Fibrinolytic activity in vascular grafts

We have demonstrated the absence of tissue fibrinolytic activator for 11 days following the transplantation of vascular grafts in dogs. The lack of a local tissue fibrinolytic activator (to dissolve intravascular thrombi) is suggested as an etiological factor in losses which occur during the first 11 days after digital replantation.     

Fingertip replantation using the subdermal pocket procedure

Restoration of finger length and function are the goals of replantation after fingertip amputation. Methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. To increase the survival rates for composite grafts, the subcutaneous pocket procedure has been used as a salvage procedure. The subdermal pocket procedure, which is a modification of the subcutaneous pocket procedure, was used for replantation of 17 fingertips in 16 consecutive patients. Eight fingertips experienced guillotine injuries and the other nine fingertips experienced crush injuries. Revascularization of one digital artery without available venous outflow was performed for six fingers, and composite graft techniques were used for the other 11 fingers. The success rate was 16 of 17 cases. The difference in success rates for guillotine versus crush injuries was statistically significant. Comparison of patients with arterial anastomoses and patients without arterial anastomoses also indicated a statistically significant difference. Thirteen fingertips survived completely. One finger, demonstrating complete loss and early termination of the pocketing procedure, was amputated on the eighth postoperative day. Two fingers were partially lost because of severe crushing injuries. One finger demonstrated partial loss of more than one quarter of the fingertip, which required secondary revision, because the patient was a heavy smoker. The pocketing period was 8 +/- 1 days (mean +/- SD, n = 6) for the fingers revascularized with one digital arterial anastomosis and 13.3 +/- 1.9 days (n = 10) for the fingers successfully replanted with composite graft techniques. The mean active range of motion of the interphalangeal joint of the three thumbs was 65 +/- 5 degrees, and that of the distal interphalangeal joint of the other 11 fingers was 51 +/- 11 degrees. The static two-point discrimination result was 6.4 +/- 1.0 mm (n = 14) after an average of 11 +/- 5 months of follow-up monitoring. Compared with other methods, the subdermal pocket procedure has the advantages of exact subdermal/subdermal contact, a shorter pocketing period, and more feasible observation. The method can offer an alternative salvage procedure for fingertip amputations with no suitable vessels available for microsurgical replantation.     

Influence of extended operation time and of occlusal force on determination of pulpal healing pattern in replanted mouse molars

The mechanism regulating the divergent healing processes following tooth replantation is unclear. This study clarifies the relationship between the healing pattern, the time taken for tooth replantation, and the influence of occlusal force. We investigated the pulpal healing process after tooth replantation by immunohistochemistry for 5-bromo-2′-deoxyuridine and nestin and by histochemistry for tartrate-resistant acid phosphatase. The upper right first molar of 3-week-old mice was extracted and repositioned in the original socket immediately or 30 min to 6 h after the operation. We divided the animals into a non-occluded group in which the lower right first molar was extracted and an occluded group without extraction of the counterpart tooth. In control teeth (upper left first molar), the periphery of the coronal dental pulp showed intense nestin-positive reaction. Tooth replantation weakened the nestin-positive reaction in the pulp tissue. On postoperative days 5–7, tubular dentin formation commenced next to preexisting dentin in which nestin-positive odontoblast-like cells were arranged in successful cases. In other cases, bone-like tissue formation occurred in the pulp chamber until day 14. The ratio of tertiary dentin formation was significantly higher in the non-occluded group. The intentionally prolonged time for the completion of tooth replantation induced bone-like tissue formation, expanded inflammatory reaction, or fibrous tissue formation in pulp tissue. Thus, the lack of a proper oxygenated medium is probably decisive for the survival of odontoblast-lineage cells, and occlusal force during and/or after operation worsens the fate of these cells. This work was supported in part by KAKENHI (B) from MEXT, Japan (no. 16390523 to H.O.) and by the Japan-Korea Joint Research Project from JSPS and KOSEF.     

The role of angiogenesis and pulpal healing in tooth replantation and allograft transplantation

Tooth transplantation is one of the treatment options for extracted teeth that can be considered before dental implantation. Although the success rate of tooth transplantation is lower than that of implantation, tooth replantation and transplantation have the great advantage of using natural teeth. Tooth replantation might be considered a promising option in some cases. In present study, the expression patterns of revascularization and pulpal healing, which are the most important for the pulp viability, were analyzed after tooth replantation and allograft in mice. The inflammatory response and root dentin resorption were observed and not different between replantation and allograft in initiation of healing process. However, bonelike tissue formation, pulp revascularization and pulp healing were faster in replantation. The difference of healing patterns between tooth replantation and allograft found in present study will be helpful to select the treatment option and to understand healing mechanism.     

Replantation

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for extremity replantation. 2. Outline the sequence and technique of replantation. 3. Identify potential complications of replantation and recognize treatment options. 4. Assess the results of replantation in terms of function and costs versus benefits.     

激光多普勒血流仪在断指再植术后血运监测应用的效果研究

目的:为了提高临床断指再植手术效果,分析断指再植术后彩色多普勒血流成像仪的临床应用效果价值。方法:从2016年9月至2017年9月在我院接受断指再植术治疗的60例患者中,采用随机数表法随机将其分为实验组和对照组各30例。实验组:采用激光多普勒血流成像仪监测再植肢体血运;对照组:采用传统方法监测再植肢体血运。探讨断指再植术后彩色多普勒血流成像仪的临床应用价值。结果:研究结果显示,和对照组相比观察组患者断指再植术后血管栓塞率、血管危象发生率明显降低,而断指成活率以及成活再植指术后功能恢复情况则明显增加(P0.05)。结论:将彩色多普勒血流监测应用于断指再植术后,能够无创、实时、灵敏的反应再植指术后的血运情况,有助于及时发现各种不良事件的,提高再植成功率,效果显著,值得推广。     

低分子肝素钙对小血管损伤术后血液流变学影响的临床研究

目的：观察应用低分子肝素钙如何提高断指再植成活率的作用机制,为临床更好的应用低分子肝素钙提供理论基础。方法：通过临床随机对照试验设计,以30例断指再植患者为研究对象,30例健康成人为参照对象。观察30例断指再植患者术前术后不同时段血液流变学指标的变化。结果：断指患者受伤至术后72h血液流变学指标均明显升高,与对照组比较有显著差异（P〈0.01）。低分子肝素钙可以显著降低断指再植患者的血液粘度,改善血液不利于断指成活状态,提高断指成活率,降低其坏死率、致残率。结论：低分子肝素钙,毒副作用小,为防治断指再植术后并发症的一种良药,为临床断指成功再植提供了一种较为理想的治疗方法。     

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.     

Rat ear reattachment as an animal model

The external ear of the rat is an excellent model for practicing microsurgical dissection and for the refinement of microvascular anastomoses, techniques that are crucial for microvascular en bloc tissue transfer and replantation. Preparation of the rat ear for replantation requires familiarity with the vascular anatomy and gentle tissue handling with atraumatic dissection of arterial and venous pedicles, steps similarly crucial in raising free flaps for microvascular transfer. The strategy of performing accurate reduction and stabilization of the tubal cartilage prior to vessel repairs, anastomosing the more deeply seated external carotid artery prior to the more superficial posterior facial vein, is as critical to rat ear replantation as for digital reattachment. In addition, the rat ear as compared to other animal models such as the rabbit ear or canine hindlimbs is much less expensive. Compared to the rat hindlimb model, rat ears are much easier to observe, which is a distinct advantage when used as a model for long-term study of replantation, revascularization, or transplantation.     

The dynamics of morphofunctional changes in the microcirculation of the pelvic extremity after modeling the chief stages of its replantation]

Under study was the effect of autotransplantation in its "pure form" upon the morpho-functional reconstruction and structural mechanisms of adaptation of the blood and lymphatic links of the microcirculatory bed of extremities during early postoperation period up to 10 days. The pathophysiological state of the extremity sufficiently close to its autotransplantation was obtained by means of circular transection of soft tissues of the medial third of the femur together with the nerves and deep collecting lymphatic vessels. It was found that after modeling the main stages of replantation in the fascia and periosteum of the operated extremity there developed a spasm of the arteriolar link and dilatation of the venular and lymphatic links of the microcirculatory bed. The areas of leukocytic infiltration with the phenomena of diapedesis and microhemorrhages were revealed along the course of postcapillaries and venules in the paravasal connective tissue. The amount of functioning arteriole-venular anastomoses was increased. Against the background of pronounced oedema of soft tissues of the operated extremity the venous pressure increased and the rate of the capillary bloodflow in the skin and muscles decreased. The above changes tend to be reduced by the 10th day after modelling the main stages of replantation of the extremity.     

Successful replantation of an amputated nasal tip by microvascular anastomosis

Successful microsurgical replantation of a completely avulsed nasal tip is presented. The result is excellent. The technical challenge involved no sizable veins for drainage. This problem was solved by an artery-to-vein shunting. For facial avulsions, there is nothing superior to the original tissue, and replantation should always be attempted first.     

Successful replantation of lower leg and foot, with good sensibility and function.

The successful replantation of the lower part of a leg with the foot is reported in a 17-year-old boy. Adequate protective sensibility was obtained, and he walks well with a 3-inch lift on that shoe. He is also able to hike, climb, swim, dive, and engage in most normal activities. The pros and cons of leg replantation are considered.     

Experimental replantation of canine forelimbs after 78.5 hours of anoxia

To assess the effect of ischemia on osteocyte survival and longitudinal growth in bone, one forelimb of eight puppies and seven dogs was amputated, perfused with iced Collins solution, maintained at 4 degrees C for 72 hours (78.5 hours total anoxia), and replanted. Five puppies were kept for 1 year to assess bone growth. Undergoing bone labeling on days 1, 8, and 15, the other animals were sacrificed at 22 days to assess osteocyte survival. Osteocytes survived replantation in all dogs and one puppy; most osteocytes died in two puppies. In five long-term puppies, central epiphyseal growth was disturbed, but the peripheral portions maintained nearly normal growth, with almost normal bone length being achieved at 1 year.     

Microsurgical replantation of the amputated nose

A case of successful replantation of the nose is presented. Two arteries and one vein were anastomosed, providing a stable framework for direct revascularization of the amputated nasal segment. This resulted in complete survival of the nose, with an excellent aesthetic result. However, despite successful microsurgical arterial and venous repair, significant postoperative blood loss still occurred as a result of anticoagulation. In cases of the amputation of specialized structures, the improved functional and cosmetic result obtained with replantation must be weighed against the risk of blood-borne disease transmission when postoperative transfusion is required. Recognizing the potential need for postoperative transfusion in these cases is important in allowing the surgeon to exercise appropriate judgment in deciding whether replantation should be performed.     

Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part

A method of salvage of mutilated extremities with temporary ectopic implantation of the undamaged distal part is described. We suggest that this method is indicated in devastating segmental injuries of extremities, where the distal part is devascularized and where a necessary radical debridement would include the structures which are indispensable for a good functional result of the replantation but which would possibly survive if treated with an open-wound technique. The method could also be used in cases where an essential length of limb could be preserved by open-wound management with improvement of the functional and aesthetic result of replantation. The method is contraindicated in injuries where perfusion of the distal part is preserved. The lateral upper part of the thorax is suggested as a convenient site, with the thoracodorsal artery and vein as recipient vessels. The timing of replantation of the ectopic implanted part must be carefully planned to avoid complications caused by remaining necrotic tissues or infection. The importance of intensive physiotherapy of the ectopic implanted part is stressed.     

Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries. SUMMARY: The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.     

Significance of venous anastomosis in fingertip replantation

Adequate venous outflow is the most important factor for successful fingertip replantation. The authors have attempted venous anastomosis in all cases of fingertip replantation to overcome postoperative congestion. In this article, the significance of venous repair for fingertip replantation is described from the authors' results of 64 complete fingertip amputations in 55 consecutive patients, which were replanted from January of 1996 to June of 2001. The overall survival rate was 86 percent. Of the 44 replantations in zone I, 37 survived, and the success rate was 84 percent. Of the 20 replantations in zone II, 18 survived, and the success rate was 90 percent. Venous anastomosis was attempted in all cases, but it was possible in 39 zone I and in all zone II replantations. For arterial repair, vein grafts were necessary in 17 of the 44 zone I and in one of the 20 zone II replantations; for venous repair, they were necessary in six zone I replantations and one zone II replantation. Postoperative vascular complications occurred in 15 replantations. There were five cases of arterial thrombosis and 10 cases of venous congestion. Venous congestion occurred in nine zone I and one zone II replantations. In five of these 10 replantations, venous anastomosis was not possible. In another five replantations, venous outflow was established at the time of surgery, but occlusion occurred subsequently. Except for the five failures resulting from arterial thrombosis, successful venous repair was possible in 49 of 59 replantations (83 percent). Despite the demand for skillful microsurgical technique and longer operation time, the authors' results using venous anastomosis in successful fingertip replantations are encouraging. By performing venous anastomosis, external bleeding can be avoided and a higher survival rate can be achieved. Venous anastomosis for fingertip replantation is a reliable and worthwhile procedure.     

Histochemical and immunocytochemical study of hard tissue formation in dental pulp during the healing process in rat molars after tooth replantation

Dental pulp is assumed to possess the capacity to elaborate both bone and dentin matrix under the pathological conditions following tooth injury. This study was undertaken to clarify the mechanism inducing bone formation in the dental pulp by investigating the pulpal healing process, after tooth replantation, by micro-computed tomography (μ-CT), immunocytochemistry for heat-shock protein (HSP)-25 and cathepsin K (CK), and histochemistry for both alkaline phosphatase (ALP) and tartrate-resistant acid phosphatase (TRAP). Under deep anesthesia, the upper right first molar of 4-week-old Wistar rats was extracted and immediately repositioned in the original socket. In control teeth at this age, the periphery of the coronal dental pulp showed intense ALP-positive and HSP-25-positive reactions, whereas there were no TRAP-positive or CK-positive cells. Tooth replantation weakened or terminated ALP-positive and HSP-25-positive reactions in the pulp tissue at the initial stages. At 3–7 days after operation, the ALP-positive region recovered from the root apex to the coronal pulp followed by HSP-25-positive reactions in successful cases showing tertiary dentin formation. In other cases, TRAP-positive and CK-positive cells appeared in the pulp tissue of the replanted tooth at postoperative days 5–10 and remained associated with the bone tissue after 12–60 days. Immunoelectron microscopy clearly demonstrated that CK-positive osteoclast-lineage cells made contact with mesenchymal cells with prominent nucleoli and well-developed cell organelles. These data suggest that the appearance of TRAP-positive and CK-positive cells is involved in the induction of bone tissue formation in dental pulp.This work was supported in part by a grant from MEXT to promote 2001-multidisciplinary research project (in 2001–2005) and by KAKENHI (B) from MEXT, Japan (no. 16390523 to H.O.).     

Psychological reactions and processes following replantation surgery: a study of 50 patients

Fifty consecutive patients admitted for replantation surgery received a psychiatric evaluation. In 28 percent of the patients there was evidence of preaccident psychopathology. Fifty-four percent of the patients reported a recent stressful life event predating the accident. Fifty-four percent of the patients were assessed as having an adverse postoperative emotional reaction. The presence of preaccident psychopathology, evidence of family dysfunction, and a history of a recent stressful life event were positively linked with an adverse postoperative emotional reaction. In addition, patients with hand or arm replants were significantly less likely to require a psychiatric intervention than patients with leg replants. The psychological processes pertaining to the replantation journey are described in five stages: the preaccident period, the initial response, the stage of uncertainty, the recognition of loss, and acceptance and reintegration. Finally, the role of a liaison psychiatrist on a replantation unit is outlined and further research is strongly urged.     

Ten-digit replantation

A case is presented of replantation of 10 digits at the proximal phalangeal level. Seven digits survived. Osteotomies and flexor tenolysis were done on the right thumb, long, and ring fingers and left index and long fingers 11 months later. A toe-to-hand transfer was done to reconstruct the failed left thumb replantation. Functional and sensory recovery is satisfactory.