or fusion at the PIPJ. What surgery can you offer the patient?
PIP Joint arthroplasty
45
Which Urbanik class of ring avulsion is considered a relative contraindication to replantation?
III - complete degloving or complete amputation
46
What type of flap can be used if there is a soft-tissue defect in a Type II ring avulsion injury?
Venous flow through flap
47
What is the average two point discrimination of a replanted thumb
9-11mm
48
What is the average two point discrimination of a replanted digit?
8-15mm - depending on sharp vs avulsion
49
What is the "no reflow phenomenon"?
Inability to maintain perfusion to he replanted tissue despite restoration of blood flow through a technically acceptable anastomosis. Thought to be the result of inschemia-induced endothelial injury
50
What is a common long-term sequelae of digit replantation?
Cold intolerance. This occurs commonly in the adult population but can also affect peds
51
How much time should you tell a patient they will have to wait for cold intolerance symptoms to resolve?
2 years, maybe never
52
What is the scientific name for medical leeches?
Hirudo medicinalis
53
Action of Hirudin?
Binds activated thrombin (1:1) Inhibits conversion of fibrinogen to fibrin Blocks activation of Factors V, VIII, XI, and vWF. Decreases activation of tPA, protein C and plasmin Prolongs thrombin-dependent coagulation tests (PTT, TT, ACT, ECT) There is no direct effect on platelets or endothelial cells Can monitor by thrombin time and PTT
54
Excretion of hirudin?
Renal
55
Organisms to cover while patient is on leech therapy?
Aeromonas hydrophilia - enteric organism that can cause severe soft tissue infection.
56
What medications to use with leech therapy?
Third generation cephalosporin (Cefizox) or aminoglycosides (tobramycin, gentamicin) in adults. Bactrim or cipro in peds.
57
What is the mechanism of heparin?
Action primarily via activation of serum antithrombin III and lowering blood viscosity, increases AT III activity
58
Mechanism of dextran
Polysaccharide - molecular weight 40,000 and 70,000 Decreases platelet aggregation by imparting a negative charge on the platelets, inactivating vWF Modifying the structure of fibrin Altering rheologic property of blood
59
Possible complications of dextran
Possible complications: antigenic test of <5ml must be given before full dose Renal failure - volume expansion Noncardiogenic pulmonary edema
60
What is the mechanism of aspirin?
Acetylates cyclooxygenase enzyme Decreases arachnodonic acid, thromboxane, and prostacycline Decreases platelet aggregation and vasoconstriction
61
What is the mechanism of Thorazine?
Potent vasodilator
62
What is the mechanism of papaverine?
Salt of opium alkaloid. Smooth muscle relaxant especially with cerebral and peripheral ischemia associated with arterial spasm
63
What is the mechanism of lidocaine?
Potent local vasodilitation. Commonly used at 2% dilution
64
What is the definitive role of anticoagulation in microsurgery?
Controversial. Not enough RCT. Common uses: high-dose heparin irrigation during microanastomosis. IV heparin after a thrombotic event with anastomotic revision

Plastic Surgery - HAND (16 decks)

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