REPLANTATION IN CHILDREN

MEHMET YILDIZ, M.D.,* MUHITTIN SENER, M.D., and

CELAL BAKI, M.D.

The rates of survival of the amputated part and the functionaloutcomes were studied retrospectively after 13 replantationsand 12 revascularizations in 25 children. The ages of thepatients ranged from 2 to 15 years (mean, 6.4 years). Theaverage duration of follow-up was 4.2 years (range, 2 to 7years). The survival rate was higher after revascularization(94.6%) than after replantation (84.6%). Sensory recovery ofall digits was satisfactory. The mean growth rate of replanteddigits relative to contralateral digits was 80%. Functional re-

sults were rated as excellent in 11 cases, good in 8 cases,moderate in 2 cases, and poor in 1 case. In order to preventfunctional and growth disturbances and due to cosmetic rea-sons, replantation or revascularization should definitely betried for children.

© 1998 Wiley-Liss, Inc.

MICROSURGERY 18:410–413 1998

There is a growing consensus in the orthopaedic literaturethat replantation at any level usually is better than amputa-tion revision or prosthetic fitting.1 Because the vessel di-ameter might be less than 0.5 mm in children, replantationprocess on the digital amputations is technically demand-ing.2 Advances in microsurgical techniques have been per-mitted replantation and reconstructive procedures to restoreinjured parts with a high degree of success in children.3,4

Vessels as small as 0.3 and 0.4 mm have been repairedsuccessfully.2,5 Saies et al.6 advised that replantation andrevascularization procedures should be performed in chil-dren who have had almost any complete or incomplete am-putation at any level when technically possible. Pediatricreplantations have different properties than those in adults.Joints should be reconstructed, epiphyses preserved, andbone shortening kept as minimal as possible. Tan and Teoh7

reported that complications of replantation are not morethan those in adults. In this study, we evaluated 25 patientsunder 16 years of age who underwent digital and hand re-plantation and revascularization between 1990 and 1995 inour clinic.

MATERIALS AND METHODS

We report a series of 25 cases of replantation in childrenwhose ages were 2 and 15 years of age. The mean age was6.4 years. In 13 cases replantations and in 12 cases revas-cularizations were done. The distribution and level of inju-

ries are indicated as defined by Tamai8 (Table 1). Twelvefemales and 13 males were included in our series. In 15cases right extremity and in 10 cases left extremity wereinvolved. The most commonly injured digits were indexfinger (10 patients) and thumb (5 patients). The follow-upperiod was between two and seven years (average, 4.2years).

Sixty-eight percent of amputations (17 cases) were dueto axe injury. In 4 of 17 cases, the amputations were done bythe patients’ friend or relatives. The rest of the amputations(8 of 25) were not clean-cut injuries. Three of these injurieswere by a pitsaw and two by cableway (used for transport inour region), and the last three cases were as follows: onegun shot injury, one crush injury with a heavy stone, andone injury with a big gardener scissor.

Average time prior to hospitalization was estimated tobe 3.4 hr. All patients were operated under general anesthe-sia. Debridement was performed according to type of injuryand damage. In cases of crush, all necrotic tissue were de-brided. In clean-cut injuries, debridement was kept to aminimum.

For bone fixation, one or two small Kirschner wires

Department of Orthopaedics and Traumatology, Karadeniz Technical Univer-sity, Medical School, Division of Hand Surgery, Trabzon, Turkey

Presented at the Third Congress of European Federation of Societies forMicrosurgery in Berlin, 1996.

*Correspondence to: Dr. Mehmet Yildiz, K.T.U. Tıp Fak, Ortopedi AbD, 61080,Trabzon, Turkey.

Table 1. Level and Distribution of Replanted Digits

LevelNumber of

patients

DigitFirst zoneSecond zone 5Third zone 9Fourth zone 7Fifth zone

Hand 2Wrist 1Forearm 1

Total 25

© 1998 Wiley-Liss, Inc.

were used. We prefer to shorten the bones a little more thanis absolutely necessary. In all digit amputations, one arteryand two vein were anastomosed. All nerves were primarysutured. Tendons were repaired with 4/0 nylon by usingmodified Kessler technique. Replanted part was placed in abulky dressing, immobilized with a dorsal long-arm splintand kept elevated.

Heparin was given intravenously just before the arterialanastomosis. In addition to heparin, aspirin and low mo-lecular dextran were given for 5 days as anticoagulanttherapy postoperatively. Broad spectrum antibiotics(Cephalosporins) were given intravenously for 3 days. Di-azepam was used as a sedative during the early postopera-tive period. Postoperatively, all children were kept in bedfor 5 days. Smoking was not allowed near the child.

Temperature, color, turgor, capillary refill, and Doppler

examinations were used to monitor the postoperative statusof the replanted extremities. Physical therapy was begun atabout 15 days postoperatively, depending on the conditionof the wound. The functional results were evaluated usingthe clasification established by Chen et al.9 In Chen et al.’ssystem, the results are classified in four grades, based on theanalysis of four parameters. ability to work (grasping a softmaterial, picking up, writing etc.); range of motion; recov-ery of sensibility; and muscle power each rated on a scale of1 to 5. In all cases, radiographs were taken before the op-eration and at latest control for bone growth rate.

RESULTS

All but three of amputed parts survived after replanta-tion and revascularization, for an overall survival rate of

Figure 1. A: A 4-year-old boy had amputated his thumb by cableway from the distal of the proximal phalanx. B and C: Excellent result wasobtained 2 years postoperatively. D: In radiogram, growth rate was measured as 95% of normal contralateral digit.

Replantation in Children 411

88% (in replantation 84.6% and in revascularizations94.6%); two of the unsurvived cases were avulsion injuries.According to Chen et al.’s criteria, 11 cases (44%) hadexcellent result (Fig. 1), 8 cases (32%) had good result, 2cases (8%) had moderate, and 1 case (4%) had a poor result.Moderate and poor results were all in avulsion injuries.Sensory recovery of all digits was satisfactory. The meangrowth rate of replanted digits relative to contralateral digitswas up to 85%. Venous congestion were observed in twocases. One with mild congestion was treated with local hep-arin administration and the other with severe congestionwas treated with leeches. All cases with venous congestionwere amputated from distal to DIP joint. In one case withundue tension, a vein graft was used. Vein graft was har-vested from the dorsal aspect of the hand.

One patient with osteomyelitis was treated successfully

with antibiotics. In another patient, the little finger has beenreamputated because of infection inspite of successfull re-plantation (Fig. 2). Pseudoarthrosis was developed in onecase. This case was treated with autologous bone grafting.In two patients, adhesions developed on tendons. After 4months of unsuccesfull physical therapy, tenolysis wereperformed.

DISCUSSION

Pediatric replantation with its minute anatomy is tech-nically very demanding. In children replantation or revas-cularization, growth rate of replanted digits is very impor-tant due to cosmetic and functional reasons. Bone growthand the development of epiphyseal plates are disturbed after

Figure 2. A: An 11-year-old girl had amputated her hand by a pitsaw. B and C: Good result was obtained clinically. D: X-ray appearanceof both hands. In the little finger, severe infection occurred, requiring reamputation.

412 Yildiz et al.

the replantation of amputated extremities in children but thepotential for continued skeletal growth is almost alwaysmaintained in the replanted part.10 In our series, averagelongitudinal growth recorded was 80%. Some authors havereported overgrowth on the replanted digits.10,11 The levelof amputation is a significant prognostic factor for theepiphyseal growth of the replanted part. Replantationshould consist of minimal bone shortening to preserveepiphyseal plates.

It has been reported that recovery of sensibility in re-planted digit is nearly as good as for isolated digitalnerve.1,12 In our series, sensory recovery of all digits wassatisfactory. But functional results are not as good as sen-sibility of the injured parts. We think that function is relatedwith the type of injury and the level of amputation. In mostreplantation, secondary procedures are required to improvefunctional results. The success depends on function notmerely on making the digit viable.

We think that in order to prevent functional and growthdisturbances and due to cosmetic reasons, replantation orrevascularization should definitely be tried. Contraindica-tions should be limited to a poor general condition as aresult of multiple trauma or to severe destruction of theamputated part.

REFERENCES

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2. Gaul JS, Nunley JA. Microvascular replantation in a seven-month-oldgirl: a case report. Microsurgery 1988;9:204–207.

3. Beris GL, Kleinert JM. Microvascular digit transposition following atwo digit amputation in an infant. J Reconstr Microsurg 1992;8:23.

4. Innis PC. Office evaluation and treatment of finger and hand injuriesin children. Clin Opin Pediatr 1995;7:83–87.

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