Basics of limb replantion monitoring

1. Free tissue transfer and
Replantation post operative
managment
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2.  Ronald Malt performed the first replantation on May 23, 1962 at Massachusetts
General Hospital on a 12-year-old boy who had his right arm amputated in a train
acciden.
 Since Malt's first replant, technological advances and the use of the microscope have
made possible the replantation of other parts, including thumbs, fingers, ears, scalps,
facial parts, and genitalia.

3. PREOPERATIVE MANAGEMENT

4. Evaluation for replantation
 Life before limb.
 Assessment of injury (Level, mechanism, dominant hand ,age ,smoking,full medical
history And previous injury to same limb ).
 Obtaining x-rays for both severd and stumb parts.
 Obtain Length of ischemia of the severed part, digits can tolerate about 12 hours of
warm ischemia and more than 24 hours cold ishemia ,muscles can tolerate about 6
hours warm ishemia, so the more proximal the amputation the faster surgery it
needs.
 Sharp amputations do better than crushed,avulsion or blunt cuts .

5. Amputated part should be warned in saline moistens
gaues then in sealed bag then to bag of ice to
prevent cold injury to tissue

6. Postoperative
 Postoperative managment is extremely important in achieving a high success
rate in replantation.
 vascular insufficiency may develop postoperatively but can frequently be
corrected if detected early.
 Eighty percent of vascular occlusions occur within the first 48 hours after
surgery. The salvage rate in a failing replantation explored early ranges from
66% to 80%.
 Arterial thrombi usually result from platelet aggregation and present on day 1,
whereas venous thrombi result from fibrin clotting and usually present by day 2 or
3.
 Patients are restricted from eating for the first 24 hours in case they need to be
taken back to the operating room.

7.  bulky dressing.
 Hand should be elevated , If arterial inflow is diminished, the hand may be
lowered. If venous outflow is slow, the hand needs additional elevation.
 The room is kept warm, limb should be warmed by lamp and the patient well
hydrated.
 Appropriate analgesics are used to control pain and anxiety because they can lead
to an adrenergic response and vasoconstriction, especially in children.dressing
change should also done under good analgesia or even sedation.
 Smoking is prohibited because it leads to hypoxia, reduction of peripheral blood
flow, and increases the risk of thrombosis, also advise patients to avoid caffinated
drinks.
 Color, pulp turgor, capillary refill, and warmth should be monitored every 1
hour for the first 48 hours, then every 4 hours till 5th day postoprtive.
 Leeches therapy can be used if congestion present.
PostoperativePostoperative

9. Postoperative
 New technology could also be used for flap monitoring including :
 pulse oximetry
 Doppler and duplex
 Digital thermometry
 Laser Doppler
Digital thermometry

10. Laser Doppler showing blood flow fingers

11. Postoperative medications
 The commonly used anticoagulants can be divided into agents that :
1. Decrease platelet function e.g. aspirin and could be used for 3 weeks.
2. Increase blood flow or decrease blood viscosity e.g. dextran , The antithrombotic effect of dextran is
thought to be due to binding to erythrocytes, platelets, and the vascular endothelium. It is
mostly thought to interfere with the formation of fibrin clot and to prevent the aggregation of
red thrombi. This effect is thought to be significantly greater than any effect on platelets.
3. Counteract the effect of thrombin on platelets and fibrinogen e.g., heparin.
 Antibiotics Cover with pointing to Aeromonas hydrophila infection if leesh therapy was used.
 Proper hydration,and good analgesics.

12. Postopertavie therapy
 Hand therapy can be started about a week after replantation, once
anticoagulation is stopped. Therapy protocols depend on the level of the replant
and the stability of skeletal fixation. A dorsal splint is provided and the patient
started on gentle active range of motion exercises.

13. Postoperative Secondary surgery
 Secondary surgery like tenolysis, nerve grafting, tendon transfer, bone, grafting,
intrinsic muscle release, and arthrodesis are frequently required in replants to
enhance function. these procedures brefered to be done approximately 3 months
after replantation.

14.  EXPECTED OUTCOMES OF DIGITAL REPLANTATION
 15-50% replant failure rate.
 50% of patients require a blood transfusion.
 10 days average hospital stay.
 Cost of replantatioo is 1 ~ 15 times that of reception amputation.
 36-77% chance of only protective sensation.
 Motion in replanted is averages 50% of normal .
 60% of patients needs additional surgery (average 2.5 procedures).
 7 mo average time off work.

15. Thanks for your time