Genesis of a Replantation Program
David W. Furnas, MD, Irvine, California Arthur H. Salibian,
MD, Irvine, California
Bruce M. Achauer,
MD, Irvine, California
The University
of California Medical Center, Irvine lies in a suburban area of the Los Angeles basin and receives trauma patients from the Orange County Area. A replantation program was developed in the following sequence: (1) acquisition of microvasuclar surgical skills in the research laboratory (University of California, Irvine and The Ralph K. Davies Medical Center, San Francisco); (2) development of operating room skills in noncritical digital injuries (where repairs enhance circulation but failure does not condemn digits to necrosis); (3) supervision of initial elective microvascular procedures by a visiting professor (Dr. Harry Buncke) (Figure 1); (4) formation of a replantation team (plastic surgery, orthopedic surgery, general surgery, and neurosurgery); (5) dissemination of information on transportation of patients and parts to paramedics and local hospitals; (6) preparation of hand therapy department for problems of rehabilitation; and (7) augmentation of surgical staff to include three members experienced in reconstructive microsurgery. We have also drawn heavily from the reported ezrperience of others [l-4]. Material
and Methods
Our organized program began in June 1975 and our experience over the subsequent two and a half years included twenty-six replantations or revascularizations, including two earlier replantations, in twenty-one patients. Twelve were complete amputations and fourteen were incomplete; that is, all major vessels were severed and less than one
Fwm the Division of Plastic Surgery, University of California, Irvine, Irvine, California. Reprint requests should be a idressed to David W. Furnas, MD, Division of Plastic Surgery, University of California, Irvine. Irvine. California 92717. Presented at the FMy-Ninth A:mual Meeting of the Pacific Coast Surgical Association. Newport Beach, CzJifornia, February 19-22, 1978.
Volume 136, July 1979
eighth of the skin attached was intact [4]. The parts involved were ten thumbs, ten fingers, three hands, two arms, and one foot. (Table I.) (Figures 2-6.) A number of other patients were evaluated but were considered unsuitable for replantation. Contraindications were: crushed amputated parts; multiple level severe injuries of amputated parts; local disease processes (such as severe rheumatoid arthritisj; single finger amputations; distal digital amputations; critical injuries of head, chest, or abdomen; or senility or other problems of general condition. Operative technic consisted of shortening the bone to facilitate the vessel repairs or the skin closure, skeletal
Figure 1. Dr. Harry J. Buncke, vlsHing protessor, supervised the first iree flap procedure in the program. Microvascular free flaps are an essential element of an active reprantation program.
TABLE I
Replantations and Revascularizations” Complete
Fingers Thumbs Hands Arms Feet All cases
4(l) 7&Y l(O) 0 0 12(l)
Incomplete
All Cases
W) 3(O) 2(O)+ 2(O) l(O) 14w
Number of failures are in parentheses. 7 Fatality from cirrhosis and liver failure in presence
lO(3) 10(O) 3(O) 2(O) l(O) W3)
l
of viable
replant.
21
Furnas, Salibian, and Achauer
Figure 3. A, avulsion-amputation of thumb by a cafeteria conveyor bett. B, groin f/ap to replace tissue loss, vein Brat% to bridge arterial and venous defect. C, limited postoperative function.
Figure 2, A, amputation of all four fingers and part of thumb of a computer operator by a circular saw (first reptantatlon performed). B, two fingers replanted with immediate restoration of blood flow. Middle finger, however, failed to survive. C, postoperative pinch ability with one finger.
22
fixation, and microvascular repair of at least one artery and two veins (if possible) for each artery. Ten immediate vein grafts and three immediate nerve grafts were used to restore continuity. Nerve and tendon repairs were done concomitantly to avoid the need for late repairs which could jeopardize the vessel anasl omoses. Special care was taken with skeletal fixation to avoid the need for secondary bone procedures. Vessel and nerve repairs were carried out with a two-man operating mmroscope (Urban Quad-
lie American Journal of Surgery
Genesis of a Replantation
Program
Figure 4. A, se/f-amputation with electric carving knife. 6, anatomic structures of proximal stump identified and labeled. C, restoration of blood flow after repair of ulnar and radial arteries, all nerves, and all tendons.
Figure 5. A, loss of elbow joint including all major vessels, radial nerve, and all structures eXCepf the median and ulnar nerve and a 2 cm bridge of skin. Vein grafts and radial nerve repair performed. 8, stainless steel plates used t0 fuse the elbow joint. C!, shortened left arm. 0, virtually complete return of function of hand postoperatively.
riscope@). Average operating time for the initial replantation was 10 hours. Often an axillary block with Marcaine”,
supplemented by sedation, gave adequate anesthesia for the entire procedure. Postoperatively, low molecular weight dextmn was given for three days and aspirin and Persantina for two weeks, in most cases. Results
Of the twenty-six replantations or revascularizations, twenty-three were successful in restoring viability to the amputated part. Each of the three failures were in fingers and involved two patients, each
Volume
136,July 1978
of whom had involvement of multiple digits. Of four fingers which were revascularized after an incomplete
amputation in a gantry two were lost, one from early arterial thrombosis and one from late arterial thrombosis. The third loss involved complete amputation of the long finger; it was one of two fingers replanted after all four fingers had been amputated by a circular saw. This was the first patient of our series. (Figure 2.) Three amputations of viable replanted structures were necessary. A little finger was removed because of a widely exposed metacarpal and a necrotic tip (this was counted as one of the replantation failures).
23
Furnas, Salibian, and Achauer
weeks) thromboses at the replantation site, which were corrected by excision of the anastomoses and repair with vein grafts; hemorrhage from rupture of an infected vein graft; malunion in a cornminuted phalangeal fracture; and nonunion of a phalangeal fracture. Neuropsychiatric complications presented some of the most difficult problems in postoperative management and included alcoholism with florid withdrawal symptoms (2 cases) and extreme agitation in an acutely schizophrenic patient. These patients required highly individualized means of immobilization and management. Summary
Development of a replantation program entails establishment of microsurgical skills in the laboratory, training in clinical microvascular technics, supervision, if possible, in the first microvascular free flaps, and close liaison with supporting personnel who transport patients, care for them acutely, and carry out their rehabilitation. Of twenty-six replantations or revascularizations (14 incomplete and 12 complete), twenty-three were successful. The three failures (1 complete and 2 incomplete procedures) were all digits, and each was part of a multiple digit injury. References
Figure 6. A, loss of neurovascuiar structures and skin at elbow joint. Circulation has been restored with saphenous vein grafts. B, free groin flap has been developed. C, coverage is obtained with free groin fiap placed with microvascular anastomoses. (Patient not included in Table I because bone was intact.)
1. Buncke HJ: Digital transplantation. Symposium on Reconstructive Hand Surgery (Littler JW, Cramer LM, Smith JW, ed). St. Louis, CV Mosby, 1974. 2. O’Brien BM, MacLeod AM, Miller GDH, Newing RK, Hayhurst JW, Morrison WA: Clinical replantation of digits. f/a& Reconstr sllrg 52:490, 1973. 3. Weiland AM, Villarreal-Rios A, Kleinert HE, Kutz J, Atasoy E, Lister G: Replantation of digitis and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg 2: 1, 1977. 4. Daniel RK, Terzis JK: Reconstructive Microsurgery. Boston, Liile Brown, 1977, pp 125, 127.
Discussion
A hand was amputated in an unsuspected chronic alcoholic when wound complications contributed to progressive, and ultimately fatal, hepatic failure. Although counted as a replantation success, it was a therapeutic failure, and the patient would probably have survived if a simple stump closure had been performed under local anesthesia instead of a replantation. A foot which was counted as a replantation success was later amputated because of chronic osteomyelitis of the ankle joint at the site of injury. Other complications included: early and delayed (2
24
John M. Goin (Los Angeles, CA): The establishment of a regional center is commendable. This type of surgery should never be done by the occasional operator. The authors’ success rate compares very favorably with published rates ranging from 50 to 88 per cent. This impressive record, however, should not distract us from a very careful examination of what, in this context, is meant by “success.” Bernard O’Brien of Melbourne, a leading authority on replantation, has said: “The primary aim in replantation is to obtain survival, but equally important, satisfactory function must be achieved.” From the sidelines I respectfully, but heartily, disagree. The primary aim in replantation is to provide the patient
The American Journal of Surgery
Genesis of a Replantation
wit!1 a functional result that is significantly better than could be had with a prosthesis. There is little doubt that most thumb replants meet this criterion and, for patients in certain occupations, so do many index and even small finger replantations. When several digits have been cut off, replantation of one can be very useful. It is in the realm of lna,lor limb replantation that some questions arise. Adequate function after replantation depends on sensation more than anything else. Good skin coverage, ability to move and position the replanted part, and freedom from pain are of great importance, but without good sensation that part is no better than a prosthesis and, in terms of recurrent pressure ulceration, soft tissue infection, and osteomyelitis, considerably more dangerous. Shaftan and McAlvanah wrote the following poignant description of a technically good but functionally poor upper extremity replantation: “The patient had refused amputation ... instead he carried this useless viable extremity in a black leather sling where it can be touched as a miraculous relic by the community.” Obviously, the decision to bring about a reunion between a patient and a severed extremity is a grave one. The functional deficit from a below-knee amputation is small enough to raise questions about the advisability of leg replant&ion when one considers the serious risks, the enormous expense, and the prolonged period of rehabilitation involved. There is very little information available about the long-term results of this procedure. There is no doubt that some upper limb replantations have been successful. Malt’s famous case in 1962, the first arm replantation in the Western World, was a patient who ten years later was a successful automobile mechanic who had won several stock car races. But there are disturbing rumors of chronic depression, prolonged idleness, drug addiction, causalgia, and even suicide among the unpublished cases. ‘Jery careful patient selection is imperative. While successful replantations have been done in patients in their fifties, younger patients are better, and children are the best candidates of all. Patients with other serious injuries or systemic diseases should probably be rejected as should the, psychologically unstable. Occupation and hand dominance should be considered. A prosthesis is often an acceptable substitute for a nondominant hand but less so for the, dominant one. Patients with avulsed and mangled extremities and with longitudinal trauma to main vessels do poorly. Warm ischemia of more than 6 hours’ duration leads to severe muscle necrosis. Guillotine amputations are rare but are ideal for replantation. In general, the major injury should be limited to the amputation site. Previous amputation paralysis or severe deformity of the opposite extremity and blindness should make one consider replantation more seriously. Jordan Phillips (Downey, CA): Gynecologists are borrowers. We have learned and utilized many of the ad-
Volume 136, July 1978
Program
vances created and performed by our colleagues. From the eye surgeon, we have taken instruments. From the plastic and hand surgeons, we have taken specialized technics, such as vessel anastomosis. In recent years, gynecologists have realized the value of microsurgery. The main indication for microsurgery we have today is the tubal reanastomosis of previously sterilized patients. The requests come from patients who have experienced the “three Ds”-death, divorce, and disaster. There are also some patients sterilized as young as twenty-one years of age who then reconsider. The success rates for gross reanastomosis of fallopian tubes have been disappointing. With microtechnics, using layer-by-layer enclosure, we can increase success rates to approximately 70 per cent. Today we have many requests throughout the United States for the repair of the fallopian tube. Isthmic-isthmic reanastomosis, isthmic-cornual reanastomosis, and salpingolysis
David W. Furnas, MD, Irvine, California Arthur H. Salibian,
MD, Irvine, California
Bruce M. Achauer,
MD, Irvine, California
The University
of California Medical Center, Irvine lies in a suburban area of the Los Angeles basin and receives trauma patients from the Orange County Area. A replantation program was developed in the following sequence: (1) acquisition of microvasuclar surgical skills in the research laboratory (University of California, Irvine and The Ralph K. Davies Medical Center, San Francisco); (2) development of operating room skills in noncritical digital injuries (where repairs enhance circulation but failure does not condemn digits to necrosis); (3) supervision of initial elective microvascular procedures by a visiting professor (Dr. Harry Buncke) (Figure 1); (4) formation of a replantation team (plastic surgery, orthopedic surgery, general surgery, and neurosurgery); (5) dissemination of information on transportation of patients and parts to paramedics and local hospitals; (6) preparation of hand therapy department for problems of rehabilitation; and (7) augmentation of surgical staff to include three members experienced in reconstructive microsurgery. We have also drawn heavily from the reported ezrperience of others [l-4]. Material
and Methods
Our organized program began in June 1975 and our experience over the subsequent two and a half years included twenty-six replantations or revascularizations, including two earlier replantations, in twenty-one patients. Twelve were complete amputations and fourteen were incomplete; that is, all major vessels were severed and less than one
Fwm the Division of Plastic Surgery, University of California, Irvine, Irvine, California. Reprint requests should be a idressed to David W. Furnas, MD, Division of Plastic Surgery, University of California, Irvine. Irvine. California 92717. Presented at the FMy-Ninth A:mual Meeting of the Pacific Coast Surgical Association. Newport Beach, CzJifornia, February 19-22, 1978.
Volume 136, July 1979
eighth of the skin attached was intact [4]. The parts involved were ten thumbs, ten fingers, three hands, two arms, and one foot. (Table I.) (Figures 2-6.) A number of other patients were evaluated but were considered unsuitable for replantation. Contraindications were: crushed amputated parts; multiple level severe injuries of amputated parts; local disease processes (such as severe rheumatoid arthritisj; single finger amputations; distal digital amputations; critical injuries of head, chest, or abdomen; or senility or other problems of general condition. Operative technic consisted of shortening the bone to facilitate the vessel repairs or the skin closure, skeletal
Figure 1. Dr. Harry J. Buncke, vlsHing protessor, supervised the first iree flap procedure in the program. Microvascular free flaps are an essential element of an active reprantation program.
TABLE I
Replantations and Revascularizations” Complete
Fingers Thumbs Hands Arms Feet All cases
4(l) 7&Y l(O) 0 0 12(l)
Incomplete
All Cases
W) 3(O) 2(O)+ 2(O) l(O) 14w
Number of failures are in parentheses. 7 Fatality from cirrhosis and liver failure in presence
lO(3) 10(O) 3(O) 2(O) l(O) W3)
l
of viable
replant.
21
Furnas, Salibian, and Achauer
Figure 3. A, avulsion-amputation of thumb by a cafeteria conveyor bett. B, groin f/ap to replace tissue loss, vein Brat% to bridge arterial and venous defect. C, limited postoperative function.
Figure 2, A, amputation of all four fingers and part of thumb of a computer operator by a circular saw (first reptantatlon performed). B, two fingers replanted with immediate restoration of blood flow. Middle finger, however, failed to survive. C, postoperative pinch ability with one finger.
22
fixation, and microvascular repair of at least one artery and two veins (if possible) for each artery. Ten immediate vein grafts and three immediate nerve grafts were used to restore continuity. Nerve and tendon repairs were done concomitantly to avoid the need for late repairs which could jeopardize the vessel anasl omoses. Special care was taken with skeletal fixation to avoid the need for secondary bone procedures. Vessel and nerve repairs were carried out with a two-man operating mmroscope (Urban Quad-
lie American Journal of Surgery
Genesis of a Replantation
Program
Figure 4. A, se/f-amputation with electric carving knife. 6, anatomic structures of proximal stump identified and labeled. C, restoration of blood flow after repair of ulnar and radial arteries, all nerves, and all tendons.
Figure 5. A, loss of elbow joint including all major vessels, radial nerve, and all structures eXCepf the median and ulnar nerve and a 2 cm bridge of skin. Vein grafts and radial nerve repair performed. 8, stainless steel plates used t0 fuse the elbow joint. C!, shortened left arm. 0, virtually complete return of function of hand postoperatively.
riscope@). Average operating time for the initial replantation was 10 hours. Often an axillary block with Marcaine”,
supplemented by sedation, gave adequate anesthesia for the entire procedure. Postoperatively, low molecular weight dextmn was given for three days and aspirin and Persantina for two weeks, in most cases. Results
Of the twenty-six replantations or revascularizations, twenty-three were successful in restoring viability to the amputated part. Each of the three failures were in fingers and involved two patients, each
Volume
136,July 1978
of whom had involvement of multiple digits. Of four fingers which were revascularized after an incomplete
amputation in a gantry two were lost, one from early arterial thrombosis and one from late arterial thrombosis. The third loss involved complete amputation of the long finger; it was one of two fingers replanted after all four fingers had been amputated by a circular saw. This was the first patient of our series. (Figure 2.) Three amputations of viable replanted structures were necessary. A little finger was removed because of a widely exposed metacarpal and a necrotic tip (this was counted as one of the replantation failures).
23
Furnas, Salibian, and Achauer
weeks) thromboses at the replantation site, which were corrected by excision of the anastomoses and repair with vein grafts; hemorrhage from rupture of an infected vein graft; malunion in a cornminuted phalangeal fracture; and nonunion of a phalangeal fracture. Neuropsychiatric complications presented some of the most difficult problems in postoperative management and included alcoholism with florid withdrawal symptoms (2 cases) and extreme agitation in an acutely schizophrenic patient. These patients required highly individualized means of immobilization and management. Summary
Development of a replantation program entails establishment of microsurgical skills in the laboratory, training in clinical microvascular technics, supervision, if possible, in the first microvascular free flaps, and close liaison with supporting personnel who transport patients, care for them acutely, and carry out their rehabilitation. Of twenty-six replantations or revascularizations (14 incomplete and 12 complete), twenty-three were successful. The three failures (1 complete and 2 incomplete procedures) were all digits, and each was part of a multiple digit injury. References
Figure 6. A, loss of neurovascuiar structures and skin at elbow joint. Circulation has been restored with saphenous vein grafts. B, free groin flap has been developed. C, coverage is obtained with free groin fiap placed with microvascular anastomoses. (Patient not included in Table I because bone was intact.)
1. Buncke HJ: Digital transplantation. Symposium on Reconstructive Hand Surgery (Littler JW, Cramer LM, Smith JW, ed). St. Louis, CV Mosby, 1974. 2. O’Brien BM, MacLeod AM, Miller GDH, Newing RK, Hayhurst JW, Morrison WA: Clinical replantation of digits. f/a& Reconstr sllrg 52:490, 1973. 3. Weiland AM, Villarreal-Rios A, Kleinert HE, Kutz J, Atasoy E, Lister G: Replantation of digitis and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg 2: 1, 1977. 4. Daniel RK, Terzis JK: Reconstructive Microsurgery. Boston, Liile Brown, 1977, pp 125, 127.
Discussion
A hand was amputated in an unsuspected chronic alcoholic when wound complications contributed to progressive, and ultimately fatal, hepatic failure. Although counted as a replantation success, it was a therapeutic failure, and the patient would probably have survived if a simple stump closure had been performed under local anesthesia instead of a replantation. A foot which was counted as a replantation success was later amputated because of chronic osteomyelitis of the ankle joint at the site of injury. Other complications included: early and delayed (2
24
John M. Goin (Los Angeles, CA): The establishment of a regional center is commendable. This type of surgery should never be done by the occasional operator. The authors’ success rate compares very favorably with published rates ranging from 50 to 88 per cent. This impressive record, however, should not distract us from a very careful examination of what, in this context, is meant by “success.” Bernard O’Brien of Melbourne, a leading authority on replantation, has said: “The primary aim in replantation is to obtain survival, but equally important, satisfactory function must be achieved.” From the sidelines I respectfully, but heartily, disagree. The primary aim in replantation is to provide the patient
The American Journal of Surgery
Genesis of a Replantation
wit!1 a functional result that is significantly better than could be had with a prosthesis. There is little doubt that most thumb replants meet this criterion and, for patients in certain occupations, so do many index and even small finger replantations. When several digits have been cut off, replantation of one can be very useful. It is in the realm of lna,lor limb replantation that some questions arise. Adequate function after replantation depends on sensation more than anything else. Good skin coverage, ability to move and position the replanted part, and freedom from pain are of great importance, but without good sensation that part is no better than a prosthesis and, in terms of recurrent pressure ulceration, soft tissue infection, and osteomyelitis, considerably more dangerous. Shaftan and McAlvanah wrote the following poignant description of a technically good but functionally poor upper extremity replantation: “The patient had refused amputation ... instead he carried this useless viable extremity in a black leather sling where it can be touched as a miraculous relic by the community.” Obviously, the decision to bring about a reunion between a patient and a severed extremity is a grave one. The functional deficit from a below-knee amputation is small enough to raise questions about the advisability of leg replant&ion when one considers the serious risks, the enormous expense, and the prolonged period of rehabilitation involved. There is very little information available about the long-term results of this procedure. There is no doubt that some upper limb replantations have been successful. Malt’s famous case in 1962, the first arm replantation in the Western World, was a patient who ten years later was a successful automobile mechanic who had won several stock car races. But there are disturbing rumors of chronic depression, prolonged idleness, drug addiction, causalgia, and even suicide among the unpublished cases. ‘Jery careful patient selection is imperative. While successful replantations have been done in patients in their fifties, younger patients are better, and children are the best candidates of all. Patients with other serious injuries or systemic diseases should probably be rejected as should the, psychologically unstable. Occupation and hand dominance should be considered. A prosthesis is often an acceptable substitute for a nondominant hand but less so for the, dominant one. Patients with avulsed and mangled extremities and with longitudinal trauma to main vessels do poorly. Warm ischemia of more than 6 hours’ duration leads to severe muscle necrosis. Guillotine amputations are rare but are ideal for replantation. In general, the major injury should be limited to the amputation site. Previous amputation paralysis or severe deformity of the opposite extremity and blindness should make one consider replantation more seriously. Jordan Phillips (Downey, CA): Gynecologists are borrowers. We have learned and utilized many of the ad-
Volume 136, July 1978
Program
vances created and performed by our colleagues. From the eye surgeon, we have taken instruments. From the plastic and hand surgeons, we have taken specialized technics, such as vessel anastomosis. In recent years, gynecologists have realized the value of microsurgery. The main indication for microsurgery we have today is the tubal reanastomosis of previously sterilized patients. The requests come from patients who have experienced the “three Ds”-death, divorce, and disaster. There are also some patients sterilized as young as twenty-one years of age who then reconsider. The success rates for gross reanastomosis of fallopian tubes have been disappointing. With microtechnics, using layer-by-layer enclosure, we can increase success rates to approximately 70 per cent. Today we have many requests throughout the United States for the repair of the fallopian tube. Isthmic-isthmic reanastomosis, isthmic-cornual reanastomosis, and salpingolysis
