Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time

Replantation of multiple fingertip amputations using super microsurgery: A case report and literature review

Background

The fingertip amputation is an amputation type of the finger beyond the proximal nail fold. There is no vein available for anastomoses on the dorsal side of the finger, and the palmar vein of the finger is small and tightly attached to the skin. Therefore, it is relatively difficult to implement surgical anastomoses, which poses challenges to the clinical treatment of fingertip amputations.

Case report

A 29-year-old male was admitted to the hospital due to "the amputation of the fingertips of the right index, middle, and ring fingers caused by a heavy object compression 3 h ago". The admission examination revealed that the right index, middle, and ring fingers were completely severed at the 1/2 plane of the nail bed, with irregular sections, severe contusion, and pollution. The X-ray examination showed comminuted fractures of the distal phalanges of the right index, middle, and ring fingers. Based on these findings, the patient was diagnosed with multiple severed fingertips of the right hand (Tamai Zone 1). The patient underwent debridement, vascular exploration, and replantation of the right index, middle, and ring fingertips under emergency general anesthesia. After surgery, anti-inflammatory, spasmolytic, and anticoagulant treatment and regular dressing changes were conducted. The patient did not receive a blood transfusion, and all three fingers survived. The appearance of these fingers was favorable 3 months after surgery, and the flexion and extension of these fingers were normal. Eventually, the patient achieved excellent Chen's hand function scores.

Conclusions

To the best of our knowledge, this may be the first successful case regarding the replantation of three fingertips after amputations in Tamai Zone 1 with favorable outcomes. It can be maintained that super microsurgery can be used for the replantation of multiple fingertip amputations.

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival

INTRODUCTION

A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates.

METHODS

The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval.

RESULTS

Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05).

DISCUSSION

Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

Common Finger Injuries: Treatment Guidelines for Emergency and Primary Care Providers

INTRODUCTION

Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care.

MATERIALS AND METHODS

The Armed Forces Health Surveillance Branch operates the Defense Medical Surveillance System, a database that serves as the central repository of medical surveillance data for the armed forces. The Defense Medical Surveillance System was queried for ICD-10 codes associated with finger injuries from 2015 to 2019 among active duty service members across the major branches of the military.

RESULTS

The most commonly reported finger injuries were open wounds to fingers without damage to nails, metacarpal fractures, phalanx fractures, and finger subluxation/dislocation. Emergency departments were the most commonly reported treatment facility type accounting for 35% of initial finger injuries, followed by 32.2% at orthopedic surgery clinics, 22.2% at family medicine clinics, and 10.8% at urgent care centers.

CONCLUSIONS

Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.

[Successful microsurgical Replantation of a completely amputated Finger Pulp frozen in Ice: Case Report and Literature Review]

The microsurgical replantation of incorrectly stored and transported amputates is generally considered impossible and without prospects of success. In particular, this applies to amputates that show cold damage due to the freezing of tissue. We present a case of successful replantation of an amputated finger pulp frozen in ice. We provide an overview of the literature on the subject of incorrect storage of amputates and the prospects of success for replantation.

Determinants of Success in Single- and Multi-Digit Replant

Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.

Survival Statistics of Digital Replantation in the UK

Background

Digital replantation is associated with a substantial risk of failure. There is considerable variation in survival rates globally, and the current data are limited by poor statistical methods and bias of selection, which limits its translation to Europe and the USA. We aimed to establish a more representative survival rate of digit replantation for western populations and evaluate espoused prognostic variables using robust statistical methodology.

Materials and Methods

Retrospective data were collected from 58 consecutive patients who underwent digital replantation following traumatic amputation in three tertiary care hand centres in the UK over seven years. The unit of analysis was the digit. Generalized linear modelling was used to estimate the odds ratio (OR) of digit survival.

Results

Forty-six of 68 replanted digits survived (68%). The typical replant candidate was a 40-year-old male manual worker. Digit survival was more likely with guillotine injuries (adjusted OR 25.5 [95% CI 5.60, 115]) and when intraoperative skeletal shortening was performed (adjusted OR 15.3 [95% CI 2.62, 89.5]). The age of the patient, seniority of the operating surgeon, and use of vein grafts was not associated with digit survival.

Conclusion

We provide robust data to show that guillotine amputations have more favourable survival rates, which can be further improved by skeletal shortening at the time of replantation. We suggest that research networks worldwide set up digit amputation registries to capture individual patient data on this uncommon injury.

Mangled extremity- Modern concepts in treatment

A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

Delayed Digit Replantation: What is the Evidence?

A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of "delayed" replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

Aesthetic functional reconstruction of the mutilated hand: Indications and selection of reconstructive techniques

Advances in microsurgery together with improvements in reconstructive surgical techniques over recent decades have enlarged the scope of available techniques for mutilated hand reconstruction, shifting the reconstructive paradigm from restoring hand function to providing the best functional and aesthetic results with minimal donor-site morbidity. Successful reconstruction of a mutilated hand should no longer be measured only by the degree of improvement of hand function but also by a more aesthetic hand appearance as well as by improved psychological well-being. In this article, the authors present their concept of aesthetic functional reconstruction of the mutilated hand with a focus on the indications and selection of reconstructive techniques. They emphasize that in order to select the most appropriate technique, providing the best functional and aesthetic outcomes with minimal donor-site morbidity for each individual patient, it is imperative for the reconstructive hand surgeon to possess perfect mastery of all available surgical techniques, thorough understanding of functional and aesthetic requirements and accurate appreciation of multidimensional reconstruction of a given defect of the hand. They have concluded that in precisely indicated cases, successful replantation of an amputated hand or digits remains the best reconstructive procedure designed to obtain a more functional and more normal-appearing hand, whereas, toe-to-hand transplantation, in cases of failed or impossible digit replantation, provides better results than any other digit reconstruction techniques aimed at achieving functioning digits with good appearance. Although skin graft and various distant pedicled flaps and free flaps may be valid options for coverage of some soft tissue defects of the hand, reverse flow forearm flaps, especially those based on the secondary arteries of the forearm, are often the best-suited reconstructive options for like-with-like hand reconstruction. They can provide the best matching of color, texture, soft-tissue volume, donor-recipient tissue interface and fulfill all the aesthetic and functional reconstruction requirements of moderate-sized or even large soft tissue defects of the hand, with acceptable donor site morbidity.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

LEARNING OBJECTIVES

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

SUMMARY

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

The fate of delayed revascularization for neglected vascular injury of incompletely amputated digits and hands

We report the fate of neglected vascular injury in cases of incomplete amputation of the digits and hand after delayed revascularization. Twelve patients underwent primary bone fixation, tendon or skin repair for hand injuries without vessel repair despite ischaemic findings. There was discoloration or necrosis of the fingertips during follow-up examination and the patients were referred to us for treatment. The mean warm ischaemic time was 53 hours (range 17-120). Delayed revascularization was performed with end-to-end anastomosis of the digital arteries in eight and vein graft in four cases. Digital nerves were repaired in four cases and flexor tendons in two cases. Of the 12 cases, eight cases showed complete survival. However, in four patients, complete necrosis of the fingers occurred, with one finger surviving partially. Revision amputation was performed in the four cases where necrosis occurred. We conclude that neglected vascular injury associated with incomplete amputation of digits and hands can be overcome in some patients by delayed revascularization even after prolonged warm ischaemic time. Level of evidence: IV.

Indications for Replantation and Revascularization in the Hand

The indications for upper extremity replantation are fluid, and it has long been appreciated that they change with time. Traditional strong indications for replantation include hand, thumb, or multiple digit amputation in adults, and almost any amputation in a child. Patients often desire replantation of single nonthumb digits based on aesthetic preference and personal/cultural values. Replantation in these situations is acceptable and rewarding, but individual consideration of patient, injury, and circumstantial factors is critical to avoid patient morbidity and unsatisfactory outcomes.

Revascularization and Replantation in the Hand: Presurgical Preparation and Patient Transfer

Replantation of a digit or hand is most successful when performed at a specialized, high-volume center. However, most patients with amputations initially present to local hospitals. Therefore, patients amenable to replantation frequently require expedited transfer to a tertiary center. To maximize success of digit replants, health care providers from both the referring and the referral hospital must be facile and expeditious at transferring the injured patient. The critical aspects of triage include assessment of the injury, patient communication, interfacility communication, preparation of the amputated part and patient, and a timely transfer.

Synchronous microsurgical anastomosis in complex replantation surgery

We conducted a retrospective case control study of digital replantations in 16 patients from September 2015 to January 2017. Half of the patients were treated by a synchronous microsurgical technique and the other half underwent conventional micro-anastomoses. The total time for anastomoses, total operation time and survival of digits were the major endpoints in this study. The number of digits replanted and the anastomosis method had significant effects on total anastomosis time. The mean anastomosis time for each digit was 46 min and 70 min in the synchronous and conventional groups, respectively, a 34% reduction in anastomosis time in the synchronous group when compared with the conventional group. Patency rates were 87% (13/15) of all the digits replanted in each group. Level of evidence: IV.

Preservation of rat limbs by hyperbaric carbon monoxide and oxygen

Cold ischemia times ranging from <6 h to as long as 24 h are generally quoted as the limits for attempting the replantation of amputated extremities. In this study, we aimed to assess the effect of hyperbaric carbon monoxide (CO) and oxygen (O₂) on rat limb preservation. Donor rat limbs were preserved in a chamber filled with hyperbaric CO and O₂ for 3 days (CO + O₂ 3 days) or 7 days (CO + O₂ 7 days). Positive and negative control groups were created by using non-preserved limbs (NP) and limbs wrapped in saline-moistened gauze for 3 days (SMG 3 days), respectively. The survival rate of transplanted limbs at postoperative day 90 was 88% in the NP and 86% in the CO + O₂ 3 days. The corresponding survival rate was 50% in the CO + O₂ 7 days at postoperative day 90 but was 0% in the SMG 3 days at postoperative day 3. Muscle mass decreased in the CO + O₂ 3 days and CO + O₂ 7 days compared with the NP, but sciatic–tibial nerve conduction velocities did not differ. These results indicate that amputated extremities preservation with hyperbaric CO and O₂ could extend the time limits of preservation, maintaining their viability for replantation.

The Concept of Door-to-Surgery Time in Distal Digital Replantation

BACKGROUND

Digital replantation has become a well-established technique that has revolutionized hand surgery. One of the most important factors to a successful replantation is less than 12 hours of warm and 24 hours of cold ischemia time. The purpose of this article was to present a concept of door-to-surgery time and test the hypothesis that success in distal digital replantation is associated with this time.

METHODS

Forty-five patients with 49 distal amputations were included in the study. Data regarding patient demographics, amputation characteristics, ischemia time, and surgical outcome were collected. Factors related to a successful replantation were analyzed. Fisher's exact test was used for statistical analysis.

RESULTS

Type I, II, and III Yamano classification were noted in 11 (22.4%), 11 (22.4%), and 27 (55.1%) amputations. All the digits had arterial anastomoses while 19 (38.8%) digits were replanted without venous anastomosis. The mean door-to-surgery time was 229 minutes. The overall success rate was 77.6%. There were no differences in the survival rates between replantations with or without venous anastomosis. Patients with less than 180 minutes of door-to-surgery time had a significantly better survival rate compared to patients with greater time.

CONCLUSION

The overall success rate was 77.6%. Patients with less than 180 minutes of door-to-surgery time had a significantly greater success rate (95.0%) compared to patients with longer door-to-surgery time (65.5%). Further effort must be made to achieve this goal in digital replantation.

"Damage Control" Hand Surgery: Evaluation and Emergency Management of the Mangled Hand

Mangled hand injuries are defined as those with significant damage to multiple structures, which may be limb threatening. Historically these injuries resulted in amputation or death, but modern surgical and perioperative advances allow for complex reconstruction and the possibility of a sensate and functional limb. Evaluation begins with surveying for life-threatening injuries followed by a systematic approach to identify injured structures; management begins with preserving all parts, minimizing warm ischemia time, performing débridement, and planning an operative approach to optimize the chance of a functional limb. With careful surgical planning and a well-executed reconstruction, most limbs can be salvaged.

Pushing the Boundaries of Salvage in Mutilating Upper Limb Injuries: Techniques in Difficult Situations

With the available microsurgical techniques, salvage of the limb can almost always provide a useful upper limb, even in the most complex combined injuries. Having a low threshold for revascularization of doubtfully viable extremities and making full use of the current armamentarium of soft tissue cover techniques, including flow through free flaps, will salvage many limbs. Secondary procedures, including free functioning muscle transfers and toe transfers, further increase the possible functional outcome. Even in the most complex combined injuries, intelligent reconstruction will obtain better outcomes than the best available prosthesis, making the efforts of salvage worthwhile.

Replantation of digits: a review of predictive factors for survival

The survival of 75 consecutive digital replantations carried out between 2006 and 2010 at a regional hand centre in the United Kingdom was determined. The patient demographics, mechanism of injury, co-morbid factors, operative and post-operative details were extracted and reviewed from the medical and hand therapy notes. Predictive factors of survival were determined by using univariate and multivariate statistical analysis. The survival rate was 70%. Arterial thrombosis was the leading cause of replant failure, followed by venous congestion. Smoking, level of amputation, number of nerves repaired, warm ischaemia time and timing of replantation were independent predictors of replant survival. However, only warm ischaemia time less than 6 hours and 30 minutes and replantations done within 'office hours' showed significance on multivariate logistic regression. Our study suggests that replantations done in daylight hours, when feasible, with rested staff and a full complement of the theatre team are likely to have better outcomes.

LEVEL OF EVIDENCE

Level IV case series.

Replantation in trauma

Following the first successful digital replant in 1968, replantation after traumatic amputation of the upper limb has become the norm in carefully selected patients. With good communication between the receiving emergency department and microsurgical team, the correct patients can be given appropriate priority and managed smoothly through their complex treatment. This article reviews the indications, initial management, surgical techniques, complications and the ex pected outcomes for upper limb replantation. This will help the nonmicrosurgeon explain to patients who have had an amputation the process of replantation and what they might expect after transfer to the microsurgical team, and it gives an overview of replantation for junior trainee microsurgeons.

Injuries to appendage extremities and digit tips: A clinical and cellular update

BACKGROUND

The regrowth of amputated appendage extremities and the distal tips of digits represent models of tissue regeneration in multiple vertebrate taxa. In humans, digit tip injuries, including traumatic amputation and crush injuries, are among the most common type of injury to the human hand. Despite clinical reports demonstrating natural regeneration of appendages in lower vertebrates and human digits, current treatment options are suboptimal, and are complicated by the anatomical complexities and functions of the different tissues within the digits.

RESULTS

In light of these challenges, we focus on recent advancements in understanding appendage regeneration from model organisms. We pay special attention to the cellular programs underlying appendage regeneration, where cumulative data from salamanders, fish, frogs, and mice indicate that regeneration occurs by the actions of lineage-restricted precursors. We focus on pathologic states and the interdependency that exists, in both humans and animal models, between the nail organ and the peripheral nerves for successful regeneration.

CONCLUSIONS

The increased understanding of regeneration in animal models may open new opportunities for basic and translational research aimed at understanding the mechanisms that support limb regeneration, as well as amelioration of limb abnormalities and pathologies.

Replantation of the upper extremity: current concepts

Replantation is the process of reattaching amputated parts. Relative indications for replantation in the upper extremity include amputation of the thumb or multiple digits as well as amputations proximal to zone II and pediatric finger amputations at any level. Preoperatively, the part should be sealed in a bag and placed on ice; maximum ischemia times are approximately 12 hours of warm and 24 hours of cold time for digits, with shorter times tolerated for amputations at more proximal levels. With multiple digit involvement, an assembly line approach is used in the operating room. Postoperatively, close attention must be paid to detect thrombosis because secondary ischemia times are shorter. Success rates vary; survival is predicted in part by the mechanism of injury, with sharp cut injuries having better outcomes. There is no consensus on appropriate postoperative anticoagulation, the number of vessels that must be anastomosed, or whether replantations should be centralized or performed in every hospital.

Management of complications relating to finger amputation and replantation

There are many options in the management of fingertip or finger amputations. Injudicious revision amputation may cause complications. These complications can be prevented by tension-free closure of the amputation stump or primary coverage with appropriate flap. Replantation is the best way to keep the original length and maintain digital function. Patent vein repair or venous drainage with bleeding until neovascularization to the replanted part is the key to successful replantation. Prevention and management of complications in replantation and revision amputation increase patients' satisfaction and decrease costs. Research is needed to define new indications of replantation for digital amputation.

Delayed and suspended replantation for complete amputation of digits and hands

PURPOSE

To analyze the clinical outcome for delayed or suspended replantation of complete amputations of digits or hands, or both.

METHODS

We analyzed 20 cases involving 28 digital and 4 hand amputations that underwent delayed or suspended replantation. In 15 cases of single-digit amputation, patients underwent delayed replantation the morning following amputation. With amputation of multiple digits, bilateral digits, or the hand, the important digits or dominant hand underwent immediate replantation, and we suspended the surgeries for the residual digits or non-dominant hand, or both, until the next morning. We then evaluated the mean warm and cold ischemic time for the operations, graft survival rates, and clinical outcomes. The mean follow-up period was 26 months. We evaluated the clinical results using the criteria of Chen.

RESULTS

The mean warm and cold ischemic times in 15 cases of delayed replantation were 2 hours 4 minutes and 7 hours 21 minutes, respectively. In 8 cases of suspended replantation, the mean warm and cold ischemic times in the first operation were 5 hours 54 minutes and 2 hours 36 minutes, respectively. In the second operation, the cold ischemic time averaged 15 hours 48 minutes. In this series, 24 of 28 digits and all 4 hands survived. Total survival incidence in both delayed and suspended replantation was 88%, not statistically different from the overall survival incidence in 711 cases of immediate replantation during the same period (84%). In delayed replantation, we observed an excellent result with 6 digits and a good result with another 6 digits. In suspended cases, we observed a good result with one multiple-digit and one hand procedure and we obtained a fair result in 3 multiple-digit and 2 hand replantation procedures.

CONCLUSIONS

Delayed and suspended replantations demonstrate results comparable to immediate replantation regarding graft survival and clinical outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of complications with flap procedures and replantation

Replantation and flap procedures employ microvascular techniques to salvage or reconstruct a severely damaged limb or digit. The most devastating complications include complete or partial flap loss, or replantation failure due to vascular complications. Often, these complications can be prevented by appropriate patient selection, careful surgical planning, meticulous technique, and proper postoperative management. This article discusses complications related to replantation and flap procedures in the upper limb, focusing on preventing and managing these complications.

Replantation: current concepts and outcomes

Techniques to improve the chance of successful replantation of digits are well established. Indications and contraindications for replantation are generally agreed on, but they continue to evolve as excellent outcomes are achieved at centers with experience and expertise. Form and function can be restored with avulsion injuries and distal amputations, with good results and high patient satisfaction. Increased financial pressure to control the costs of health care and increased accountability for evidence-based outcomes may lead to the regionalization of replantation care and shared decision making in recommending replantation or revision amputation.

Challenges in replantation of complex amputations

Surgical ingenuity has resulted in continuing microsurgical innovation in replantation. In this article, the authors define complex amputations as those that stretch the boundaries or fall outside traditionally defined indications for replantation. They discuss management of difficult situations involving multiple digit amputations, multiple-level amputations, prolonged ischemia, and multiple trauma. The role of transpositional and ectopic replantation, as well as the requirement for secondary procedures in replantation is also discussed. Although technically challenging, microsurgical management of complex amputations ultimately results in far superior outcomes.

Upper extremity replantation: current concepts

BACKGROUND

Upper extremity replantation is a procedure that has revolutionized hand surgery. Since its introduction, a rapid evolution has occurred with a shifting focus from implant survival to optimization of functional outcomes and surgical efficiency. In this review, the current concepts surrounding the indications for replantation, variations in surgical technique, the factors affecting outcomes, and future directions of the specialty are analyzed.

METHODS

A literature review was performed of all recent articles pertaining to digit, hand, and upper extremity replantation surgery. Particular emphasis was placed on comparative studies and recent meta-analyses.

RESULTS

The indications and contraindications for replantation surgery are largely unchanged, with mechanism of injury remaining one of the most important determinants of implant survival. With advances in surgical technique, improved outcomes have been observed with avulsion injuries. Distal tip replantations appear to be more common with improved microsurgical techniques, and for these distal injuries, digital nerve and vein repair may not be necessary. Cold ischemia time for a digit amputation should not preclude transfer to a replantation facility or significantly affect the decision to perform a replantation. However, transferring physicians should thoroughly review the options with patients to prevent unnecessary transfers, which is an area where telemedicine may be useful.

CONCLUSION

This review provides an update on the current concepts of the practice of replantation and the treatment and management of patients with upper extremity amputations.

Particularities of hand and wrist complex injuries in polytrauma management

Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a "one lesion-one solution" approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.

Double flap from amputated opposite lower limb for cover of plantar and dorsal surfaces of a crushed foot

Bilateral limb trauma poses many possibilities for management. In a situation of bilateral amputation, if the amputated limb is not salvageable or replantation is not advisable, the amputated limb can be used to harvest tissue for free tissue transfer to cover the amputation stump. We describe a case here in which we have used these principles.

Distal digital replantation

BACKGROUND

Hand surgeons have been hesitant to perform distal digital replantation because of the technical challenges and the perception of a high cost-to-benefit ratio. Recent studies, however, have shown high survival rates and excellent functional and aesthetic results, providing renewed enthusiasm for distal replantation.

METHODS

The authors reviewed the literature and summarize key points regarding the surgical treatment, perioperative care, and outcomes of distal digital replantation. They describe specific techniques and considerations for surgical repair in each of four distal zones as described by Sebastin and Chung.

RESULTS

Zone 1A replantation involves an artery-only anastomosis of a longitudinal pulp artery. Venous anastomosis first becomes possible in zone 1B. Zone 1C involves periarticular amputations where arthrodesis of the distal interphalangeal joint is usually indicated. Repair of the artery, vein, and nerve is technically optimal in zone 1D, where venous anastomosis should be performed. Overall, survival rates for distal digital replantation are similar to those reported for more proximal replantation. The literature reports good outcomes regarding nail salvage, fingertip sensibility, and range of motion, with restoration of length and aesthetic appearance.

CONCLUSIONS

Distal replantation performed at institutions that specialize in microsurgery and specifically tailored to the level of injury is associated with good survival, function, and patient satisfaction and superior aesthetic outcome. More prospective data are needed to evaluate the cost of treatment, psychological outcomes, and functional outcomes of distal replantation compared with revision amputation.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Six years of follow-up after bilateral hand replantation

Replantation is the gold standard surgical treatment of amputations of the upper limb; however, this demanding procedure is not always preformed in bilateral limb amputation. The objective of this study was to analyze, six years after surgery, the sensorimotor recovery of both replanted hands. A 21-year-old patient with bilateral hand amputation was benefited from limb replantation. Surgery included debridement of the amputated hands and recipient's stumps, bone fixation, arterial and venous anastomoses, nerve sutures, tendon sutures and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Sensory and motor evaluation was performed 6 years after replantation. At 6 years, the patient presented a good/satisfactory recovery of range of motion and strength, better at right hand. The patient was able to perform right thumb opposition. Static two-point discrimination was 20mm, sensitivity to pain and thermal stimuli and ability to sweat were present on both hands. Reinnervation was confirmed by electromyography. Functional recovery was higher at the right hand when compared to the left hand. He was highly satisfied with the result of surgery for right hand and fairly satisfied with the result for left hand. He was able to return to a secretary work 16 months after the accident. A proper functional result can be accomplished with bilateral hand replantation.

Current management of the mangled upper extremity

Mangled describes an injury caused by cutting, tearing, or crushing, which leads to the limb becoming unrecognizable; in essence, there are two treatment options for mangled upper extremities, amputation and salvage reconstruction. With advances in our understanding of human physiology and basic science, and with the development of new fixation devices, modern microsurgical techniques and the possibility of different types of bony and soft tissue reconstruction, the clinical and functional outcomes are often good, and certainly preferable to those of contemporary prosthetics. Early or even immediate (emergency) complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. Before any reconstruction is attempted, injuries to other organs must be excluded. Each step in the assessment and treatment of a mangled extremity is of utmost importance. These include radical tissue debridement, prophylactic antibiotics, copious irrigation with a lavage system, stable bone fixation, revascularization, nerve repair, and soft tissue coverage. Well-planned and early rehabilitation leads to a better functional outcome. Despite the use of scoring systems to help guide decisions and predict outcomes, the decision to reconstruct or to amputate still ultimately lies with the surgical judgment and experience of the treating surgeon.

Upper extremity and digital replantation

Digital replantation has become a well-established technique among reconstructive hand surgeons. Numerous replantation centers around the world have published series with impressive survival rates. The ultimate goal of replantation is the restoration of normal hand or digital function; thus, replantation success is not solely related to the outcome of the microvascular anastomosis, but also to the adequacy of bone, tendon, skin, and nerve repairs. In this manuscript, we review the literature on upper extremity and digital replantation from its historical background to current surgical outcomes, outlining surgical indications and contraindications, and the preoperative, operative, and postoperative management of these patients.

Fingertip replantation: Technical considerations and outcome analysis of 24 consecutive fingertip replantations

Fingertip amputations are one of the most common injuries faced in an emergency department. Finger tip replantation though technically possible, are not regularly done due to the presumed complexity of the procedure and doubts about the outcome. This article deals with our experience of 24 fingertip replantations in 24 patients done over a period of 8 years since the year 2000. Twenty-one fingertips survived. The most common affected digit in the series was thumb followed by index, middle, and ring. The overall success rate was 87%. Both arterial and venous repair were done in all cases. Replantation was not done if no suitable vein was found for anastomosis. Nine patients did not have nerve repair. Seven of them survived and all of them had satisfactory sensation when examined after 1 year. No patient suffered from cold intolerance. All patients were satisfied with the functional outcome and aesthetic appearance. This article highlights the technical considerations and the outcome of these fingertip replants.

Replantation of an amputated hand: a rare case report and acknowledgement of a multidisciplinary team input

An amputation of the hand is a devastating injury. It adversely affects the victim's ability to earn a livelihood, support a family, and carry out daily activities. It has a great psychological impact. We report a middle aged male with an amputation at the level of the distal forearm who underwent replantation. The operative details of this case are described. Awareness of the possibility of salvage should be spread among healthcare personnel and the need for immediate attention by a multispeciality team is advocated. This report reviews the literature related to the operative technique, contraindications and long term results.

Hand and finger replantation after protracted ischemia (more than 24 hours)

Ischemia tolerance has been a major concern during hand and finger replantation. Because of multiple referrals and damage control resuscitation, ischemia is occasionally prolonged for more than 24 hours. Amputation impairs functional efficiency in amputees; therefore, if there is a favorable indication for replantation, microsurgical replantation can be performed to salvage the function of the affected part to an acceptable extent.Between 1998 and 2006, 14 patients underwent 25 replantations after prolonged ischemia of more than 24 hours. Of the 14 patients, 12 were referred to our hospital after unsuccessful replantations and admitted to the emergency room. Two of these patients underwent thumb amputations, and 10 patients underwent multiple digit amputations. Two patients underwent wrist amputation with associated polytrauma and profound shock, both hand replantations were performed on the following day after ICU management with damage control resuscitation was performed to control excessive bleeding and stabilize vital signs.In this study, 16 replantations were successful and 9 failed; thus, the success rate was 64.0%. Several secondary procedures were required for restoring the functional ability of the reconstructed parts.Ischemia time is critical for limb salvage. Hands and fingers have very little muscle tissue. Hence, replantation of these parts can be performed even in the case of prolonged ischemia to restore the hand function.

An overview of limb replantation

This review aims to provide an overview of the complex topic of limb replantation. The historical developments in limb replantation are detailed and the technical considerations of this surgery are discussed. Specific concerns relating to limb replantation surgery such as total ischaemic time and the amputation level are considered. It is important for rehabilitation to be tailored to the individual and the level of the injury. Attempted upper limb replantation is advocated in most cases but lower limb replantation is rarer. Lower limb replantation may have successful outcomes provided careful selection of patients takes place. Future improvements in replantation surgery may be influenced by developments in limb allograft surgery and nerve regeneration. Despite varying outcomes following successful replantation surgery, patients generally prefer to retain their own limbs rather than have a prosthesis and this should be considered as part of the informed decision making process by clinicians.

Xenotransplantation of cryopreserved composite organs on the rabbit

Nowadays, It is easy to define optimal conditions (cryoprotective agent, speed and steps of freezing, speed of warming) for the cryopreservation of a homogeneous cell population or a one cell-layer tissue. Meanwhile, It is still hard to obtain cryopreservation of composite organs. Each tissue has its own requirements and its own reactivity to the cryopreservation process. The challenge consists of, on the one hand, to select the ideal combination of cryoprotective agents that can fit the needs of the different tissues, and the definition of adequate technical parameters, on the other hand. All the experimental trials have studied the survival rate of non-vascularized cryopreserved tissues. The aim of our experimental work is to demonstrate the feasibility of cryopreserving a composite organ with its nutrient vessels "artery and veins" in order after thawing to revitalize it by reestablishing the blood irrigation by microsurgical vascular anastomosis. We report our experimental results on the cryopreservation of composite organs-amputated digits-xenotransplanted in the rabbit. Digital segments were cryopreserved, then revitalized after warming using vascular microsurgical techniques. Preliminary results are encouraging and may pave the way in the future to the microvascular allotransplantation of cryopreserved composite organs.

Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischaemia

In this investigation, the influence of hyperbaric oxygen (HBO) therapy on the survival of a replanted extremity subjected to prolonged warm ischaemia is evaluated. Among the relative contraindications to replantation are prolonged warm ischaemia time, since an obstruction to blood reflow ('no-reflow phenomenon') may occur in amputated parts that are subjected to more than 6h of warm ischaemia. Twenty-three rat hindlimbs were amputated and subjected to 4h of normothermic ischaemia. The average weight of the animals was 500 gm, and re-plantation of the hindlimb was performed by bone fixation followed by microvascular anastomosis of the femoral vessels. Limb re-vascularisation was confirmed at the end of all procedures by the milk test, clinical assessment and pulse oximetry recordings (>90%). Eleven animals served as a control group and no further therapy was instituted, whereas 12 animals served as the study (replantation) group and were subjected to HBO therapy for 3 days postoperatively. The therapy was conducted in a large animal chamber for 90 min at 2.5 ata. Limb survival was assessed by capillary refill upon compression, skin turgor assessment and colour. Confirmation of clinical findings was conducted with daily pulse oximetry readings of >90%. Animals were followed up for 7 days at which point all animals were euthanized or were euthanized earlier if a non-viable limb was present. Two of the 11 limbs in the control group survived following re-plantation, whereas eight of the 12 limbs in the experimental HBO group survived at least 7 days following replantation. This difference was statistically significant (p=0.0361) using chi-square analysis and Fisher's exact test. Although re-plantation of an amputated extremity after prolonged warm ischaemia is considered a relative contraindication due to the possibility of poor outcomes, our results indicate that the window for replantation may be increased if adjunctive HBO therapy is employed in the postoperative period.

Late salvage of the ischemic finger after crush injury using flow-through flaps: case report

The progressive evolution and late salvage of a posttraumatic digit with poor vascularization has not been discussed in the literature. We report the cases of 3 patients whose fingers were rescued at referral 5 to 16 days after the traumatic event by restoring the arterial inflow by means of flow-through free flaps. All 3 fingers were compromised vascularly with patchy necrosis and absence of Doppler signal distal to the injury. All were salvaged. In our experience, in the setting of a posttraumatic digit with poor vascularization, it is possible to reverse impending necrosis by late revascularization. Frank infection or mummification is considered an irreversible state and a contraindication to salvage.