Debridement is critical: postoperative infection is evidence of inadequate debridement. Debridement must include tissues that are devascularized and those that can not be revascularized. Debridement should be approached in the same fashion as tumor surgery: removal, not rinsing; surgical excision, not scrubbing. Debridement is best done under tourniquet control and before vascular repairs, which reduces intraoperative blood loss and allows for the most accurate evaluation of injury. Pulsatile irrigation should be withheld until after sharp debridement, for it may blur evidence of the zone of injury.
Muscle ischemia time should be limited to four hours, but definitive vascular repairs should be deferred until after debridement, skeletal fixation, and repair of muscular tenderness structures adjacent to the site of vascular or repair. This requires planning and a deliberate stepwise approach, and may involve provisional revascularization with a shunt (Fig. 20). A common pitfall in the management of large wounds involving transection of artery and muscles is for the first step to have vascular surgeon perform vascular repair using a vein graft. Then, after adjacent muscles are repaired, the original ends of the vessel are indirectly approximated to the extent that the vein graft becomes redundant, kinks, and must be removed. Debridement and muscle repair prior to vessel repair "bypasses" this scenario.
If grafts are needed, vein grafts are generally satisfactory for forearm vessels, but in the palm and fingers, branches and small diameter may be difficult to match with vein grafts. In some circumstances, a branched arterial graft from the thoracordorsal system may provide a solution.
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