|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| Frequently, in complex, multidigital, multilevel injuries, the best function can be achieved by "part-salvage" surgery6-8 in which "unreplantable" amputated parts are used to reconstruct the injured extremity or, in the case of amputated digits, to reconstruct other digits more satisfactorily. For example, a patient has had a multiple-level thumb and an MP level index finger amputation. The thumb cannot be replanted for technical and surgical reasons, and to replant the index finger at that level would produce only poor function. But because the amputated index finger is otherwise intact, it will work well as a thumb when transplanted to the stump at the first metacarpal. Such decisions must be made by an experienced surgeon on an individualized basis.9,10 Vital to the patient's care is the surgeon's ability to assess the immediate situation and develop a long-range plan of reconstruction. This initial management determines the final outcome, especially when early steps may preclude later reconstructive options.
An additional example further illustrates these two concepts of "salvage replantation" and the need for long-term planning. A young man has a grade III midtibial fracture, a 20 cm bone gap, and an insensate foot. Many surgeons would perform a below-knee amputation, believing that prosthetic rehabilitation would offer the best restoration of function. In the past, if soft tissue were also lost on the proximal tibia, some surgeons might have performed a knee disarticulation or even an above-knee amputation to achieve primary closure. Nowadays, even when amputation is chosen, attempts to salvage a below-knee stump will be made by either preserving intact gastrocnemius muscle flaps or early free-flap stump coverage. If the foot is undamaged, a "fillet-of sole" flap is a good choice for immediate free-flap stump coverage. This is available only at the time of amputation surgery, so careful initial planning is essential, using unreplantable spare parts where possible.
| Finally, if the surgeon decides to restore circulation to the foot and reconstruct the soft and bony tissues, a short-range FIG. 31-93. To reduce ischemia time during bone fixation, temporary shunts are placed into the arterial circulation and restore the ischemia time to zero.
Vascular clamps also come in a variety of shapes and sizes, either single20 or double,21 and aid in approximating vessel ends. Clamp-closing pressures of 30 grams or less do not produce intimal damage.22 The small, curved, serrated clamps used in microsurgery help stabilize 1 mm to 2 mm vessels and prevent their retraction into surrounding tissues.
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