The Decision for Replantation

Indication and Contraindications

INDICATIONS

SINGLE FINGER

INDEX REPLANT

TWO FINGER

HAND REPLANT

FOREARM REPLANT

THUMB

Many factors go into the decision of whether to perform a replantation or to proceed with closing an amputation wound.  The factors include:

• Anatomical features of the affected part or parts

• Other injuries

• Mechanism of injury

• Patient age

• Work status

• Motivation of the patient

• Ischemia time

Anatomic features that are specific to the amputation and not related to the patients health or history include the level and complexity of the injury.  More distal injuries have better success in terms of function, but an exception is very distal replants where establishing circulation may be more difficult.   Sharp injuries tend to do better than crushing or avulsion injuries.  Crush and avulsive injuries tend to involve a wide path of tissue that is irreversibly damaged.  Similarly, multi-level injuries do not do as well as single level injures.

Ischemia time refers to the total time the part is lacking circulation and therefore not receiving oxygen.  The longer the ischemia itme the worse the prognosis.  This is particularly true for warm ischemia where oxygen consumption and free radical formation is increase.  For this reason parts are kept cool, but not frozen, on ice. 

Upper extremity replants tend to have better results than lower extremity replants.  Feet tend to heal slowly and not recover sensation well.  Under many circumstances, prosthetic lower limbs do better than replanted ones.

 Each patient needs to be evaluated on an individual basis, taking into account all aspects of the patients history and needs and many other factors, including the ones addressed above.

Generally, the following elements point toward strong indications for replantation:

• Multiple finger amputations.

• Thumb amputations.

• Hand amputations at the palm or wrist.

• Childhood amputations

The following types of amputations are considered controversial by many.  However, in appropriately selected cases, with motivated patients, results can be excellent.

• Loss of a single digit, excluding the thumb

• Ring finger avulsion injures.

The following are considered contraindications to replantation:

•  Upper extremity amputation proximal to the mid-forearm with ischemia time greater than 6 hours

• Concomitant life-threatening injuries

• Multiple level injures

• Severe crush or avulsion

• Extreme contamination

• Systemic illness or surgical history precluding replantation

• Self mutilation cases, psychotic patients