Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 31:
Replantation Surgery
  If the wrist joint is fused or preserved, it is held in 30-degree extension while the flexor and extensor tendons are repaired and also during the healing period. Because the flexor tendons can accommodate length discrepancies better than the extensor, the MP joints are placed in 80- to 90-degree flexion and the PIP joints at 0 degrees.

When possible, a cuff of periosteum should be retained during bone shortening and used to cover the osteosynthesis site. This promotes quicker healing and may reduce adhesion of overlying tendons.


If avulsive, these amputations may also involve injuries of the subclavian vessels, the brachial plexus, and the intrathoracic structures. Chest x rays and careful evaluation for these injuries must be made. A Horner's sign, if present, indicates root level avulsion, and replantation should not be considered because, even if the replant survives, the limb function will be poor.

Patients with multiple level (upper and lower) arm injuries may be better treated by amputation at the distal level and replantation at the proximal level to improve the filling and function of a prosthetic device, particularly if the elbow joint can be salvaged. Immediate coverage and restoration of function can be achieved by pedicled latissimus and pectoralis major flaps that can also provide valuable elbow flexion and extension.



Some additional considerations not referred to earlier in the chapter include the concept of "foot-switch" operations that may allow salvaging one leg when both legs are injured, but at different levels.61 A typical example is when the foot is badly crushed on one side and a tibial-level amputation is present on the other side. The relatively uninjured foot from the amputated side is transplanted to the shortened stump of the relatively uninjured contralateral lower leg. Rehabilitation is completed by prosthetic fitting of the leg with the higherlevel amputation.


This is one of the most vexing problems confronting the microsurgeon. Ear injury is usually avulsive and often involves crushing because it results from motor accidents or human and animal bites.

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