Replantation 

  • Author: Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 11, 2011
 

Background

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.

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, and Thumb Reconstruction.

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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 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. 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.

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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.

Lacey King  University of California, Irvine School of Medicine

Lacey King is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; 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.

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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Ziad N Kazzi, MD, and Akiva Kahn, MD, to the development and writing of this article.

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Complete amputation of two digits.
Radiologic appearance of a hand with two-digit amputation.
After two-digit replantation.
Complete thumb amputation.
Radiologic appearance of a complete thumb amputation.
Complete thumb amputation.
After thumb replantation.
Surgical amputation of a left big toe.
Toe-to-thumb transfer.
 
 
 
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