Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 32:
Bony Fixation in Replantation
  In a preliminary review of our experience with Kirschner and intraosseous wires in replanted digits, complications, including shifts in bony alignment or initial poor reduction, were seen in approximately 30% of patients, regardless of the method of fixation. Malunion or complete nonunion occurred in approximately 16% of patients overall, with two thirds requiring corrective osteotomy. Intraosseous wires, placed perpendicular to each other, were found to have a reduced rate of nonunion, probably as a result of the compression achieved.24


The severely traumatized extremity is a composite of injuries to bone, soft tissue, motor units and gliding structures. All degrees of severity may be seen, including partial amputation with devascularization, multiple fractures, and areas of absolute soft and hard tissue loss. The high-energy injuries are associated with a marked inflammatory reaction, swelling, and an increased risk of postoperative stiffness. Although the time frame for successful replantation remains precious, adequate bony fixation remains the common building block upon which all subsequent therapy and reconstruction are based. When many fractures are present, rigid fixation becomes significantly more important, and the stability of plate fixation becomes the implant of choice. If the wounds are not ready for internal implants, external fixation remains a useful adjunct.


Implant fixation of the bony skeleton provides a range of fracture stabilization methods from simple placement of an internal splint, such as a K-wire to complete rigid fixation with application of screws and plates. Between these extremes lie multiple options enabling the surgeon to select and match the clinical findings with techniques that are the most feasible and applicable to the level and severity of injury. Most methods allow adequate immobilization of the fracture while re-establishing the bone contact necessary to restore stress-sharing capability of bone. In general, the simpler the technique, the less rigid the method because of the nature of the bone/implant interface. The application of compression requires an increase in the complexity of technique and implant, which in turn requires increased expertise in selection and application. Finally, the more distal the injury, the less forgiving the soft tissue envelope, which restricts the implant selection. In all situations, the fixation technique selected should be one that the surgeon is familiar with and that can be applied expeditiously with a consistent degree of quality.

Clinical Cases


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