Replantation in Emergency Medicine

Updated: Jan 31, 2017
  • Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Ron Shapiro, MD  more...
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Overview

Practice Essentials

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 for best results.

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. This being said, most experts believe thumbs should be reattached regardless of mechanism of injury due to their representation of almost half of hand function.

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

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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]

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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 the following [4]

  • Injury mechanism (crushing and avulsion have the worst prognosis)
  • Platelet count
  • Smoking after the operation
  • Preservation method of the amputated part
  • Use of vein grafting

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]

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Epidemiology

Frequency

United States

In the United States, 9,407 patients were treated for upper extremity amputation in a 3-year period spanning the first decade of the new millennium, 1,361 of whom underwent replantation (14.5%). [6]  Although finger amputation injuries have increased over time, the rate of replantation has declined. In 2001, 2004, and 2007 combined, only 27% of thumb and 12% of finger traumatic amputations were replanted. [7]  

Mean age of patients undergoing replantation was 36 years (range, 0-86 y), compared with 44 years (range, 0-104 y) in patients not undergoing replantation. [6]

Hospital charges and length of inpatient stay were significantly higher ($43,000, 5.8 days) for patients with replantations versus those without replantations ($28,000, 3.5 days). [6]

Patients treated at teaching facilities were more likely to undergo replantation than those at a nonteaching facility (19% vs 7%). Large hospitals and urban hospitals were more likely to perform replantation. Self-pay, Medicare, and Medicaid patients all had lower replantation rates than patients with private insurance or workers’ compensation. [6]  

Mortality/Morbidity

Replantation survival rates of 80-90% have been described in selected reports, but outcome is related not only to the success of the microvascular anastomosis, but to the adequacy of bone, tendon, and nerve repairs. Sensory recovery following digit replantation occurred in 70% of patients, as defined by 2-point discrimination of less than 15 mm. Sensory recovery is better following replantation with sharp-cut mechanism rather than avulsion. Overall, 61% of thumbs and 54% of fingers recovered useful sensory function by 2-point discrimination. [6]

Average finger flexion for reimplanted digits has been shown to be 129°. Replantation in zones 1 and 5 fared better than those in zones 2 through 4. As with survival and nerve function, avulsion mechanisms had poorer outcomes. [6]

Despite recent microsurgical advancements, evidence suggests that in contrast to other developed countries, replantation success rates in the United States have fallen to approximately 60%. [7]

Race-, sex-, and age-related demographics

African-American patients are less likely to undergo a replantation procedure after experiencing a finger/thumb amputation injury, likely due to disparities in surgical settings associated with system-level differences in access to care. [7]

In the United States, 87% of patients with amputation who underwent replantation were male. [6]

The mean age of patients in the United States who undergo upper extremity replantation is 36 years. [6]

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