REPLANTATION

Stiching a piece of body back to it’s location with the purpose of regaining its function is called replantation.

Replantations are separated into 3 groups:

1- Major replantation: Ruptures in the upper region of the wrist.

2- Minor replantation: Ruptures in the lower region of the wrist.

In finger and extremity replantation surgeries, re stitching the ruptured part is not the only concern. The main concern is that the patients would be able to regain their motor sensory functions and joint movements at least 60 to 80 percent. The success of the surgery depends on bones, tendons, muscles and nerves to face each other properly. For this reason, replantation surgeries require special equipments, special techniques, experienced and patient surgeons and assistants. Surgery alone is not enough. The patient has to be in an intensive rehabilitation program after the surgery. If something goes wrong in one of the steps during the process it can effect the postsurgery rehabilitation and even could make it impossible.

INDICATIONS AND CONTRAINDICATIONS OF REPLANTATION:

AGE: Replantation can be done at any age however in young ages, especially in finger replantations, low diameter of the blood vessels can create a hard situation in anastomose of the vessels.  Postoperative anxiety could cause vasospasm and problems during rehabilitation. It is difficult to determine an upper ager limit for replantation surgeries. Patient’s physiological state, other illnesses, general activity level has to be evaluated carefully. In elders major replantation surgeries usually doesn’t give a good result.

TYPE OF INJURY, AVULSED FRAGMENT STATUS:

Probability of success in replantation surgeries is higher in clean cut wounds.

In ruptures with minimal local contusion and minimal distal and proximal injury, positive results can be seen after the surgery.

In injuries caused from the tensile strength of the avulsion type ruptures replantation surgeries must be evaluated carefully because of the different levels of injured tissue.  Vein grefts could be needed to substitute the shortage of arteries.

Additional injuries in ruptured pieces decrease the chance of success in replantation surgeries.

Replantation surgeries should not be made in injuries with wide tissue contusion and contaminated ruptures because of the extensive blood vessel damage and the high probability of infection caused by anaerobic bacterias.

LEVEL OF RUPTURE: In young patients replantation surgeries could show positive results if the rupture is a clean cut one. (in humerus, elbow or proximal front arm ruptures) If a patient shows slow neural healing, muscle atrophy, joint stiffness it is not good concerning regaining the motor abilities of the hand. Especially in elders replantation surgeries that are made close to shoulders show way more negative results compared to younger patients.

In replantation surgeries below the wrist the probability of regaining motor skills and sensation is high. Thumb amputation must be replanted under any circumstance but one finger amputations doesn’t always indicate replantation. In cases of multiple finger amputations the primary concerns are forefingers and ring fingers. By this way the patient would gain the ability of holding and griping.

In bilateral amputations replantion should be made to both sides. If one side is not suitable for replantation the ruptured pieces form that side could be used in the other side.

WARM ISCHEMIA PERIOD: Necrosis in skeletal muscles starts after 6 hours of ischemia in normal heat. If the ruptured piece is cooled to +4 degrees the changes can be postponed. Replantation should not be made if the ruptured parts blood circulation regained in 6-8 hours. If the procedure is done the patient can suffer from acidosis, cardiac arrhythmia, kidney damage and metabolic acidosis because of the hyperkalemia plus the surgery will increase the probability of infection. Even if the limb survives it will lose some of it’s functions.

In finger(without muscle) ruptures ischemia period can be delayed up to 30 hours if the finger is cooled down to +4 degress.

CONDITION OF THE PATIENT: Some patients are not fit for replantation surgeries. Patients with head, thorax, and abdominal trauma cannot have replantation surgeries because they cannot be under anesthesia for too long and their fast blood loss.

It is best not to do a replantation surgery on patients with romatoid arthritis, diabetics, SLE, myocardial infarct, chronic heart, lung and kindney diseases because of their blood vessel problems. It’s best not to do a replantation surgery on a psychiatric patient because of the difficulties in rehabilitation process.

TRANSPORTATION OF PATIENTS AND RUPTURED PARTS: Transporting the patient and the ruptured part to a replantation center quickly and properly is one of the factors which affect the success of the surgery. An improper style of transportation of the ruptured part could make the piece impossible to replant.

The first thing to do with a patient whose limb is ruptured is controlling  the bleeding. Blood vessels should not be clamped. The damage to the vessels complicates the procedure. Pressure bandages should be enough. If not tourniquet can be used to slow the bleeding.

All of the pieces of the ruptured limb must be protected. If the limb is contaminated enough it will require removal of tissue contamination. The ruptured limb has to be cleaned gently. Disinfectants like iodize tincture or oxygen mustn’t be used under any circumstance. The ruptured limb has to be wrapped up with a cloth moistured with saline and put into a plastic bag

If the replantation center in not close, the ruptured limb must be put between two plastic bags containing 1/3 water 2/3 ice. This enables the limb to cool down to +4 degrees and postpones necrosis. The limb must not touch with ice because if it freezes there is no chance for a replantation surgery. Both plastic bags containing ice has to be at the same temperature.