Technical advances in the commercial production of precision instruments and the availability of a variety of microscopes for operating room use coupled with an interest on the part of surgeons from many different subspecialties, have led to the development of microvascular techniques with wide application. Although the great majority of patients evaluated by our group for replantation or placement of tissue flaps fall into the adult age group, children may also benefit from these techniques provided injured tissues are handled properly and referral is expeditious following overall stabilization of the child.
Initial replantation procedures described over a decade ago were usually successful only if the part were sharply amputated yielding cleanly cut structures for repair.' In injuries secondary to crushing or avulsive forces, it was often necessary to shorten the distal structures to obtain tension-free vascular anastomoses. This was at times associated with limited functional and cosmetic results.2 This problem was exaggerated in small children who could ill afford further loss of digital length. The use of vein grafts and redirection of nearby vessels to the injured tissue have greatly increased the chances of obtaining a statisfactory result in this type of injury.
Injuries secondary to dog bites, such as that described in Case 2, are not uncommon in children. In the past, with loss of large segments of tissue, it was necessary to allow these injuries to heal by granulation or by skin graft which often resulted in the formation of disfiguring scars. Some of these lesions can now be treated by replantation of the injured tissue if it is available, byrotationof nearby tissue flaps, or by use of free flaps from areas of the body of less cosmetic significance.
This article will review the preoperative care of replantation patients and present four cases that illustrate the types of injuries that we see in this age group. Two of these cases have been reported in a previous publication. 3
The severed part should be wrapped in a clean cloth, put in a plastic bag and placed on regular ice. The part should be kept cool but not frozen. Proper care and cooling of amputated digits may extend the ischemie time beyond 24 hours. The patient and amputated part should be transported together in the same vehicle if possible. Personnel at the hospital where the replantation will be attempted should be given notification of the type of injury, status of the patient and the extent of any associated injuries. This information helps to mobilize necessary equipment and personnel while the patient is in transport. Upon arrival, the patient receives a rapid preoperative evaluation, including a thorough history and physical examination, chest x-ray, x-rays of the severed part and extremity, a urinalysis and type and match for blood. If considered to be a candidate for replantation surgery, the family is carefully informed of the extent of surgery, including anticipated and unforeseen complications. The possibility of failure of the replantation attempt is discussed in detail. Transient or permanent loss of function, if anticipated, is also discussed.
A two-year-old boy received a sharp amputation of his left index finger through the middle phalanx (Figure I). Replantation was performed with anastomosis of both digital arteries and one digital vein. Tendon and nerves were also repaired. The patient displays normal growth and use of the replanted finger (Figures 2 and 3). In considering single digit amputations for replantation, the attainment of good cosmetic and functional results must be weighed against the risks of surgery which is associated with two to three and one-half hours of anesthesia for a single digit.
A four-year-old girl was attacked by a dog and a large portion of her left scalp, forehead and eyebrow were completely avulsed (Figure 4). Microanastomosis of the temporal artery to a branch of the temporal artery in the severed part was successful in establishing arterial supply. Venous drainage was established by rotating a posterior auricular vein and anastomosing it to the temporal vein in the severed part. Arterial occlusion threatened the survival of the replanted scalp on two separate occasions, but ultimately it survived except for a small patch at the top of the head which had been almost completely separated from the major portion of the avulsed scalp by the initial injury. This case was successful in preserving this young girl's forehead, eyebrow and most of the hairbearing scalp that had been avulsed (Figure 5).
A 19-month-old female sustained an avulsion amputation of her right thumb in an automobile accident (Figure 6). One artery and one vein were repaired and the avulsed tendon was sutured into anatomical position in the forearm. The patient was using her thumb naturally in play two months after her accident (Figures 7 and 8).
A 19-year-old male completely severed his right hand with a saw while working part-time in a plastics factory (Figure 9). The hand was successfully replanted in a 12hour microsurgical procedure. Several subsequent lesser surgical procedures followed to remove scar around tendons and joints to enhance function. One year following the accident, the patient has good sensation of the replanted hand with approximately 70% of the function (Figures 10 and 11).
In children, almost any amputated part should be replanted. If the part survives, excellent function can be expected. Factors that determine survival include the condition of the amputated part and wound site, ischemia time, the level of amputation, the mechanism of amputation and the overall condition of the child. The availability of equipment and a surgical team trained in microvascular techniques are other important factors. Survival of replanted parts in children can be expected in 60% to 90% of the cases and will vary with the factors mentioned above. In general, children are not afraid to use their replanted fingers following surgery and are a delight to their surgeons and physical therapists in the postoperative period.
1. K. orna ts u S. Tamai S: Successful replantation of a completely cut off thumb: Case repon. Plastic and Reconstructive Surgery 1968; 42:374.
2. Converse J M (ed): Reconstructive Plastic Surgery: The Hand and Upper Extremity, ed 2. Philadelphia. WB Saunders Co. 1977. vol 6. pp 3243-3265.
3. Black EB IH, Day JD, Johnson JB: Replantation: A presentation often cases. Journal of Louisiana Slate Medical Society 1980; 132:112.
4. Kleinen H. et al: Digital replantation - Selection, techniques, and results, in Symposium on replantation and reconstructive microsurgery. Onhop CHn North Am 1977; 8:309-317.