EXTREMITY REPLANTATION: INDICATIONS AND TIMING

Published on 10/03/2015 by admin

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CHAPTER 73 EXTREMITY REPLANTATION: INDICATIONS AND TIMING

Matthew Trovato, Boris Mordikovich, Ramazi O. Datiashvili

The years since the first successful replantation of an arm in a 12-year-old boy by Malt and McKhann1 in 1964 were marked by evident progress in the reconstructive surgery of limbs. That first revolutionary report was followed by the reports of revascularization of incompletely amputated fingers by Kleinert and colleagues in 19652 and the first successful thumb replantation by Komatsu and Tamai in 1968.3,4 The evolution of microsurgical techniques and an accumulation of experience worldwide, along with the organization of specialized centers, has made replantation of completely or partially amputated extremities a generally accepted treatment of choice.

INCIDENCE

Traumatic amputation of the extremity is a devastating trauma, both physically and psychologically, leading to a lifelong disability of an individual.

According to the National Center for Health Statistics, the incidence of traumatic amputations is 38,500 per year. The exact number of replantations performed annually is unknown, although it seems to be on the decline, due to more conservative selection criteria and likely, as well, to improvements in safety protocols in the workplace.

Digital amputations comprise the group of the most common upper extremity amputations, followed by more proximal amputations.

The largest proportion of amputations occurs in the upper extremity distal to the elbow, accounting for 70%. Upper extremity amputations have the highest prevalence at ages 21–64 and account for 60% of the reported injuries. Fewer than 10% of all reported upper extremity amputations are sustained by persons less than 21 years of age.

Needless to say, the loss of an extremity or its parts has a great economic impact, accounting for billions of dollars lost every year.

CLASSIFICATION

All traumatic amputations of extremities are classified based on:

Type of amputation
Level of amputation
Mechanism and character of injury

This approach to classification serves both academic and clinical purposes and presents a foundation upon which the indications for replantation are predicated and functional outcomes assessed and compared.

Types of amputations are classified by anatomic criteria. The complete type is clearly defined by its term, that is, an amputation without any tissue connection between amputated and proximal parts of the extremity. An incomplete, or partial amputation is where most of vital anatomic structures are disrupted, and blood circulation in the amputated part of the extremity is absent; without replantation the amputated segment will neither survive nor be functional (Figure 1).

image

Figure 1 (A) Incomplete traumatic amputation of the hand at the level of carpus. (B, C) Functional result of replantation 1 year after replantation: (B) flexion; (C) extension.

The level of traumatic amputation of the extremities is defined by the level of the skeletal rather than soft-tissue disruption. Based on these criteria, we divide all traumatic amputations (replantations) of the extremities into two main groups: major and minor amputations (replantations).

The necessity of differentiating the extremity amputations and replantations has been stressed by many authors for important clinical reasons, especially for indications and timing of surgery. This is due to the fact that major segments of the extremities contain large muscle mass, and anoxia of the muscles largely determines successful outcome of, and therefore indications for, replantation.

Minor segments are those amputated distal to the wrist or ankle level, and major segments are those amputated at and proximal to the level of the respective joints.

More precise classification of upper extremity amputations and replantations is based on the “zonal” principle, where the upper extremity is divided into six anatomic zones (Figure 2):

Zone I—distal to the insertion of the flexor digitorum superficialis (FDS) tendons
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