eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Replantation

Author: Ziad N Kazzi, MD, Assistant Professor, Director of Medical Toxicology, Department of Emergency Medicine, University of Alabama in Birmingham; Assistant Medical Director, Alabama Poison Center; Medical Toxicologist, Regional Poison Center of Birmingham
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Sep 4, 2007

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

References

  1. Schumer E, Friedman FD. Pulse oximetry for preoperative vascular assessment in a thumb near-amputation. J Emerg Med. Nov-Dec 1995;13(6):753-5. [Medline].

  2. Ridha H, Jallali N, Butler PE. The use of dextran post free tissue transfer. J Plast Reconstr Aesthet Surg. 2006;59(9):951-4. Epub 2006 May 2. [Medline].

  3. Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. Sep 2006;10(3):124-9. [Medline].

  4. Adani R, Castagnetti C, Landi A. Degloving injuries of the hand and fingers. Clin Orthop Relat Res. May 1995;(314):19-25. [Medline].

  5. Askari M, Fisher C, Weniger FG, Bidic S, Lee WP. Anticoagulation therapy in microsurgery: a review. J Hand Surg [Am]. May-Jun 2006;31(5):836-46. [Medline].

  6. Buntic RF, Siko PP, Buncke GM, Ruebeck D, Kind GM, Buncke HJ. Using the Internet for rapid exchange of photographs and X-ray images to evaluate potential extremity replantation candidates. J Trauma. Aug 1997;43(2):342-4. [Medline].

  7. Chiu HY, Shieh SJ, Hsu HY. Multivariate analysis of factors influencing the functional recovery after finger replantation or revascularization. Microsurgery. 1995;16(10):713-7. [Medline].

  8. Kocher MS. History of replantation: from miracle to microsurgery. World J Surg. May-Jun 1995;19(3):462-7. [Medline].

  9. Merle M, Dautel G. Advances in digital replantation. Clin Plast Surg. Jan 1997;24(1):87-105. [Medline].

  10. Partington MT, Lineaweaver WC, O'Hara M, et al. Unrecognized injuries in patients referred for emergency microsurgery. J Trauma. Feb 1993;34(2):238-41. [Medline].

  11. Povlsen B, Nylander G, Nylander E. Natural history of digital replantation: a 12-year prospective study. Microsurgery. 1995;16(3):138-40. [Medline].

  12. Schlenker JD, Koulis CP. Amputations and replantations. Emerg Med Clin North Am. Aug 1993;11(3):739-53. [Medline].

  13. Sood R, Bentz ML, Shestak KC, Browne EZ Jr. Extremity replantation. Surg Clin North Am. Apr 1991;71(2):317-29. [Medline].

  14. Soucacos PN, Beris AE, Touliatos AS, Vekris M, Pakos S, Varitimidis S. Current indications for single digit replantation. Acta Orthop Scand Suppl. Jun 1995;264:12-5. [Medline].

  15. Troum S, Floyd WE. Upper extremity replantation at a regional medical center: a six-year review. Am Surg. Sep 1995;61(9):836-9. [Medline].

  16. Wilhelmi BJ, Lee WP, Pagensteert GI, May JW Jr. Replantation in the mutilated hand. Hand Clin. Feb 2003;19(1):89-120. [Medline].

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

Contributor Information and Disclosures

Author

Ziad N Kazzi, MD, Assistant Professor, Director of Medical Toxicology, Department of Emergency Medicine, University of Alabama in Birmingham; Assistant Medical Director, Alabama Poison Center; Medical Toxicologist, Regional Poison Center of Birmingham
Ziad N Kazzi, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

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.

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: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric 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 Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, 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: Nothing to disclose.

 
 
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