Efficient Replantation: Techniques, Tricks, and Secondary Procedures for Improved Functional Outcomes

Abstract

Successful digit replantation is dependent on multiple factors, including patient demographics, comorbidities, the mechanism of injury, and the skill and experience of the surgical team and microsurgery center. Although patient and injury characteristics cannot be controlled, the microsurgeon can incorporate specific techniques to improve efficiency and optimize outcomes. Replantation can be tedious, and minimizing surgeon fatigue is important. This article aims to review strategies and tricks to increase efficiency and success in digit replantation, while also reviewing postreplant rehabilitation and secondary surgeries to optimize hand function.

Keywords: Hand surgery; Hand trauma; Microsurgery; Replantation; Revascularization.

Figure 1

Operating room setup. Note the tagging table with microscope on the left.

Figure 2

Example of a back table setup consisting of micro and macro instruments for dissection and sutures for skin retraction and tendon repair. K-wires and driver are available for distal skeletal fixation, but not pictured here.

Figure 3

Prepared parts. Vessels and nerves have been identified through Bruner incisions and clipped. Double loop locking sutures have been placed in the flexor tendons. K-wires are placed for distal bony fixation.

Figure 4

Double loop locking suture.

Figure 5

Double loop locking suture tenorrhaphy.

Figure 6

Use of the Tupper hand table. A Positioning in a supinated position. B and C Positioning in a hypersupinated position. The latter provides excellent visualization of the volar structures of the thumb.

Figure 7

Dotting out volar veins prior starting the procedure allows for identification of potential vein grafts and venous flaps once the tourniquet is inflated. Large dots are used to mark large veins, and small dots mark small veins.

Figure 8

Nerve coaptations using nerve allograft and vessel anastomoses.