Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 33:
Secondary Reconstruction After Replantation
  In summary, secondary procedures are frequently required following replantation, for restoration of function, sensation and contour. There are few tissues in or adjacent to a replanted part that cannot be revised or replaced with like autologous tissue. One wonders when the homologous parts will be available for reconstruction in these less-than-life-threatening problems.

Clinical Cases


A 23-year-old man amputated his nondominant long, ring, and little fingers through the proximal phalanx with a table saw. All were successfully replanted with primary nerve and tendon repairs.

FIG. 33-01. Appearance of wound.

FIG. 33-02. X ray shows mini T plate in long and interosseous wires in ring and little fingers.

FIG. 33-03. Four months after injury, the ring and little fingers had flexion contractures of the proximal interphalangeal joints, limited extension, and profundus tendon pull-through was limited despite aggressive physical therapy. Sixty degrees of extensor lag were present.

FIG. 33-04. Tenolysis was performed through volar Brunner's incisions, protecting the neurovascular bundles and exposing the tendon sheath in the midline. Remnants of the flexor sheath were excised, with the A-2 and A-4 pulleys left intact (arrows).


FIG. 33-05. A counterincision was made at the wrist to allow lyse of palmar adhesions. Intraoperative traction at the wrist confirms excellent pullthrough.

FIG. 33-06. Early postoperative follow-up shows improved extension.

FIG. 33-07. Flexion.

FIG. 33-08. Tips of ring and little fingers can touch the palm.

FIG. 33-09. Secondary tenolysis may require pulley reconstruction to avoid bowstringing, as seen in this replant patient.

FIG. 33-10. The A-2 pulley has been reconstructed with remnant tendon sheath, sutured to the gutter created by the resected tendon sheath.

FIG. 33-11. Completed pulley.

FIG. 33-12. Drawing of repair.

FIG. 33-13. Another method of pulley reconstruction using a woven tendon graft through slits on the risidual tendon sheath or MC joint capsule. A. slits in sheath remnant. B, woven tendon graft.


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