Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 33:
Secondary Reconstruction After Replantation
  Secondary neurolyses, neuroraphies, and/or interpositional nerve grafts are indicated 2 to 3 months after Tinel's sign fails to cross the site of repair. Intervention should be early rather than late because useful global hand function is delayed and dependent on some degree of nerve regeneration. In digits, particularly if the nerve defect is on the same side as the vascular repair, jump grafts should be used bridging the area of repair from normal proximal nerve to normal distal nerve. With avulsive injuries, one may have to go several centimeters proximally to find viable nerves. In some instances, a proximal neuroma may not be found, and sharing or transferring of nerves from less critical areas may be useful. The dorsoradial sensory branches may be transferred into the digital nerves of an avulsed replanted thumb or index finger, the proximal superficial peroneal nerve to the sural nerve, or the saphenous nerve to the calcaneal nerve in the lower extremity with irreversible nerve injury.60 Other nerve grafts and nerve transfers may be needed to restore muscle function to the ulnar or medial intrinsics or to damaged or missing proximal muscle groups. Secondary nerve procedures in proximal replants of the arm or leg are common, 11,29,61 but are seldom worthwhile except when the segmental area of nerve injury is short, and in young individuals. This suggests that avulsive injuries at these levels should not be replanted because the major nerves are often pulled out at the spinal cord level. Replants without protective sensation, particularly in the lower extremity, become a liability to the patient and an albatross to both patient and surgeon.

  Secondary Soft Tissue Procedures

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