Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 33:
Secondary Reconstruction After Replantation
  One can see from Tables 33-1 and 33-2 that the commonest indication for secondary operations is poor tendon function.1,2,4,6,14,15,17-21,28-31 Tendon adhesions and replants are caused by all the factors affecting an isolated tendon repair39-41 plus the variables unique to the amputation injury. 14,32 Transection of both tendons and both neurovascular bundles, even without bone or extensor injury, has been suggested as the reason for amputation, particularly if a single border digit is involved.42 One can understand the less-than-universal acceptance of the new field of replantation surgery. Circulation to the site of repair stressed by Hunter and others can be improved by the initial repair of both digital arteries.9,43 Recent work on vincular circulation has re-emphasized the importance of blood flow in Zone II injuries.44 Even with the best technical initial repairs, almost all replants in Zone II will require secondary tenolyses 2,12,18,27 and a fair percentage of these will result in secondary ruptures and the need for a tendon rod and secondary tendon graft.27,45 Tenolysis of the tendon graft may yet be necessary, and even rupture of the secondary graft must be anticipated and guarded against. Continuous monitoring by experienced hand therapists is necessary 6,32,33 and can be augmented by specific home therapy programs, the use of sophisticated splints, continuous passive motion machines, muscle stimulators, and a variety of other modalities. Constant communication among the hand therapist, surgeon, and patient is needed to document and update the recovery process. When improvement levels off, secondary procedures are considered in light of all the variables and are usually begun when evidence of early sensory return has occurred. Realistic goals must be set for each patient and each digit, and hand dominance and the needs of the patient must again be considered. Pinch between the thumb pulp and the pulp of a replanted index and/or long finger may be an acceptable result,4 rather than attempting to gain flexion of the radial digits to touch the palm, unless these are the only digits remaining in the hand. Fixed functional flexion contractures of the PIP and DIP joints of the ulnar two digits may be acceptable with a mobile metacarpophalangeal joint, which may allow the ability to forcefully grasp objects of reasonable size, and avoid the need for multiple bone and joint procedures, often with depreciating returns.


next page...

  2002 © This page, and all contents, are Copyright by The Buncke Clinic