Review Article
Replantation of the Upper Extremity: Current Concepts Abstract Valerie M. Wolfe, MD Angela A. Wang, MD
Replantation is the process of reattaching amputated parts. Relative indications for replantation in the upper extremity include amputation of the thumb or multiple digits as well as amputations proximal to zone II and pediatric finger amputations at any level. Preoperatively, the part should be sealed in a bag and placed on ice; maximum ischemia times are approximately 12 hours of warm and 24 hours of cold time for digits, with shorter times tolerated for amputations at more proximal levels. With multiple digit involvement, an assembly line approach is used in the operating room. Postoperatively, close attention must be paid to detect thrombosis because secondary ischemia times are shorter. Success rates vary; survival is predicted in part by the mechanism of injury, with sharp cut injuries having better outcomes. There is no consensus on appropriate postoperative anticoagulation, the number of vessels that must be anastomosed, or whether replantations should be centralized or performed in every hospital.
Epidemiology
From the Orthopaedics Center, University of Utah, Salt Lake City, UT. Dr. Wang or an immediate family member has received royalties from Biomet. Neither Dr. Wolfe nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2015;23: 373-381 http://dx.doi.org/10.5435/ JAAOS-D-14-00039 Copyright 2015 by the American Academy of Orthopaedic Surgeons.
Replantation is the reattachment of a completely amputated anatomic part. In a recent study of 9,407 patients with upper extremity amputations from the National Inpatient Sample database, Friedrich et al1 reported that 1,361 (14.5%) underwent replantation. The average age of these patients was 36 years, and the average age of those who did not have replantation was 44 years. Of the total number of replantations, approximately 27% were thumbs, 12% were digits, and 12% were hands or forearms. Seventy-four percent of the procedures were performed at large hospitals. Teaching hospitals received 63% of all patients with amputations and performed 81% of all replants. This finding is in contrast to previous data published in 2000, which documented that university hospitals performed only 24% of replantations.2
The exact reasons for this increase in the number of replantations performed at university hospitals is unclear and likely multifactorial.
Indications and Contraindications Although tissue viability is certainly the initial concern, it is not the sole determinant of successful replantation. Many issues must be considered, including the level and type of injury, ischemia time, chance of survival, expected functional outcome, patient characteristics, predicted morbidity, length of rehabilitation, and total cost incurred by the patient (including lost wages). The ideal candidate is a young, healthy person with a sharp mechanism of injury and minimal tissue destruction and contamination. Indications for replantation include loss of a thumb, multiple digit amputations, and amputations at or
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Replantation of the Upper Extremity: Current Concepts
Figure 1
Figure 2
Clinical photograph of the hand demonstrating amputation of multiple digits, which is an indication for replantation even when the amputations occur through zone II.
Clinical photographs of the hand demonstrating amputation of the thumb at the interphalangeal joint (A) and the replanted thumb at 12 months postoperatively (B). Despite the relatively distal level of the amputation and the small vessels involved, replantation was successful.
proximal to the palm (Figures 1 and 2). Replantation should be considered for pediatric finger amputations at any level given the plasticity of the digits and healing capacity. Single digit amputation in flexor tendon zone I (distal to the insertion of the flexor digitorum superficialis) is also a relative indication for replantation. Relative contraindications to the procedure include single digit amputations through zone II (especially in a border digit); severe crush, mangling, heavily contaminated, or segmental injuries; and amputations with prolonged warm ischemia time (Figure 3). Replantation is also contraindicated in patients who are medically unsuitable. Advanced age in an otherwise healthy person is not a contraindication. The red line sign, a red stripe along the mid lateral aspect of the avulsed digit that represents hemorrhage along the vessel, is a poor prognostic sign.3 Additionally, the ribbon sign, in which tortuous, spiraled blood vessels are seen, indicates
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significant intimal injury and potentially unsuccessful outcomes.4 For cases in which there is significant question as to whether a part is replantable, microscopic evaluation of the vessels can be helpful in making a final decision.
Preoperative Evaluation and Initial Management Control of bleeding at the stump can be accomplished with elevation and a clean compressive dressing. The amputated part should be wrapped in saline-moistened gauze and placed in a plastic bag that is then sealed and placed on ice.5 Even if amputated parts are not replantable, they can provide a valuable source of tissue. Classically, the maximum ischemia times are 12 hours warm and 24 hours cold for a digit and 6 hours warm and 12 hours cold for the hand and proximal amputations. However, these limits have been increasingly challenged,
with a cold ischemia time of up to 96 hours reported for digits.6 Ischemia times become problematic with proximal amputations because of the increased risk of myonecrosis and the potential complications of acute tubular necrosis and sepsis. Patients with proximal amputations should be well hydrated, and the arterial repair should be completed first to allow the effluent to drain, reducing myoglobin and lactate levels before venous anastomosis. The effects of myonecrosis can be further combated by encouraging osmotic diuresis with 50 mL of 20% mannitol and urine alkalinization with 100 mL of sodium bicarbonate to prevent precipitation of myoglobin in the kidneys. A photographic record of the stump and amputated part should be made; this is especially important for medicolegal purposes because litigation over the decision not to replant is more common than for failure of replantation.7 The risks and benefits of replantation, the possibility of additional incisions for graft harvest, the time course of surgery, the ensuing hospital stay, the need for therapy and time off work, and the possibility of future surgeries should
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Valerie M. Wolfe, MD, and Angela A. Wang, MD
be discussed with the patient and family. Realistic expectations should be set regarding eventual sensation, mobility, and function. The appropriate prophylactic antibiotics and tetanus updates should be administered along with fluid resuscitation and warming to prevent proximal vessel spasm. A Foley catheter is used for volume monitoring, although this may not be necessary with single digit replantations in zone I. Special attention should be paid to padding pressure points. An aspirin can be administered to inhibit platelet aggregation. The use of a regional nerve block preoperatively or postoperatively can also be considered for pain relief, sympathetic blockade, and vasodilation.
Surgical Techniques The use of two surgical teams is helpful, one to prepare the amputated part and the other to work on the retained stump. Thorough irrigation and débridement should be performed to remove contaminated and necrotic tissue. A mid axial exposure is used in digit replantation to lessen the risk of scarring and joint contracture. Vessels, nerves, and tendons are tagged with small nonabsorbable sutures. Fracture sites are shortened to accommodate soft-tissue loss, facilitate anastomosis outside the zone of injury, and ease tension on repairs. The fractures can be fixed initially with Kirschner wires for rapid stability, with transition to plates or screws later, if desired. The order of soft-tissue repair is debatable. Extensor tendons are commonly repaired first, followed by flexors. Some surgeons prefer to perform vein repair next, with a tourniquet used to provide a bloodless field for the repair.8 Others prefer to repair the arteries first for expedient revascularization of the part. Additionally, restoring inflow allows the surgeon to
see which veins will provide the best outflow.9 Nerves are then repaired, followed by soft-tissue coverage. When multiple digits are amputated, an assembly line approach is faster (ie, completing all of a single type of repair on all digits before proceeding to the next structure). In the setting of more proximal replantations, the vascular repair should be completed immediately after bony stabilization and before tendon and nerve repair to minimize muscle necrosis and reperfusion issues, and the artery should be repaired first. Alternatively, a temporary vascular shunt can be inserted quickly to minimize ischemia time.10 For arterial repairs, the vessels are débrided to healthy intima, and the adventitia is removed. If a tourniquet is being used, it should be released to confirm adequate outflow from the proximal stump. The mean arterial pressure should be maintained at a level that encourages perfusion and prevents physiologic vasoconstriction, and the surgeon should note the pressure frequently. If an arterial defect results in excessive tension on the repair even after bone shortening, an arterial or reversed vein graft can be used to bridge the gap. Vein grafts can be harvested from the forearm or the dorsum of the foot. Graft redundancy should be avoided because it can lead to thrombosis. Arterial grafts are appealing because they have higher patency rates and provide vessel walls with a similar thickness. The descending branch of the lateral femoral circumflex artery, the deep inferior epigastric artery (which is harvestable with the patient in the supine position), and the thoracodorsal artery are expendable.11 Vascular surgeons commonly use synthetic grafts in larger vessels, but there is no current evidence to support the use of synthetic graft in the hand. Microscope visualization is used to place interrupted 9-0 or 10-0 nylon suture; the number of stitches is
Figure 3
PA radiograph of the hand and wrist demonstrating a segmental amputation; such injuries are not replantable.
based the size of the vessel (Figure 4). An intravenous bolus of heparin helps to prevent clotting. At our institution, a 5,000-unit bolus of heparin is given when the arterial anastomosis is completed. However, the reported doses vary, and the bolus can also be given at the start of surgery5 or if the tourniquet needs to be reinflated for any reason. Bathing the vessels in xylocaine or papaverine once the anastomosis is completed can decrease vasospasm. For nerve repair, traumatized stumps should be resected to healthy fascicles. Primary repair is ideal; however, if tension-free repair is not possible, a conduit can be used to bridge gaps of ,3 cm. Nerve grafts also can be taken. Donor nerves include the terminal posterior interosseous nerve, the medial antebrachial cutaneous nerve, the lateral antebrachial cutaneous nerve, or the sural nerve. In the setting of fingertip replantations
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Figure 4
anastomosed to a distal vein to salvage a digit that would otherwise not be replantable. Fusion of a destroyed joint allows shortening and lessens concerns about tendon mobility (useful with a muscle belly avulsion). In some situations, nonreplantable tissue can be an excellent graft source.
Figure 5
Postoperative Management
Intraoperative photograph of the hand demonstrating successful reestablishment of flow through arterial anastomosis. Note the blue background used to improve visualization for microvascular work. No. 10-0 nylon sutures should be evenly spaced; eight stitches are typically used for each repair, although this number varies based on the size of the vessel.
in flexor tendon zone I, it has not yet been determined whether sensory nerves require repair; similar overall outcomes have been reported with and without distal digital nerve repair.12 Venous repair is similar to arterial repair, but venous walls are thinner and more prone to stretch. The microscope field can be flooded with saline to “float” open the vein lumens. Vein grafts should be used if there is tension on the primary venous repair. If recreating direct venous outflow in a distal replanted part is not possible, an arteriovenous fistula can be created between the distal artery and a proximal vein.13 Another option is to remove the nail from the replanted digit to allow outflow bleeding through the nail bed, with hourly rubbing of the bed with heparin-soaked pledgets14 (Figure 5).
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Postoperative photograph of the fingers demonstrating removal of the nail from a replanted digit to help prevent venous congestion. Heparinsoaked pledgets should be rubbed gently on the nail bed every hour to remove any accumulated blood clots and encourage continued bleeding.
The skin should be closed loosely, with priority given to neurovascular coverage. Local flaps and skin grafts can be used. Additionally, mid lateral incisions can be left open to heal by secondary intention.5 We have found that it is helpful to cover the replanted part with antibiotic ointment to prevent adhesion of the dressings. Nonconstricting bandages and a splint can be applied to provide adequate visualization of the replanted part. For complicated multiple digit amputations, heterodigital replantation (ie, replanting one digit in the more critical position of another that is not replantable to optimize function) can be considered. For thumb replantation, the ulnar-sided digital artery tends to be larger and is often desirable to repair. To facilitate direct repair, the arm can be positioned with the shoulder abducted and internally rotated, the elbow extended, and the hand hyperpronated. Alternatively, a vein graft can be used with end-toside anastomosis to the radial artery in the anatomic snuffbox, which allows the hand to rest in a more relaxed position when performing thumb replantation. A proximal artery can be
For the first 24 hours, the replanted part should be kept warm with a heating blanket or lamp or by raising the room temperature to .80°F (27°C). Food and oral fluids should be withheld to accommodate a rapid return to the operating room, if necessary. Pain medication should be given along with anxiolytics to prevent the vasoconstriction of peripheral vasculature that can occur with a fight-or-flight response. Oversedation can lead to hypotension and should be avoided. Historically, the use of chlorpromazine has been recommended because of its calming effects and its use as an a-blockade; however, the possibility of irreversible tardive dyskinesia renders it a less popular option. The patient is kept quiescent at first, with gradual increases in mobilization. Intravenous hydration should be administered at a high rate to maintain blood pressure and prevent peripheral vasoconstriction, decreasing gradually starting on postoperative day 2. There is no consensus on the best postoperative anticoagulation method.15 Heparin binds to damaged endothelium, activating antithrombin III and decreasing fibrinogen clotting and platelet aggregation. Known complications associated with the use of the drug include bleeding and thrombocytopenia. Equivalent success rates have been reported with the use of low-molecular-weight heparin or unfractionated heparin, but the former has a lower risk of bleeding and hypocoagulability.16 A 3-mg/kg
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dose of aspirin blocks the cyclooxygenase pathway, although higher doses will also block prostaglandin I2, an important local vasodilator and inhibitor of platelet aggregation. Dextran has both antiplatelet and heparin-like effects. Previously reported doses range from 40 mL to 500 mL daily, and the potential adverse effects include anaphylaxis, renal failure, cardiac failure, and bleeding complications in children. In one study that included 18 replantation cases, no antithrombotic agents were used and 91% of replantations were successful.17 The hand should be elevated to decrease swelling and congestion. The surgical team should perform a physical examination every hour to assess the color, turgor, capillary refill, and temperature of the replanted part. Thermometry can be a useful monitoring tool; a change of 2° to 3°C can indicate arterial or venous thrombosis.18 Laser Doppler flowmetry also has proved useful for detecting thrombosis at an early stage.19 Finally, continuous oxygen saturation monitoring or intermittent Doppler ultrasonography can be used to confirm persistent flow. Thrombolytics, such as streptokinase, are reserved mainly for salvage and are not indicated for prophylaxis. If the nail has been removed, heparin-soaked sponges can be used to wipe clots off the nail bed hourly for the first 24 hours to encourage outflow bleeding. After 24 hours, the patient is allowed to begin oral intake, with the exception of caffeine (eg, coffee, tea, soda, chocolate). No smoking is allowed at any point. If there is a change in perfusion status, dressings should be loosened or removed for closer inspection. Congealed, hardened blood within the dressing can often compress a replanted digit. If the part is engorged and bluish but has good turgor and brisk capillary refill, venous congestion should be suspected, and the hand should be elevated. Sutures may be
removed to accommodate swelling. A pale hand with flaccid turgor and slow refill indicates issues with arterial flow; the hand should be lowered. Flow to the digit can also be tested clinically by poking the tip with a 22-gauge needle. Bright red bleeding is normal, whereas slow, dark blue blood indicates venous congestion. Lack of bleeding is evidence of arterial insufficiency. For replantation failure within 24 hours, return to the operating room is beneficial when undertaken expeditiously. Secondary critical ischemia times are only half that of primary times, and revisions after 4 to 6 hours of ischemia rarely result in digit salvage.5 Common arterial issues that can be addressed include previously unrecognized intimal damage (resulting in a clot that can be resected), excess tension on the repair, or technical issues that cause irregularities in the wall. The use of intravenous heparin has also been reported, with partial salvage possible through recannulation of digital arterial thromboses.20 Venous congestion is suspected if failure occurs 24 to 48 hours postoperatively. Leech therapy can be helpful; leeches can ingest 10 times their body weight in blood and release hirudin, a powerful anticoagulant that allows the site to continue bleeding for hours after the leech has detached (Figure 6). Difficulties with leech therapy include the possibility of attachment off the replanted digit, and hematocrit levels should be checked daily because blood transfusion may be required. Antibiotic prophylaxis against Aeromonas hydrophila and Serratia marcescens is needed when leech therapy is used. Aeromonas hydrophila is not sensitive to cefazolin; ciprofloxacin and sulfamethoxazole/ trimethoprim are usually used for prophylaxis, although the use of ciprofloxacin should be avoided in children because of the risk of tendon rupture and possible toxicity to immature cartilage. In a recent study of two cases of ciprofloxacin-resistant
Figure 6
Photograph of medical-grade leeches used to treat venous congestion. Infection with Aeromonas hydrophilia or Serratia marcescens is a concern with leech therapy; therefore, the patient should be treated prophylactically with ciprofloxacin or trimethoprim/ sulfamethoxazole.
Aeromonas infections, the infections were treated successfully with ceftriaxone.21 In general, venous thrombosis becomes less of an issue by 4 to 6 days postoperatively, when drainage is supplemented by external outflow regrowth.22
Rehabilitation Each replantation is unique. A certified hand therapist can assist the clinician in tailoring a specific regimen for each patient. Evaluation can occur as early as 48 hours postoperatively, and early treatment includes adaptive equipment, creation of a protective splint, and reinforcement of education on wound care, elevation, and avoidance of cold temperatures and of smoking. One general protocol for digit replantation is early protective motion with the tenodesis effect starting as early as 5 days postoperatively.23 Active and passive motion of uninvolved joints is emphasized. If the quality of the tendon repair is adequate, place-and-hold exercises in intrinsic plus and minus positions can begin at 2 weeks postoperatively. Scar
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Replantation of the Upper Extremity: Current Concepts
transported long distances for replantation and return home where no hand therapy resources are locally available. When therapy begins more than 14 days after injury or is not done at all, long-term active motion results are significantly worse.24
Figure 7
Outcomes
A, Photograph demonstrating a contaminated, mangling injury of the thumb caused by a potato conveyor belt. B, Oblique radiograph of the hand demonstrating segmental bone loss at the thumb metacarpal. Because the dominant thumb was amputated and the patient was a young laborer, replantation was attempted. C, Intraoperative photograph of the hand following thumb replantation. Despite successful perfusion even at postoperative day 5, the digit was infected and necrotic at 14 days postoperatively, emphasizing the difficulties of replantation following these complex injuries.
massage and edema management with a self-adherent elastic wrap and retrograde massage are initiated at 3 weeks. At week 4, finger flexion with the wrist in neutral is begun. Composite wrist and finger flexion and extension exercises begin at week 5, as well as dynamic splinting of the fingers. By week 6, light functional activities are begun. At 8 weeks, resistive exercises can be added. The patient begins job simulation at 12 weeks. Difficulties in the postoperative course may arise when patients are
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Digit replantation survival rates as high as 80% to 90% have been reported;25,26 however, more recent evidence demonstrates a less optimistic success rate of 57%.27 Factors that positively predict replantation survival include a sharp mechanism of injury, radial-sided replantation, and nonsmoking status.27,28 Negative factors include high platelet count, diabetes mellitus, prolonged ischemia times, avulsion injuries, and inappropriate preservation of the amputated part.29 In children, the survival rates may be worse (43% for replanted digits in one study,30 which could be attributed to the more aggressive approach toward replantation in this population); however, when successful, replantations in children result in better functional outcomes than those performed in adults.30,31 When injuries are delineated by mechanism, sharp injuries have the best outcomes followed by crush injuries, avulsions, and deglovings26 (Figure 7). Digital replantations following avulsion injuries have a success rate of 66%, whereas the success rate following degloving injuries is closer to 50%; however, some small studies of avulsions specifically show more successful results with respect to motion and two-point discrimination.26,32,33 A viable part does not guarantee function. The range of motion in a replanted digit is typically half of normal function, with zone I and V injuries demonstrating better results than injuries in zones II to IV.24 Tendon adhesions and joint stiffness are
common complications, and nonunion can be a significant problem associated with extensive soft-tissue injury and devascularization. Up to 60% of replanted digits require secondary surgeries for the aforementioned complications.34 Single-digit replantations demonstrate weaker grip strength and lower functional scores than those of single-digit amputations, whereas replanted thumbs and multiple digits have improved grip strength.35,36 Average overall two-point discrimination in replanted digits has been reported to be as good as 7 mm;25 however, other reports have demonstrated 8 mm for sharp injuries and 15 mm for avulsion injuries,37 which is more consistent with our experience. Patent digital arteries are associated with improved nerve function; nerves with a patent artery had twopoint discrimination that was 6 mm greater than that of nerves with a nonpatent artery.38 Interestingly, it is not uncommon for repaired arteries to occlude over time; one study that used duplex ultrasonography and angiography found that 37% of successfully microanastomosed digital arteries in living, replanted digits were occluded after an average of 15 postoperative days.39 The digits were presumably perfused by soft-tissue neovasculature and not by the occluded arteries. In a large systematic review of replantation outcomes in patients with distal digital amputations, 98% of patients returned to work.25 In one of the studies included in the review, 87% of patients returned to the same job they had before the thumb amputation.36 In another well-known review, a group of 183 surgeons with partial hand amputations at various levels were surveyed and only 3 claimed disability; the remainder continued to work as surgeons.40 Most replantation patients suffer from cold intolerance; however, this decreases over time and may not prevent return to work or require a change of profession.41,42
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Controversies Controversy exists regarding the number of venous anastomoses required for each amputated part. In a single-digit replantation, one or two arteries and two veins are typically repaired. In fingertip replantations, however, it is not uncommon to opt for external bleeding rather than attempt repair of a distal vein. In a study of 24 artery-only fingertip replantations, Erken et al14 removed the nail and administered intravenous heparin, with a reported success rate of 88%. Other studies of fingertip replantations have used dextran or leeches. Chen et al43 successfully avoided nail removal and used a small 2-mm incision in the fingertip to encourage bleeding while heparin was injected around the incision daily. In contrast, Lee et al44 found that, in zone I replantations, vein repair had better survival rates than did external bleeding. In the same study, zone II injuries had better outcomes when the number of veins repaired was equal to or greater than the number of repaired arteries. In patients with replantations in zone III, repair of an equal number of veins and arteries was recommended, whereas repair of two veins for every one artery was superior for zone IV replantations. Recent improvements in supermicrosurgery (on 0.3- to 0.8-mm vessels) now allow replantation for more distal zone I amputations. As described, techniques for artery-only as well as artery-vein repairs have been used with great success. In the United States, these procedures remain uncommon and, although numbers are unavailable, it is our belief that most of these digits are shortened and closed in the emergency department. Although shortening frequently results in little or no functional deficit, the cosmetic loss of the fingertip should be considered; it is frequently a reason for more distal
replantation, particularly in Asian countries. Another area of debate involves the appropriate setting and personnel for replantation. In 2012, a survey of level I and II trauma centers demonstrated that only 55% of level I and 29% of level II centers polled had “immediate and consistent” access for microvascular replantation.45 Chung et al2 surveyed 906 hospitals on the rates of replantation and reported that only 15% had performed a replantation that year, and most hospitals (60%) performed only one case. Thirty percent of hospitals performed 2 to 5 cases, 8% performed 5 to 9 cases, and 2% performed $10 cases. It could be argued that patients would be better served at institutions with a higher number of replantations because the surgeons would have increased exposure to and experience in performing this relatively rare procedure. In a study of 40 patients with amputated fingers who were airlifted to a level I trauma center, Ozer et al46 reported that 65% did not undergo replantation, with injury characteristics being the primary reason cited in most cases (72%). In addition, physicians face a changing healthcare environment where resources and enthusiasm for replantation are waning. In a 2007 survey of 561 members of the American Society for Surgery of the Hand, only 56% of respondents performed replantations and, of those, 62% performed fewer than five in the prior year.47 Reasons for not performing the procedure included busy elective schedules (51%), inadequate confidence (39%), and disappointing results (23%). Hand surgeons trained in plastic surgery residency programs are more likely to perform replantations.48 The costs associated with replantation are also a significant consideration. Hoxie et al49 calculated that the lost wages for the average patient following a table saw injury were $14,220, and medical costs
were $40,121. Patients returned to work at an average of 125 days after digit replantation compared with 60 days after revision amputation. Friedrich et al1 focused on amputations only, reporting an average hospital stay of 5.8 days for replantation and average total charges of $42,561 compared with an average stay of 3.5 days and charges of $27,541 when a part was not replanted. Combined with the high likelihood of repeat surgeries, prolonged rehabilitation, and loss of work days associated with replantation, amputation had lower costs and quicker rehabilitation and return to work.
Summary Successful replantation relies on many factors, the most important of which remains patient selection. Relative indications for replantation include amputations of the thumb or multiple digits, amputations outside zone II, and amputations at any level in a child. In general, avulsion injuries result in poor outcomes, and smoking, diabetes mellitus, and prolonged ischemia are also negative factors. There is still no consensus on the best method of monitoring the viability of a replant and the appropriate anticoagulation protocol. The specifics of technique, the location where surgery should be performed, and cost remain controversial. However, the experience of the past decade has shown that good outcomes can be achieved with replantation.
References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 2, 16, 19, 24, 26, 39, 41, 45, 46, and 49 are level II studies. References 3, 8, 12, 15, 25, 28, 29, 32, 34-38, and 44 are level III studies. References 1, 6,
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7, 9, 13, 14, 17, 18, 20, 22, 27, 30, 31, 33, 40, 42, 43, 47, and 48 are level IV studies. References 4, 10, 11, and 21 are level V expert opinion.
12. Wong C, Ho PC, Tse WL, Cheng S, Chan DK, Hung LK: Do we need to repair the nerves when replanting distal finger amputations? J Reconstr Microsurg 2010; 26(5):347-354.
References printed in bold type are those published within the past 5 years.
13. Suzuki Y, Ishikawa K, Isshiki N, Takami S: Fingertip replantation with an efferent A-V anastomosis for venous drainage: Clinical reports. Br J Plast Surg 1993;46(3): 187-191.
1. Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB: Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am 2011;36(11): 1835-1840. 2. Chung KC, Kowalski CP, Walters MR: Finger replantation in the United States: Rates and resource use from the 1996 Healthcare Cost and Utilization Project. J Hand Surg Am 2000;25(6):1038-1042. 3. Replantation of severed fingers: Clinical experiences in 217 cases involving 373 severed fingers. Chin Med J (Engl) 1975;1 (3):184-196. 4. Van Beek AL, Kutz JE, Zook EG: Importance of the ribbon sign, indicating unsuitability of the vessel, in replanting a finger. Plast Reconstr Surg 1978;61(1): 32-35. 5. Goldner RD, Urbaniak JR: Replantation, in Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds: Green’s Operative Hand Surgery, ed 6. Philadelphia, PA, Elsevier Churchill Livingstone, 2011, pp 1585-1601. 6. Wei FC, Chang YL, Chen HC, Chuang CC: Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 1988;82 (2):346-350. 7. Bastidas N, Cassidy L, Hoffman L, Sharma S: A single-institution experience of hand surgery litigation in a major replantation center. Plast Reconstr Surg 2011;127(1):284-292. 8. Weiland AJ, Villarreal-Rios A, Kleinert HE, Kutz J, Atasoy E, Lister G: Replantation of digits and hands: Analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg Am 1977;2(1):1-12. 9. Tamai S, Hori Y, Tatsumi Y, et al: Microvascular anastomosis and its application on the replantation of amputated digits and hands. Clin Orthop Relat Res 1978;133:106-121. 10. Davins M, Llagostera S, Lamas C, López S: Role of temporary arterial shunt in the reimplantation of a traumatic above-elbow amputation. Vascular 2007;15(3):176-178. 11. Trocchia AM, Hammert WC: Arterial grafts for vascular reconstruction in the upper extremity. J Hand Surg Am 2011;36 (9):1534-1536.
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14. Erken HY, Takka S, Akmaz I: Artery-only fingertip replantations using a controlled nailbed bleeding protocol. J Hand Surg Am 2013;38(11):2173-2179. 15. Buckley T, Hammert WC: Anticoagulation following digital replantation. J Hand Surg Am 2011;36(8):1374-1376. 16. Chen YC, Chi CC, Chan FC, Wen YW: Low molecular weight heparin for prevention of microvascular occlusion in digital replantation. Cochrane Database Syst Rev 2013;7:CD009894. 17. Veravuthipakorn L, Veravuthipakorn A: Microsurgical free flap and replantation without antithrombotic agents. J Med Assoc Thai 2004;87(6):665-669. 18. Reagan DS, Grundberg AB, George MJ: Clinical evaluation and temperature monitoring in predicting viability in replantations. J Reconstr Microsurg 1994; 10(1):1-6. 19. Hovius SE, van Adrichem LN, Mulder HD, van Strik R, van der Meulen JC: Comparison of laser Doppler flowmetry and thermometry in the postoperative monitoring of replantations. J Hand Surg Am 1995;20(1):88-93.
strategies to enhance total active motion. Ann Plast Surg 2003;51(2):141-146. 25.
Sebastin SJ, Chung KC: A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011;128(3):723-737.
26. Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A: Results of 1018 digital replantations in 552 patients. Injury 2000;31(1):33-40. 27.
Fufa D, Calfee R, Wall L, Zeng W, Goldfarb C: Digit replantation: Experience of two U.S. academic level-I trauma centers. J Bone Joint Surg Am 2013;95(23): 2127-2134.
28. Li J, Guo Z, Zhu Q, et al: Fingertip replantation: Determinants of survival. Plast Reconstr Surg 2008;122(3):833-839. 29. Dec W: A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg 2006;10(3):124-129. 30.
Lindfors N, Marttila I: Replantation or revascularisation injuries in children: Incidence, epidemiology, and outcome. J Plast Surg Hand Surg 2012;46(5): 359-363.
31. Saies AD, Urbaniak JR, Nunley JA, Taras JS, Goldner RD, Fitch RD: Results after replantation and revascularization in the upper extremity in children. J Bone Joint Surg Am 1994; 76(12):1766-1776. 32.
Sears ED, Chung KC: Replantation of finger avulsion injuries: A systematic review of survival and functional outcomes. J Hand Surg Am 2011;36(4):686-694.
20. Noguchi M, Matsusaki H, Yamamoto H: Intravenous bolus infusion of heparin for circulatory insufficiency after finger replantation. J Reconstr Microsurg 1999; 15(4):245-253.
33. Adani R, Marcoccio I, Castagnetti C, Tarallo L: Long-term results of replantation for complete ring avulsion amputations. Ann Plast Surg 2003;51(6):564-568, discussion 569.
21. van Alphen NA, Gonzalez A, McKenna MC, McKenna TK, Carlsen BT, Moran SL: Ciprofloxacin-resistant Aeromonas infection following leech therapy for digit replantation: Report of 2 cases. J Hand Surg Am 2014;39(3): 499-502.
34. Yu JC, Shieh SJ, Lee JW, Hsu HY, Chiu HY: Secondary procedures following digital replantation and revascularisation. Br J Plast Surg 2003;56 (2):125-128.
22. Yabe T, Muraoka M, Motomura H, Ozawa T: Fingertip replantation using a single volar arteriovenous anastomosis and drainage with a transverse tip incision. J Hand Surg Am 2001;26(6): 1120-1124. 23. Jones N, et al: The surgical and rehabilitative aspects of replantation and revascularization of the hand, in Mackin EJ, Callahan AD, Osterman AL, et al, eds: Rehabillitation of the Hand and Upper Extremity, ed 5. St.Louis, MO, Mosby, 2002, pp 1443-1448. 24. Ross DC, Manktelow RT, Wells MT, Boyd JB: Tendon function after replantation: Prognostic factors and
35. Jones JM, Schenck RR, Chesney RB: Digital replantation and amputation: Comparison of function. J Hand Surg Am 1982;7(2):183-189. 36. Goldner RD, Howson MP, Nunley JA, Fitch RD, Belding NR, Urbaniak JR: One hundred eleven thumb amputations: Replantation vs revision. Microsurgery 1990;11(3):243-250. 37. Glickman LT, Mackinnon SE: Sensory recovery following digital replantation. Microsurgery 1990;11(3):236-242. 38. Piquet M, Obert L, Laveaux C, et al: Influence of the permeability of the palmar digital artery on the recovery in nerve lesions palmar digital nerves [French]. Chir Main 2010;29(2):94-99.
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Valerie M. Wolfe, MD, and Angela A. Wang, MD 39. Lee CH, Han SK, Dhong ES, Kim HP, Kim WK: The fate of microanastomosed digital arteries after successful replantation. Plast Reconstr Surg 2005;116(3):805-810.
43. Chen YC, Chan FC, Hsu CC, Lin YT, Chen CT, Lin CH: Fingertip replantation without venous anastomosis. Ann Plast Surg 2013;70(3):284-288.
40. Brown PW: Less than ten: Surgeons with amputated fingers. J Hand Surg Am 1982;7 (1):31-37.
44. Lee BI, Chung HY, Kim WK, Kim SW, Dhong ES: The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation. Ann Plast Surg 2000;44(3):288-294.
41. Craigen M, Kleinert JM, Crain GM, McCabe SJ: Patient and injury characteristics in the development of cold sensitivity of the hand: A prospective cohort study. J Hand Surg Am 1999;24(1):8-15. 42. Vaksvik T, Hetland K, Røkkum M, Holm I: Cold hypersensitivity 6 to 10 years after replantation or revascularisation of fingers: Consequences for work and leisure activities. J Hand Surg Eur Vol 2009;34(1): 12-17.
45. Peterson BC, Mangiapani D, Kellogg R, Leversedge FJ: Hand and microvascular replantation call availability study: A national real-time survey of level-I and level-II trauma centers. J Bone Joint Surg Am 2012;94(24):e185. 46. Ozer K, Kramer W, Gillani S, Williams A, Smith W: Replantation versus revision of amputated fingers in
patients air-transported to a level 1 trauma center. J Hand Surg Am 2010;35 (6):936-940. 47. Payatakes AH, Zagoreos NP, Fedorcik GG, Ruch DS, Levin LS: Current practice of microsurgery by members of the American Society for Surgery of the Hand. J Hand Surg Am 2007;32(4):541-547. 48.
Elliott RM, Baldwin KD, Foroohar A, Levin LS: The impact of residency and fellowship training on the practice of microsurgery by members of the American Society for Surgery of the Hand. Ann Plast Surg 2012;69(4):451-458.
49. Hoxie SC, Capo JA, Dennison DG, Shin AY: The economic impact of electric saw injuries to the hand. J Hand Surg Am 2009;34(5):886-889.
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Replantation of the Upper Extremity: Current Concepts Abstract Valerie M. Wolfe, MD Angela A. Wang, MD
Replantation is the process of reattaching amputated parts. Relative indications for replantation in the upper extremity include amputation of the thumb or multiple digits as well as amputations proximal to zone II and pediatric finger amputations at any level. Preoperatively, the part should be sealed in a bag and placed on ice; maximum ischemia times are approximately 12 hours of warm and 24 hours of cold time for digits, with shorter times tolerated for amputations at more proximal levels. With multiple digit involvement, an assembly line approach is used in the operating room. Postoperatively, close attention must be paid to detect thrombosis because secondary ischemia times are shorter. Success rates vary; survival is predicted in part by the mechanism of injury, with sharp cut injuries having better outcomes. There is no consensus on appropriate postoperative anticoagulation, the number of vessels that must be anastomosed, or whether replantations should be centralized or performed in every hospital.
Epidemiology
From the Orthopaedics Center, University of Utah, Salt Lake City, UT. Dr. Wang or an immediate family member has received royalties from Biomet. Neither Dr. Wolfe nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2015;23: 373-381 http://dx.doi.org/10.5435/ JAAOS-D-14-00039 Copyright 2015 by the American Academy of Orthopaedic Surgeons.
Replantation is the reattachment of a completely amputated anatomic part. In a recent study of 9,407 patients with upper extremity amputations from the National Inpatient Sample database, Friedrich et al1 reported that 1,361 (14.5%) underwent replantation. The average age of these patients was 36 years, and the average age of those who did not have replantation was 44 years. Of the total number of replantations, approximately 27% were thumbs, 12% were digits, and 12% were hands or forearms. Seventy-four percent of the procedures were performed at large hospitals. Teaching hospitals received 63% of all patients with amputations and performed 81% of all replants. This finding is in contrast to previous data published in 2000, which documented that university hospitals performed only 24% of replantations.2
The exact reasons for this increase in the number of replantations performed at university hospitals is unclear and likely multifactorial.
Indications and Contraindications Although tissue viability is certainly the initial concern, it is not the sole determinant of successful replantation. Many issues must be considered, including the level and type of injury, ischemia time, chance of survival, expected functional outcome, patient characteristics, predicted morbidity, length of rehabilitation, and total cost incurred by the patient (including lost wages). The ideal candidate is a young, healthy person with a sharp mechanism of injury and minimal tissue destruction and contamination. Indications for replantation include loss of a thumb, multiple digit amputations, and amputations at or
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Figure 1
Figure 2
Clinical photograph of the hand demonstrating amputation of multiple digits, which is an indication for replantation even when the amputations occur through zone II.
Clinical photographs of the hand demonstrating amputation of the thumb at the interphalangeal joint (A) and the replanted thumb at 12 months postoperatively (B). Despite the relatively distal level of the amputation and the small vessels involved, replantation was successful.
proximal to the palm (Figures 1 and 2). Replantation should be considered for pediatric finger amputations at any level given the plasticity of the digits and healing capacity. Single digit amputation in flexor tendon zone I (distal to the insertion of the flexor digitorum superficialis) is also a relative indication for replantation. Relative contraindications to the procedure include single digit amputations through zone II (especially in a border digit); severe crush, mangling, heavily contaminated, or segmental injuries; and amputations with prolonged warm ischemia time (Figure 3). Replantation is also contraindicated in patients who are medically unsuitable. Advanced age in an otherwise healthy person is not a contraindication. The red line sign, a red stripe along the mid lateral aspect of the avulsed digit that represents hemorrhage along the vessel, is a poor prognostic sign.3 Additionally, the ribbon sign, in which tortuous, spiraled blood vessels are seen, indicates
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significant intimal injury and potentially unsuccessful outcomes.4 For cases in which there is significant question as to whether a part is replantable, microscopic evaluation of the vessels can be helpful in making a final decision.
Preoperative Evaluation and Initial Management Control of bleeding at the stump can be accomplished with elevation and a clean compressive dressing. The amputated part should be wrapped in saline-moistened gauze and placed in a plastic bag that is then sealed and placed on ice.5 Even if amputated parts are not replantable, they can provide a valuable source of tissue. Classically, the maximum ischemia times are 12 hours warm and 24 hours cold for a digit and 6 hours warm and 12 hours cold for the hand and proximal amputations. However, these limits have been increasingly challenged,
with a cold ischemia time of up to 96 hours reported for digits.6 Ischemia times become problematic with proximal amputations because of the increased risk of myonecrosis and the potential complications of acute tubular necrosis and sepsis. Patients with proximal amputations should be well hydrated, and the arterial repair should be completed first to allow the effluent to drain, reducing myoglobin and lactate levels before venous anastomosis. The effects of myonecrosis can be further combated by encouraging osmotic diuresis with 50 mL of 20% mannitol and urine alkalinization with 100 mL of sodium bicarbonate to prevent precipitation of myoglobin in the kidneys. A photographic record of the stump and amputated part should be made; this is especially important for medicolegal purposes because litigation over the decision not to replant is more common than for failure of replantation.7 The risks and benefits of replantation, the possibility of additional incisions for graft harvest, the time course of surgery, the ensuing hospital stay, the need for therapy and time off work, and the possibility of future surgeries should
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be discussed with the patient and family. Realistic expectations should be set regarding eventual sensation, mobility, and function. The appropriate prophylactic antibiotics and tetanus updates should be administered along with fluid resuscitation and warming to prevent proximal vessel spasm. A Foley catheter is used for volume monitoring, although this may not be necessary with single digit replantations in zone I. Special attention should be paid to padding pressure points. An aspirin can be administered to inhibit platelet aggregation. The use of a regional nerve block preoperatively or postoperatively can also be considered for pain relief, sympathetic blockade, and vasodilation.
Surgical Techniques The use of two surgical teams is helpful, one to prepare the amputated part and the other to work on the retained stump. Thorough irrigation and débridement should be performed to remove contaminated and necrotic tissue. A mid axial exposure is used in digit replantation to lessen the risk of scarring and joint contracture. Vessels, nerves, and tendons are tagged with small nonabsorbable sutures. Fracture sites are shortened to accommodate soft-tissue loss, facilitate anastomosis outside the zone of injury, and ease tension on repairs. The fractures can be fixed initially with Kirschner wires for rapid stability, with transition to plates or screws later, if desired. The order of soft-tissue repair is debatable. Extensor tendons are commonly repaired first, followed by flexors. Some surgeons prefer to perform vein repair next, with a tourniquet used to provide a bloodless field for the repair.8 Others prefer to repair the arteries first for expedient revascularization of the part. Additionally, restoring inflow allows the surgeon to
see which veins will provide the best outflow.9 Nerves are then repaired, followed by soft-tissue coverage. When multiple digits are amputated, an assembly line approach is faster (ie, completing all of a single type of repair on all digits before proceeding to the next structure). In the setting of more proximal replantations, the vascular repair should be completed immediately after bony stabilization and before tendon and nerve repair to minimize muscle necrosis and reperfusion issues, and the artery should be repaired first. Alternatively, a temporary vascular shunt can be inserted quickly to minimize ischemia time.10 For arterial repairs, the vessels are débrided to healthy intima, and the adventitia is removed. If a tourniquet is being used, it should be released to confirm adequate outflow from the proximal stump. The mean arterial pressure should be maintained at a level that encourages perfusion and prevents physiologic vasoconstriction, and the surgeon should note the pressure frequently. If an arterial defect results in excessive tension on the repair even after bone shortening, an arterial or reversed vein graft can be used to bridge the gap. Vein grafts can be harvested from the forearm or the dorsum of the foot. Graft redundancy should be avoided because it can lead to thrombosis. Arterial grafts are appealing because they have higher patency rates and provide vessel walls with a similar thickness. The descending branch of the lateral femoral circumflex artery, the deep inferior epigastric artery (which is harvestable with the patient in the supine position), and the thoracodorsal artery are expendable.11 Vascular surgeons commonly use synthetic grafts in larger vessels, but there is no current evidence to support the use of synthetic graft in the hand. Microscope visualization is used to place interrupted 9-0 or 10-0 nylon suture; the number of stitches is
Figure 3
PA radiograph of the hand and wrist demonstrating a segmental amputation; such injuries are not replantable.
based the size of the vessel (Figure 4). An intravenous bolus of heparin helps to prevent clotting. At our institution, a 5,000-unit bolus of heparin is given when the arterial anastomosis is completed. However, the reported doses vary, and the bolus can also be given at the start of surgery5 or if the tourniquet needs to be reinflated for any reason. Bathing the vessels in xylocaine or papaverine once the anastomosis is completed can decrease vasospasm. For nerve repair, traumatized stumps should be resected to healthy fascicles. Primary repair is ideal; however, if tension-free repair is not possible, a conduit can be used to bridge gaps of ,3 cm. Nerve grafts also can be taken. Donor nerves include the terminal posterior interosseous nerve, the medial antebrachial cutaneous nerve, the lateral antebrachial cutaneous nerve, or the sural nerve. In the setting of fingertip replantations
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Figure 4
anastomosed to a distal vein to salvage a digit that would otherwise not be replantable. Fusion of a destroyed joint allows shortening and lessens concerns about tendon mobility (useful with a muscle belly avulsion). In some situations, nonreplantable tissue can be an excellent graft source.
Figure 5
Postoperative Management
Intraoperative photograph of the hand demonstrating successful reestablishment of flow through arterial anastomosis. Note the blue background used to improve visualization for microvascular work. No. 10-0 nylon sutures should be evenly spaced; eight stitches are typically used for each repair, although this number varies based on the size of the vessel.
in flexor tendon zone I, it has not yet been determined whether sensory nerves require repair; similar overall outcomes have been reported with and without distal digital nerve repair.12 Venous repair is similar to arterial repair, but venous walls are thinner and more prone to stretch. The microscope field can be flooded with saline to “float” open the vein lumens. Vein grafts should be used if there is tension on the primary venous repair. If recreating direct venous outflow in a distal replanted part is not possible, an arteriovenous fistula can be created between the distal artery and a proximal vein.13 Another option is to remove the nail from the replanted digit to allow outflow bleeding through the nail bed, with hourly rubbing of the bed with heparin-soaked pledgets14 (Figure 5).
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Postoperative photograph of the fingers demonstrating removal of the nail from a replanted digit to help prevent venous congestion. Heparinsoaked pledgets should be rubbed gently on the nail bed every hour to remove any accumulated blood clots and encourage continued bleeding.
The skin should be closed loosely, with priority given to neurovascular coverage. Local flaps and skin grafts can be used. Additionally, mid lateral incisions can be left open to heal by secondary intention.5 We have found that it is helpful to cover the replanted part with antibiotic ointment to prevent adhesion of the dressings. Nonconstricting bandages and a splint can be applied to provide adequate visualization of the replanted part. For complicated multiple digit amputations, heterodigital replantation (ie, replanting one digit in the more critical position of another that is not replantable to optimize function) can be considered. For thumb replantation, the ulnar-sided digital artery tends to be larger and is often desirable to repair. To facilitate direct repair, the arm can be positioned with the shoulder abducted and internally rotated, the elbow extended, and the hand hyperpronated. Alternatively, a vein graft can be used with end-toside anastomosis to the radial artery in the anatomic snuffbox, which allows the hand to rest in a more relaxed position when performing thumb replantation. A proximal artery can be
For the first 24 hours, the replanted part should be kept warm with a heating blanket or lamp or by raising the room temperature to .80°F (27°C). Food and oral fluids should be withheld to accommodate a rapid return to the operating room, if necessary. Pain medication should be given along with anxiolytics to prevent the vasoconstriction of peripheral vasculature that can occur with a fight-or-flight response. Oversedation can lead to hypotension and should be avoided. Historically, the use of chlorpromazine has been recommended because of its calming effects and its use as an a-blockade; however, the possibility of irreversible tardive dyskinesia renders it a less popular option. The patient is kept quiescent at first, with gradual increases in mobilization. Intravenous hydration should be administered at a high rate to maintain blood pressure and prevent peripheral vasoconstriction, decreasing gradually starting on postoperative day 2. There is no consensus on the best postoperative anticoagulation method.15 Heparin binds to damaged endothelium, activating antithrombin III and decreasing fibrinogen clotting and platelet aggregation. Known complications associated with the use of the drug include bleeding and thrombocytopenia. Equivalent success rates have been reported with the use of low-molecular-weight heparin or unfractionated heparin, but the former has a lower risk of bleeding and hypocoagulability.16 A 3-mg/kg
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dose of aspirin blocks the cyclooxygenase pathway, although higher doses will also block prostaglandin I2, an important local vasodilator and inhibitor of platelet aggregation. Dextran has both antiplatelet and heparin-like effects. Previously reported doses range from 40 mL to 500 mL daily, and the potential adverse effects include anaphylaxis, renal failure, cardiac failure, and bleeding complications in children. In one study that included 18 replantation cases, no antithrombotic agents were used and 91% of replantations were successful.17 The hand should be elevated to decrease swelling and congestion. The surgical team should perform a physical examination every hour to assess the color, turgor, capillary refill, and temperature of the replanted part. Thermometry can be a useful monitoring tool; a change of 2° to 3°C can indicate arterial or venous thrombosis.18 Laser Doppler flowmetry also has proved useful for detecting thrombosis at an early stage.19 Finally, continuous oxygen saturation monitoring or intermittent Doppler ultrasonography can be used to confirm persistent flow. Thrombolytics, such as streptokinase, are reserved mainly for salvage and are not indicated for prophylaxis. If the nail has been removed, heparin-soaked sponges can be used to wipe clots off the nail bed hourly for the first 24 hours to encourage outflow bleeding. After 24 hours, the patient is allowed to begin oral intake, with the exception of caffeine (eg, coffee, tea, soda, chocolate). No smoking is allowed at any point. If there is a change in perfusion status, dressings should be loosened or removed for closer inspection. Congealed, hardened blood within the dressing can often compress a replanted digit. If the part is engorged and bluish but has good turgor and brisk capillary refill, venous congestion should be suspected, and the hand should be elevated. Sutures may be
removed to accommodate swelling. A pale hand with flaccid turgor and slow refill indicates issues with arterial flow; the hand should be lowered. Flow to the digit can also be tested clinically by poking the tip with a 22-gauge needle. Bright red bleeding is normal, whereas slow, dark blue blood indicates venous congestion. Lack of bleeding is evidence of arterial insufficiency. For replantation failure within 24 hours, return to the operating room is beneficial when undertaken expeditiously. Secondary critical ischemia times are only half that of primary times, and revisions after 4 to 6 hours of ischemia rarely result in digit salvage.5 Common arterial issues that can be addressed include previously unrecognized intimal damage (resulting in a clot that can be resected), excess tension on the repair, or technical issues that cause irregularities in the wall. The use of intravenous heparin has also been reported, with partial salvage possible through recannulation of digital arterial thromboses.20 Venous congestion is suspected if failure occurs 24 to 48 hours postoperatively. Leech therapy can be helpful; leeches can ingest 10 times their body weight in blood and release hirudin, a powerful anticoagulant that allows the site to continue bleeding for hours after the leech has detached (Figure 6). Difficulties with leech therapy include the possibility of attachment off the replanted digit, and hematocrit levels should be checked daily because blood transfusion may be required. Antibiotic prophylaxis against Aeromonas hydrophila and Serratia marcescens is needed when leech therapy is used. Aeromonas hydrophila is not sensitive to cefazolin; ciprofloxacin and sulfamethoxazole/ trimethoprim are usually used for prophylaxis, although the use of ciprofloxacin should be avoided in children because of the risk of tendon rupture and possible toxicity to immature cartilage. In a recent study of two cases of ciprofloxacin-resistant
Figure 6
Photograph of medical-grade leeches used to treat venous congestion. Infection with Aeromonas hydrophilia or Serratia marcescens is a concern with leech therapy; therefore, the patient should be treated prophylactically with ciprofloxacin or trimethoprim/ sulfamethoxazole.
Aeromonas infections, the infections were treated successfully with ceftriaxone.21 In general, venous thrombosis becomes less of an issue by 4 to 6 days postoperatively, when drainage is supplemented by external outflow regrowth.22
Rehabilitation Each replantation is unique. A certified hand therapist can assist the clinician in tailoring a specific regimen for each patient. Evaluation can occur as early as 48 hours postoperatively, and early treatment includes adaptive equipment, creation of a protective splint, and reinforcement of education on wound care, elevation, and avoidance of cold temperatures and of smoking. One general protocol for digit replantation is early protective motion with the tenodesis effect starting as early as 5 days postoperatively.23 Active and passive motion of uninvolved joints is emphasized. If the quality of the tendon repair is adequate, place-and-hold exercises in intrinsic plus and minus positions can begin at 2 weeks postoperatively. Scar
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transported long distances for replantation and return home where no hand therapy resources are locally available. When therapy begins more than 14 days after injury or is not done at all, long-term active motion results are significantly worse.24
Figure 7
Outcomes
A, Photograph demonstrating a contaminated, mangling injury of the thumb caused by a potato conveyor belt. B, Oblique radiograph of the hand demonstrating segmental bone loss at the thumb metacarpal. Because the dominant thumb was amputated and the patient was a young laborer, replantation was attempted. C, Intraoperative photograph of the hand following thumb replantation. Despite successful perfusion even at postoperative day 5, the digit was infected and necrotic at 14 days postoperatively, emphasizing the difficulties of replantation following these complex injuries.
massage and edema management with a self-adherent elastic wrap and retrograde massage are initiated at 3 weeks. At week 4, finger flexion with the wrist in neutral is begun. Composite wrist and finger flexion and extension exercises begin at week 5, as well as dynamic splinting of the fingers. By week 6, light functional activities are begun. At 8 weeks, resistive exercises can be added. The patient begins job simulation at 12 weeks. Difficulties in the postoperative course may arise when patients are
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Digit replantation survival rates as high as 80% to 90% have been reported;25,26 however, more recent evidence demonstrates a less optimistic success rate of 57%.27 Factors that positively predict replantation survival include a sharp mechanism of injury, radial-sided replantation, and nonsmoking status.27,28 Negative factors include high platelet count, diabetes mellitus, prolonged ischemia times, avulsion injuries, and inappropriate preservation of the amputated part.29 In children, the survival rates may be worse (43% for replanted digits in one study,30 which could be attributed to the more aggressive approach toward replantation in this population); however, when successful, replantations in children result in better functional outcomes than those performed in adults.30,31 When injuries are delineated by mechanism, sharp injuries have the best outcomes followed by crush injuries, avulsions, and deglovings26 (Figure 7). Digital replantations following avulsion injuries have a success rate of 66%, whereas the success rate following degloving injuries is closer to 50%; however, some small studies of avulsions specifically show more successful results with respect to motion and two-point discrimination.26,32,33 A viable part does not guarantee function. The range of motion in a replanted digit is typically half of normal function, with zone I and V injuries demonstrating better results than injuries in zones II to IV.24 Tendon adhesions and joint stiffness are
common complications, and nonunion can be a significant problem associated with extensive soft-tissue injury and devascularization. Up to 60% of replanted digits require secondary surgeries for the aforementioned complications.34 Single-digit replantations demonstrate weaker grip strength and lower functional scores than those of single-digit amputations, whereas replanted thumbs and multiple digits have improved grip strength.35,36 Average overall two-point discrimination in replanted digits has been reported to be as good as 7 mm;25 however, other reports have demonstrated 8 mm for sharp injuries and 15 mm for avulsion injuries,37 which is more consistent with our experience. Patent digital arteries are associated with improved nerve function; nerves with a patent artery had twopoint discrimination that was 6 mm greater than that of nerves with a nonpatent artery.38 Interestingly, it is not uncommon for repaired arteries to occlude over time; one study that used duplex ultrasonography and angiography found that 37% of successfully microanastomosed digital arteries in living, replanted digits were occluded after an average of 15 postoperative days.39 The digits were presumably perfused by soft-tissue neovasculature and not by the occluded arteries. In a large systematic review of replantation outcomes in patients with distal digital amputations, 98% of patients returned to work.25 In one of the studies included in the review, 87% of patients returned to the same job they had before the thumb amputation.36 In another well-known review, a group of 183 surgeons with partial hand amputations at various levels were surveyed and only 3 claimed disability; the remainder continued to work as surgeons.40 Most replantation patients suffer from cold intolerance; however, this decreases over time and may not prevent return to work or require a change of profession.41,42
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Controversies Controversy exists regarding the number of venous anastomoses required for each amputated part. In a single-digit replantation, one or two arteries and two veins are typically repaired. In fingertip replantations, however, it is not uncommon to opt for external bleeding rather than attempt repair of a distal vein. In a study of 24 artery-only fingertip replantations, Erken et al14 removed the nail and administered intravenous heparin, with a reported success rate of 88%. Other studies of fingertip replantations have used dextran or leeches. Chen et al43 successfully avoided nail removal and used a small 2-mm incision in the fingertip to encourage bleeding while heparin was injected around the incision daily. In contrast, Lee et al44 found that, in zone I replantations, vein repair had better survival rates than did external bleeding. In the same study, zone II injuries had better outcomes when the number of veins repaired was equal to or greater than the number of repaired arteries. In patients with replantations in zone III, repair of an equal number of veins and arteries was recommended, whereas repair of two veins for every one artery was superior for zone IV replantations. Recent improvements in supermicrosurgery (on 0.3- to 0.8-mm vessels) now allow replantation for more distal zone I amputations. As described, techniques for artery-only as well as artery-vein repairs have been used with great success. In the United States, these procedures remain uncommon and, although numbers are unavailable, it is our belief that most of these digits are shortened and closed in the emergency department. Although shortening frequently results in little or no functional deficit, the cosmetic loss of the fingertip should be considered; it is frequently a reason for more distal
replantation, particularly in Asian countries. Another area of debate involves the appropriate setting and personnel for replantation. In 2012, a survey of level I and II trauma centers demonstrated that only 55% of level I and 29% of level II centers polled had “immediate and consistent” access for microvascular replantation.45 Chung et al2 surveyed 906 hospitals on the rates of replantation and reported that only 15% had performed a replantation that year, and most hospitals (60%) performed only one case. Thirty percent of hospitals performed 2 to 5 cases, 8% performed 5 to 9 cases, and 2% performed $10 cases. It could be argued that patients would be better served at institutions with a higher number of replantations because the surgeons would have increased exposure to and experience in performing this relatively rare procedure. In a study of 40 patients with amputated fingers who were airlifted to a level I trauma center, Ozer et al46 reported that 65% did not undergo replantation, with injury characteristics being the primary reason cited in most cases (72%). In addition, physicians face a changing healthcare environment where resources and enthusiasm for replantation are waning. In a 2007 survey of 561 members of the American Society for Surgery of the Hand, only 56% of respondents performed replantations and, of those, 62% performed fewer than five in the prior year.47 Reasons for not performing the procedure included busy elective schedules (51%), inadequate confidence (39%), and disappointing results (23%). Hand surgeons trained in plastic surgery residency programs are more likely to perform replantations.48 The costs associated with replantation are also a significant consideration. Hoxie et al49 calculated that the lost wages for the average patient following a table saw injury were $14,220, and medical costs
were $40,121. Patients returned to work at an average of 125 days after digit replantation compared with 60 days after revision amputation. Friedrich et al1 focused on amputations only, reporting an average hospital stay of 5.8 days for replantation and average total charges of $42,561 compared with an average stay of 3.5 days and charges of $27,541 when a part was not replanted. Combined with the high likelihood of repeat surgeries, prolonged rehabilitation, and loss of work days associated with replantation, amputation had lower costs and quicker rehabilitation and return to work.
Summary Successful replantation relies on many factors, the most important of which remains patient selection. Relative indications for replantation include amputations of the thumb or multiple digits, amputations outside zone II, and amputations at any level in a child. In general, avulsion injuries result in poor outcomes, and smoking, diabetes mellitus, and prolonged ischemia are also negative factors. There is still no consensus on the best method of monitoring the viability of a replant and the appropriate anticoagulation protocol. The specifics of technique, the location where surgery should be performed, and cost remain controversial. However, the experience of the past decade has shown that good outcomes can be achieved with replantation.
References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 2, 16, 19, 24, 26, 39, 41, 45, 46, and 49 are level II studies. References 3, 8, 12, 15, 25, 28, 29, 32, 34-38, and 44 are level III studies. References 1, 6,
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