Introduction
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. Modern replantation is now available in most large hospitals.
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. Experienced hand surgeons can successfully replant most amputations. However, viability alone is an inadequate measure of success. The goal in replantation is the restoration or reconstruction of a functional limb, not merely the restoration of adequate tissue perfusion.
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.
Clinical
History
An adequate history of the 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.
- 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.
- 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 sign 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 sign is also of negative prognostic value.
- 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 GI bleeding.
Causes
The 6 mechanisms of amputation injury are the following:
- Sharp cut, as from a knife or meat slicer
- Dull cut, as from a saw or dull edge (eg, fan blade)
- Cut with a narrow segment of crush injury, as from a punch press
- Cut and avulsion, as from a machine that causes partial amputation and subsequent reflexive withdrawal of the hand that completes the amputation
- Avulsion, as from a finger or hand caught in an anchor rope or horse reins
- 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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References
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Further Reading
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
