|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| autotransfusions of this blood.28,29 An alternative is to irrigate the amputated part with heparinized cold Ringer's solution, followed by venous shunting or vein-first anastomosis. This also clears the system of metabolic products without incurring a large blood loss. Frequently, patients with extremity injuries are given steroids, sodium bicarbonate, and mannitol before and during the operative procedure. If these measures are followed, potassium load is limited, and good fluid and electrolyte balance are maintained, serious metabolic disturbances are avoided. Almost all major amputations require a fasciotomy to prevent potential or impending compartment syndromes that develop with the significant muscle edema that follows revascularization.28-32 In arm replantations, dorsal and volar forearm fasciotomies, and carpal and Guyon tunnel release, an intrinsic compartment decompression should be performed. When the structures have been identified and labeled, the wound is debrided, and all foreign material and necrotic or crushed tissue are removed. A valuable tool for wound cleansing is pulse lavage with or without antibiotic solutions. A sterile toothbrush is ideal for cleansing small parts and bone stumps. Proximal injuries of the extremities involving severe crush or a large area may require a "second-look" procedure the following day to look for delayed necrosis of injured tissue. This may save a replant before sepsis sets in.
| Operative Sequence
Bone shortening and osteosynthesis are the first important steps in replantation. If well planned, bone shortening can permit primary tension-free anastomoses of vessels and nerves without compromising length and function. Primary soft tissue coverage is also facilitated.
There are a number of techniques for osteosynthesis (Fig. 31-3): 1. Single or double parallel longitudinal wires 2. One longitudinal and one oblique K-wire 3. Crossed K-wires 4. Intramedullary pins 5. Interosseous wires by mattress, figure-8, or Cassel techniques 6. Plate fixation 7. Screw or bolt fixation 8. External fixation 9. Bone peg.
Each of these techniques is useful and depends on the requirements of each case. (For a more detailed discussion, see Chapter 32.)
Arterial repair is performed next to re-establish circulation and perfusion quickly and to assess the viability of the amputated part. Venous and arterial anastomoses are performed
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