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Definition and Briefing

Definitions and Necessary Information:

Please call  112 EMERGENCY SERVICES for First Aid, Selection/Coordination of Replantation Center and Transfer of Patient to “Emergency Microsurgery Center On Duty” in case of limb ruptures!

What is MICROSURGERY?

Reconstructive microsurgery is a field of surgery utilizing specialized surgery microscopes and very small special tools in order to perform sensitive operations on small structures of our body. The surgeons in the field of microsurgery where very thin sutures are used as thin as hair under magnification fifty times greater than that can be seen with naked eye can repair cut veins and nerves with diameters smaller than 1mm.


This field is of great importance to ensure continuity of veins and blood flow in veins and for restoration of injured veins and nerves as well as for reparation of form and function deformations resulting from cancer and congenital anomalies.  At the beginning of 1960s, developments in technology and surgical techniques enabled surgeons to replant ruptures fingers and limbs in place.


Thanks to these innovations, toe transplantations to hand started; transfer of toe instead of a ruptured hand finger by using microsurgical techniques break a new ground in surgical rehabilitation of injured hands. At the beginning of 1970s, free tissue transplantations have started, so surgeons have transplanted the organs received from regions with more muscle, skin, bone and intestine to open wounds or to regions with missing tissues by using micro vascular techniques.   Free tissue transplantations so called as free flaps have provided great capabilities in the treatments of extremities and other organ cancers for reconstruction surgeons.


Significant steps are taken in the microsurgical treatment of injured nerves. Peripheral nerve injuries which are deemed as hopeless cases are now become injuries where recovery of motion and sensing abilities are possible.  Degenerated integrity of cut nerves can be restored with great precision with the aid of surgical microscope; damaged or lost parts can be repaired with nerve pieces called as graft, in this way, the patients experiencing facial paralysis or birth paralysis can be cured.  Functional muscles can be transplanted to other sections with technical developments in nerve restoration, paralyzed faces and organs may regain vitality. The nerves with branches or divisible nerves can be mouthed with damaged nerves with Nerve Transfers thus lost motion and sensing abilities can be regained.


Reconstructive microsurgery has witnessed great advancements during last ten years in emergent hand surgery, arm transplantation and face transplantation; thanks to such new techniques, problems of severely injured patients which cannot be solved with traditional techniques become treatable. www.acelemder.org


What are REPLANTATION / REVASCULARIZATION?

Reattachment of separated   limbs or parts from body by completely rupturing and ensuring sense and other functions, primarily blood circulation, is called as replantation.  Ensuring circulation only in parts which are completely separated or not fully separated but only partially bound to the body without any blood circulation is generally called as revascularization. Without recovery of functionality and sense ensuring circulation via revascularization cannot be considered as a successful replantation. Injury of hands and fingers by rupturing completely, i.e. cases of amputation are observed frequently in daily life and especially in cases of occupational accidents.


The color of amputated part is white since it has no circulation. The color of parts which are not completely amputated but have no circulation is also white. Since it is difficult to determine the degree of damage when there is no circulation in structures ruptured by being crushed, detailed examination and exploration of such parts under magnification may be necessary. In this way, other injuries beyond the line of rupture, separation can be determined.    

It is not always possible to replant every piece detached from body. Furthermore, although it may be possible to replant, it is not mandatory to replant every ruptured part in place. In each case the question “Is amputation or replantation is the best option for this patient?” should be replied by a surgeon assessing the patient as a whole. The features of impacted extremity, the manner of injury of the patient, general condition of patient as well as age and profession are the factors to be taken into consideration in replying such question.  

General health status of patient as well as other impacted systems during injury other that such extremity is taken into account. In addition to these systemic and general factors, there are factord related to extremity and region of injury for replantation and revascularization. There are in general form, level or injury and further injuries in the same section.


Protection and transport of detached part

Time of ischemia of detached part, i.e. separation from blood circulation and method of storage are of importance. Ischemia durations, i.e. remaining without blood supply in hot (medium temperature) or cold environment are evaluated separately.


It is necessary to bring detached part with patient and to protect properly while carrying. If possible, detached part should be washed with sterile physiological saline solution or ringer lactate solution when removed from injury region and put into a water resistant plastic bag after wrapping in gauze bandage moisture slightly with such solution.  Then this plastic bag with detached part wrapped in gauze bandage is put into another plastic bag with iced water in. This second bag should not include only ice but iced water and detached part should not contact with ice in any way. Detached part should never be cooled to lead freezing of it. The ischemia durations of detached parts protected and transported in this way are the longest ones.

The success of replantation operation is directly affected by how long the part  remained without blood supply under medium temperature and how long it remained in above described cold medium. Existence of muscle component in the detached extremity part shortens such duration. Ideal cold ischemia duration protected under ideal conditions is about 2-6 hours. A finger without any muscle component can be kept longer under suitable conditions of cold ischemia and can be replanted.  Hand or other detached parts of upper levels with muscle component can be replanted up to 12 hours when protected under ideal conditions of cold ischemia. There is little chance of success after such durations.

Figure- Protection and transport of detached part:

Detached part should be put into a plastic bag (A) by wrapping in sterile bandage after washing with physiological saline solution, this bag should be placed in another container (B,C) filled with ice, proper bleeding control should be made on proximal section, while for serious injuries without complete detachment, wound should be bandaged with sterile bandage avoiding tightening and a plastic band full of ice should be placed (D) on wound and should be delivered to replantation team or emergency services as soon as possible.


Therapy

Replantation surgery carried with microsurgery and atraumatic methods are performed by Hand Surgery Specialists trained on this matter. A surgical microscope suitable for the purpose and microsurgery set are needed for replantation. Arteries and veins up to 1 mm can be subject to standard anastomosis. Anastomosis of veins with narrower diameters can be carried by more experienced surgeons. It is necessary to perform reparations of nerves, tendons, joint capsules and soft tissues if any along with vein anastomosis.    


Although such operations requires to act urgently in order to ensure blood circulation without exceeding ischemia durations, these are extremely long and patience necessitating operations. If anastomosis is required in more than one fingers or on a double sided extremity, a second surgery team may be needed. If nerves or veins cannot be jointed end-to end, continuity is ensured by adding vein or nerve parts between them in the form of bridge (Graft). Such type of complex interventions for complicated injuries takes longer time periods.

Thumb is tried to be replanted in any case. If detachment of more than one fingers including thumb is the case and if thumb is impaired uselessly, replantation can be carried by transferring one of other fingers which best fits instead of thumb.


Indications

The indications listed here can be considered in two categories as absolute and relative indications:

“Absolute” indications for Replantation or Revascularization:

• Thumb amputations

• Amputation of more than one finger

• Amputations involving wrist or palm

• Amputations at childhood

• Patients with high general motivation and high level of intelligence and understanding


“Relative” indications for replantation or revascularization:

•Amputations at distal phalanx  

• Amputations associated to crushing or avulsion injuries

• Single finger amputations except thumb

• Amputations over elbow of elderly,


Contraindications

Replantation interventions cannot be carried sometimes even in case of availability of microsurgery possibilities.

Contraindications which can be deemed as absolute sometime and as partial on the other varying from case to case for Replantation and Revascularization:

• Additional injuries of patients posing vital risks

• Amputations of forearm and proximal levels (from proximal half of forearm) including muscle compartment inside, exceeding 6 hours of ischemia duration

• Repetitive amputations at more than one level

• In cases where amputated part is crushed, burnt seriously or avulsion type injuries

• If hot ischemia period of amputated part exceed 16 hours for fingers and 6 hours for wrist proximal

• Extremely dirty or contaminated wounds

• Systemic diseases preventing so long lasting operation


Some diseases previously existing:

• Diabetes

• Heart disease andatherosclerosis

• Recently suffered myocardial infarction or cerebrovascular attack

• Smoking

• Amputations carried intentionally for personal harm or suicide (as a result of psychological disease)

• Patients refusing to stop smoking after replantation in early periods (some surgeons are claiming this situation as an definite contraindication).


Surgical Treatment:

Revascularization operation is to ensure circulation again via vein anastomosis.  

Surgical intervention starts with determination of bone structures in case of full detachments. Bone structure is shortened in order to obtain proper vein and nerve integration more easily and without strain. Then jointing bone ends adapted to each other, osteosynthesis is carried by connecting with plate screw or wires. Then tendon and vein anastomosis are applied. In case of small organ replantation, first vein then artery anastomosis is carried. Nerve restorations are carried at last following tendon and vein reparations. At this stage dorsal vein anastomosis is performed.


Most frequently observed reasons of circulations defects that may arise after replantation are vascular spasms and thrombus. Venous accumulation can be directly discharged out by applying bloodsucker in cases of insufficiency of venous drainage.  

Most frequent reason of failure of replantation is the long period od ischemia and then, formation of venous thrombus. Therefore, therapy with anticoagulant and antioxidants is initiated following every replantation.

Although physical therapy varies case to case, it lasts at about 1 year and physical therapy programs are carried along with rehabilitation programs after some time. In this process, some operations such as tenolysis, neurolysis, tendon transfer, contracture    opening  may be necessary for reconstructive purposes.

Please call  112 EMERGENCY SERVICES for First Aid, Selection/Coordination of Replantation Center and Transfer of Patient to “Emergency Microsurgery Center On Duty” in case of limb ruptures!

TİSK Microsurgery and Reconstruction Foundation

Ayazağa Mahallesi Mimar Sinan Sokak No:21 Seba Ofis Bulvar

D Blok Kat:10 Ofis:69 Sarıyer-İstanbul - Tel: 0212 345 05 43/44 - Fax: 0212 345 05 45