eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Replantation

Author: Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS, Professor of Clinical Emergency Medicine, Department Chair, Associate Residency Director, Department of Emergency Medicine, University of California at Irvine
Coauthor(s): J Akiva Kahn, MA, University of California, Irvine, School of Medicine
Contributor Information and Disclosures

Updated: Sep 14, 2009

Introduction

Replantation aims to restore the amputated part to its anatomical site, preserving function and appearance. Outcome depends on factors intrinsic to the patient and to the nature of the injury. Young patients who have distal, cleanly amputated extremities have the best return of function; multiple levels of injury, crush, or avulsing injuries have less. Patients must be fully informed about the commitment to rehabilitation and the possibility of multiple surgeries needed for best results.

Background

In the past 200 years, successful replantation of amputated digits has gradually moved from fantasy to reality. William Balfour performed the first successful fingertip reattachment in 1814; Thomas Hunter is credited with the first thumb replantation performed in the following year.

Little progress was made until the pioneering work of William Steward Halstead and Alexis Carrel, who performed replantation experiments with dog limbs in the 1880s. Dr Carrel won the Nobel Prize in 1912 for his work on vascular anastomoses and for pioneering renal transplantation. 

In 1962, Ronald A. Malt performed the first successful replantation of an entire limb in a 12-year-old boy whose arm had been severed in a train accident. With the development of the operating microscope by Julius Jacobson and Ernesto Suarez in the early 1960s, replantation became easier, and its use began to spread throughout the Western world. 

With the advent of microvascular reanastomosis, digit replantation became tenable. In 1965, Shigeo Kmatsu and Susumu Tamai were the first to perform such a procedure. Since then, medicine has advanced to include the successful replantation of a child’s completely amputated ear as well as replantation of multiple digits and hands.1,2

Modern replantation is now available in most large hospitals and favorable functionality and cosmetic appearance is increasingly common.3

For additional information, see eMedicine articles Hand, Amputation and Replantation, Digital Amputations, Replantation, and Thumb Reconstruction.

Pathophysiology

Amputation replantation is the reattachment of a completely severed part. This is distinguished from incomplete nonviable amputations, which require revascularization. Revascularization is the reconstruction of the blood supply of an incompletely amputated part. In general, revascularization usually provides better functional results than replantation itself.

However, viability alone is an inadequate measure of success. The main predictive factors include injury mechanism (crushing and avulsion have the worst prognosis), platelet count, smoking after operation, preservation method of amputated part, and the use of vein grafting.4 The amputations of the distal phalanx and the thumb, male gender, and ischemia time greater than 12 hours along with presence of diabetes seem to portend a somewhat worse prognosis. Age and history of alcohol use are less significant factors toward the success of replantation.5  

As replantation techniques advance, and success rates increase regardless of adverse factors, the focus is shifting from merely achieving anatomic survival through adequate tissue perfusion, to reconstruction of a functional limb. In some instances, a hand with a well-formed stump may be more functional than one with a functionless digit. The goal of replantation should not be the indiscriminate replantation of all severed fingers but the preservation of quality of life through regained function and appearance.

Clinical

History

An adequate history of the amputation injury is important and should include the mechanism, time, and place of injury; condition of the injured part; hand dominance; and general condition of the patient.

  • The mechanism of amputation is important; injuries due to sharp mechanisms have a much better chance of successful replantation than those caused by blunt crushing forces.
    • If a narrow zone of crush injury is present, replantation may be possible by excising the crush zone and replanting with clean margins.
    • Avulsion amputations caused by rollers offer a markedly reduced chance of successful, functional replantation, although such repairs are not impossible.
    • Degloving injuries are those in which the soft tissue is torn from the underlying bone, as when a glove is removed from the hand. These often are a result of jewelry getting caught in machinery.
  • The time elapsed since injury affects the amount of local and systemic hemorrhage and, hence, the degree of ischemia in the tissue and amputated part.
  • Wound contamination progresses with time because bacteria proliferate on the wound surface. The source of contamination may influence the choice of antibiotic, method and duration of irrigation, and degree of debridement prior to replantation.
  • Determine the patient's dominant hand, although this information is of only relative importance.
  • Ask about allergies, immunizations, and chronic active disease processes.
  • Ask if any old injury is present. Negative prognostic factors include old age, peripheral vascular disease, congestive heart failure, and diabetes mellitus with complications. In the surgeon's judgment, these factors may make replantation inadvisable.
  • Assess the patient's psychiatric history. If the amputation was self-inflicted, a psychiatric evaluation is recommended.

Physical

  • Perform a detailed examination of the hand, and describe the injury and neurovascular status. Check sensation on both sides of the distal part to assess digital nerve function before any digital nerve anesthesia.
    • In cases of amputated digits, determine whether the amputation is within zone II of the hand (proximal to the flexor digitorum superficialis tendon insertion). Injuries in this zone are associated with poor postoperative functional outcome.
    • A red-line sign may be seen in avulsion injuries with associated traction on the neurovascular bundle. These are small subcutaneous hematomas caused by intimal tears along the bundle. This is usually a negative prognostic sign.
    • A ribbon sign is seen in patients where the blood vessel was subjected to stretch and torsion. The vessel will resemble a gift-wrap ribbon. This also portends a negative prognosis.
Complete amputation of two digits.

Complete amputation of two digits.

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Complete amputation of two digits.

Complete amputation of two digits.


Complete thumb amputation.

Complete thumb amputation.

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Complete thumb amputation.

Complete thumb amputation.


Complete thumb amputation.

Complete thumb amputation.

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Complete thumb amputation.

Complete thumb amputation.


Surgical amputation of a left big toe.

Surgical amputation of a left big toe.

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Surgical amputation of a left big toe.

Surgical amputation of a left big toe.

  • Perform a general physical examination, concentrating on cardiovascular disease.
  • Perform a rectal examination to ensure that anticoagulation can be accomplished during or after surgery, if necessary, without placing the patient at risk for gastrointestinal bleeding.

Causes

The 6 mechanisms of amputation injury are the following:

  1. Sharp cut, as from a knife or meat slicer
  2. Dull cut, as from a saw or dull edge (eg, fan blade)
  3. Cut with a narrow segment of crush injury, as from a punch press
  4. Cut and avulsion, as from a machine that causes partial amputation and subsequent reflexive withdrawal of the hand that completes the amputation
  5. Avulsion, as from a finger or a hand caught in an anchor rope or horse reins
  6. Crush avulsion, as from a machine (eg, rollers) that crushes the limb then pulls the digits off

More on Replantation

Overview: Replantation
Differential Diagnoses & Workup: Replantation
Treatment & Medication: Replantation
Follow-up: Replantation
Multimedia: Replantation
References
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Further Reading

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Keywords

replantation, amputated digits, amputated finger, amputated toe, amputation injury, amputation, amputated, digital replantation, severed finger, severed limb, severed toe, red-line sign, ribbon sign, avulsion, crush avulsion, toe-to-thumb transfer

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Contributor Information and Disclosures

Author

Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS, Professor of Clinical Emergency Medicine, Department Chair, Associate Residency Director, Department of Emergency Medicine, University of California at Irvine
Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

J Akiva Kahn, MA, University of California, Irvine, School of Medicine
J Akiva Kahn, MA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Student Association/Foundation, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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