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6.

Postoperative Management and Rehabilitation in


Limb/Digit Replantation
YUTAKA MAKI and TAKAE YOSHIZU

Postoperative Management Monitoring of the Replant

Dressing and Position of the Replant The replanted digits or hand should be observed every
1 or 2 h for 3 days and every 3 h for another 4 days by
Postoperative management starts in the operating the doctor and nurse. In the uncomplicated condition
room after the replantation surgery has been com- of the digital pulp of replanted digits or hand, the
pleted. Dressing of the hand and arm is important to color is pink, which is more reddish than normal; the
keep the functional position of the replanted digits and volume, in other words, the tension of the digital pulp,
hand and to keep the wound clean by letting the gauze is normal; and the capillary refill is fast. Pale color, cold,
soak up the discharge from the wound. The intrinsic plus volume loss, and slow or no capillary refill show the dis-
position of the fingers, palmar abduction of the thumb, turbance of arterial flow, which indicates spasms, com-
and neutral position of the wrist are the basic functional pression, or thrombosis of the sutured artery. Dark red
positions of the hand, even though both flexor and or violet color with full volume, fast capillary refill, and
extensor tendons are repaired. The first interdigital color improvement after squeezing show venous con-
space should be kept open by packing enough gauze to gestion, which indicates compression or thrombosis of
prevent adduction contracture of the thumb. Thin gauze the sutured vein. Sometimes an increase in interpha-
is sandwiched between the fingers without compressing langeal joint flexion may stretch the anastomosed dorsal
the replanted fingers. Thick gauze is then applied to the vein. In those conditions, changing of the wet and tight
dorsal and palmar aspects of the hand and forearm. A dressing, removal of the tight skin stiches, and realign-
bandage is bound around the gauze dressing from the ment of the finger position should be done at first. If
distal to the proximal direction with mild compression. these conditions are not improved soon, reoperation
After this the position of the hand should be kept al- should be performed as soon as possible. Skin temper-
most in the intrinsic plus position (Fig. 1). In the care of ature monitoring by thermometer is generally used as a
amputation at the proximal metacarpal level, the first quantitative measure. The temperature probes are set
interdigital space and digital MP joints should be tem- on a nonreplanted and a replanted digit, and the tem-
porarily fixed by Kirschner wires in the functional posi- peratures are compared. The continuous low tempera-
tion. A plaster cast or plastic splint is the applied at the ture and sudden temperature drop of the replant may
dorsum of the hand and forearm. When splinting of the indicate circulatory disturbance. However, direct ob-
elbow joint is added, the position of the elbow should servation of the replant by the medical stuff is most
be set around 60°. More than 90° of elbow flexion may reliable.
disturb the venous drainage. The digital tips should
be kept open after dressing to check the circulatory
condition.
After the patient is transferred to the recovery room,
Salvage
he or she is laid on the bed for a week with the hand
and forearm elevated on the soft triangular pillow If the anastomosed site of the artery or vein or both
is occluded by thrombosis, after resection of the
except for times of meals and hygiene. The replanted
anastomosis, interposition of a vein graft between the
hand is covered by a cotton pad and towel to keep the
hand warm except for observation times (Fig. 2). The good proximal and distal stumps is the best measure.
If the replanted amputated digital tip is congested
room is also kept warm.
and venous reconstruction is impossible, a small inci-
sion on the digital tip or removal of the nail plate is

179
S. Tamai et al. (eds.), Experimental and Clinical Reconstructive Microsurgery
© Springer Japan 2003
180 D. Preoperative and Postoperative Management

added to promote venous drainage. Scratching or Anticoagulants and Antibiotics


squeezing of the pulp is the done every 30min or
1 h, and a small, wet, heparinized gauze pad is laid We use urokinase 240,000 units per day for 4 to 5 days
on the bleeding site for 1 week. Sometimes these and prostaglandin E) 60 units per day for 7 days, added
procedures can save the replanted digital tip with to the intravenous drip infusion of 2000 ml per day,
congestion. including 500ml of low-molecular-weight dextran. If the
crushing of the replanted digits or limb is severe, 10,000
to 20,000 units of heparin per day is continuously added
for 1 week. Antibiotics are administered routinely for 1
week.

Rehabilitation
Mild active-motion exercises of the nonaffected joint,
such as the elbow or shoulder joint in the case of digit
replantation, as well as walking to the rest room, are
generally permitted 1 week after surgery. Exercise of
the replanted finger, wrist, or arm starts 3 or 4 weeks
b after surgery following the schedule of extensor tendon
a surgery, the aim of which is to minimize the extension
loss of the proximal interphalangeal (PIP) joint by
attenuation of the sutured extensor tendon. At this
point, bone healing and tendon healing have moder-
ately progressed, and the vascular suture site is almost
covered with regenerating intima. Passive stretching
of the repaired flexor and extensor tendons should
be started 6 weeks after surgery at the earliest. Early
motion exercise of the replanted digit, which has
already been introduced, is mild passive flexion and
extension of the interphalangeal (IP) and metacar-
pophalangeal (MP) joints by the dynamic tenodesis
effect of accompanied wrist motion [1]. This method
c d starts 1 week after surgery and may prevent contracture
of the digital joints, but it may still be insufficient to
Fig.1. Dressing of the replant. a The wound is covered by tulle prevent tendon adhesion. To start very early active-
gauze. b Gauze packing. c, d A bandage is applied motion exercise of the replant to prevent tendon adhe-

Fig. 2. Position of the replant


on the bed. a Elevation on the
pillow and coverage by towel.
b Coverage by cotton pad.
a-c c Observation of digital tips
6. Postoperative Management and Rehabilitation in LimblDigit Replantation 181

months to prevent adduction contracture of the thumb


and intrinsic minus contracture of the fingers (Fig. 3).
Maintenance of the intrinsic plus position may increase
the intrinsic plus contracture of the fingers by con-
tracture of interosseous the muscles, which disturb
flexion of the PIP and distal interphalangeal (DIP)
joints. Careful observation should be made to detect this
condition, and intrinsic release operation is indicated if
it occurrs. Because delayed union of the bony fixation
site disturbs the smooth rehabilitation process, early
bone grafting is indicated if it is suspected.
a * rubber band

Tenolysis
* Tenolysis is planned after 4 to 6 months of rehabilita-
tion. In cases of digital replantation, if the extensor
mechanism is acting functionally with full passive
flexion of the finger joints, only flexor tenolysis is indi-
* cated. The result of extensor tenolysis at the finger
proper level is poor. In cases of replantation proximal
b to the metacarpal level, if the forearm muscles have
functional activity, both extensor and flexor tenolysis is
indicated with a 3-month interval.

Others

c When the patient has some sensation in the pulp, a


sensory reeducation program should be started [2,3]. If
Fig.3. Splinting for the replant. a Cock-up splint with flexion he or she has paresthesia in the pulp, desensitization
assist of metacarpophalangeal (MP) joints, extension assist of exercise should be started, which includes rubbing a
proximal interphalangeal (PIP) joints, and palmar abduction coarse towel over the pulp or grasping and manipulat-
assist of thumb for replant at forearm or wrist level. b Knuckle ing soybeans. For good functional sensory recovery,
bender with extension assist of distal interphalangeal (DIP)
functional movement of the digits is indispensable.
joints and palmar abduction assist of thumb for replant at
Release of intrinsic muscle contracture, opponens
metacarpal level. c Static splint with functional position of the
hand, which is mainly used at night plasty, and tendon transfer are planned case by case,
depending upon the circumstances.

sion, we need rigid bony fixation, a rigid flexor and ex- References
tensor tendon suture technique, and a safe technique of
reconstruction of the artery and vein to resist bending 1. Buncke HJ, Jackson RL, Buncke GM, Chan SW (1995) The
and traction forces in the swelling of the surrounding surgical and rehabilitative aspects of replantation and
revascularization of the hand. In: Hunter JM, Mackin EJ,
tissue. So far we have not established these techniques.
Callahan AD (eds) Rehabilitation of the hand: surgery
However, early passive motion exercise of the digits in and therapy. CV Mosby, St Louis, Chapter 62, pp 1075-
the case of upper arm replantation is permissible to 1100
prevent digital joint contracture. Because the recovery 2. Dellon AL (1981) Evaluation of sensibility and re-
of directly damaged or denervated intrinsic muscle education of sensation in the hand. Williams & Wilkins
of the hand is poor, dynamic splinting in the daytime 3. Parry CBW, Balter M (1976) Sensory re-education after
and static night splinting should be applied for several median nerve lesions. Hand 8:250-257