Few studies have evaluated the impact of amputations and replantations on 

society. A study from Sweden determined the incidence to be 1.9 per 
100,000 person-years (males 3.3, females 0.5). Eighty-six percent occurred in 
males and 9% in children (age 0 to 14 years). The majority occur in 
males 45 to 54 years of age. Factory workers (26%) and carpenters (14%) 
were most commonly injured.3 A large national database study of upper 
extremity amputation and replantation cases in the United States demonstrated 
that the patients undergoing replantation were younger (average age 36 years) 
than those suffering amputation but not undergoing replantation (average age 
44 years). Replantation was most often performed in teaching hospitals and 
larger urban hospitals.14

Emergency Management

The patient sustaining an upper extremity amputation should be rapidly and 
efficiently transported to a specialty center capable of replantation. The 
patient’s candidacy for replantation should be determined after he or she has 
been assessed in the emergency department. The field trauma care of such 
a patient should follow the principles of global trauma management. It may 
be easy to overlook more urgent basic trauma protocols in the setting of 
the distracting, and sometimes  dramatic, appearance of extremity amputations. 
The ABCs of trauma management should never be neglected. Specific 
management of the amputated parts should include collection of all 
amputated parts in the field, regardless of the degree of contamination or 
quality of tissue. These parts should be wrapped in a sponge saturated with 
saline, placed in a plastic bag, and subsequently placed in a bag of ice 
or on a bed of  ice. The goal is to cool the part but avoid freezing 
of the tissue. The bag should be labeled with the patient’s demographic  
information and transported with the patient to the hospital setting. The 
amputated stump should be treated with pressure dressings and elevation to 
control bleeding. Tourniquets should be avoided as well as attempts at 
ligation of blood vessels in the field, if possible. In the emergency 
department, the amputated parts and the amputated stump should be 
evaluated for the purposes of operative planning and decision making. The 
patient’s limb and amputated parts should be evaluated radiographically. 
Tetanus prophylaxis should be provided.

Patient Selection

Very few indications or contraindications for replantation are absolute. The 
most compelling indications for replantation include thumb amputations at any 
level (Figure 42.1), multipledigit amputations (Figure 42.2), any amputation in 
the pediatric population, and amputations through the wrist, forearm,  and 
elbow.  Contraindications  for  replantation  include  medical instability  that  would 
make  lengthy  surgical  intervention  excessively  risky.  Relative  contraindications 
include  single-digit amputations  through  zone  2  of  the  flexor  tendon 
sheath,  multilevel  segmental  amputations,  and  ring  finger  avulsion 
amputations.  These  are  felt  to  be  relative  contraindications  because the 
procedures  are  difficult  to  perform  and  satisfactory  functional  results  are 
difficult  to  achieve. Reports  of  series  of  patients in  these  categories  have 
been  published  demonstrating  surprisingly  good  results,  with  authors 
questioning  whether  these  conditions  should  be  considered  relative 
contraindications.1,5,6,22,33 A  relative  indication  for  replantation  is  a  single 
digit  distal to  the  flexor  digitorum  superficialis  insertion.  Although  the 
functional  loss  from  such  an  amputation  in  a  digit  other  than the 
thumb  is  not  great,  surgical  replantation  of  such  an  amputated  digit 
can  be  performed  quite  speedily  and  the  functional outcomes  are  good. 
Lack  of  involvement  of  the  proximal  interphalangeal  joint  and  preservation 
of  the  flexor  digitorum superficialis  insertion  will  likely  provide  good 
proximal  interphalangeal  motion  and  an  overall  satisfying  functional  result 
even  without  significant  return  of  distal  interphalangeal  flexion. For  this 
reason,  amputations  at  this  level  are  felt  to  have  a  more favorable 
prognosis  than  those  through  zone  2  (Figure  42.3). Special  consideration 
should  be  given  to  major  replantation cases.  Good  functional  outcomes 
can be achieved with replantation  through  the  midpalm, wrist, and  forearm. 
The  more  proximal  the  amputation,  however,  the  less  promising  will  be 
the result  because  of  the  amount  of  nerve  regeneration  needed  to 
achieve  protective  sensation  and  the  potential  for  stiffness  of  the elbow 
joint;  also,  myonecrosis  may  occur  in  proximal  replantation  cases  with  a 
prolonged  ischemia  time. The  length  of  the  ischemia  time  is  a  much 
less  critical  issue in  digit-level  amputations  because  muscle  sensitive  to 
ischemia is  not  present. At  the  level  of  the  midpalm  or  wrist,  the 
intrinsic muscles  may  be  débrided  if  injured.  If  they  are  uninjured  and 
are  left  intact  despite  a  prolonged  ischemia  time,  the  resultant f ibrosis 
and  dysfunction  may  be  manageable.  In  more  proximal injuries,  however, 
the  muscle  burden  of  an  amputation  through the  proximal  forearm  or 
transhumeral  level  is  quite  significant. In  these  cases,  the  ischemia  time 
becomes  paramount. Digit  replantation  is  considered  feasible  if  the  warm 
ischemia  time  is  limited  to  6  to  12  hours.  With  a  well-preserved, 
cooled  part,  cold  ischemia  can  likely  be  tolerated  for  up  to  24 hours 
after  digital  amputation  prior  to  replantation.28  Sporadic cases  of  delayed 
digit  replantation  have  been  reported  after  33 hours  and  94  hours  of 
warm  and  cold  ischemia, respectively.  9,45 Successful  hand  replantation  has 
been  reported  in  one  case  after 54  hours  of  cold  ischemia.42  The 
limits  of  tolerated  ischemia time  in  distal  amputations  are  thus  poorly 
defined.  Indeed,  Lin and  colleagues  studied  ischemia  time  in  31  cases  of 
hand  and f inger  replantation  that  exceeded  24  hours  and  found  no 
correlation  between  ischemia  time  and  postoperative  outcome.28 In 
amputations  involving  the  forearm,  even  2  to  3  hours  of warm  ischemia 
time  can  result  in  substantial  muscle  necrosis, which  can  produce  a 
coagulopathy  after  reperfusion.  Venous outflow  from  the  reperfused  extremity 
contains  toxic  compounds  such  as  oxygen-free  radicals  that  can  cause 
tissue damage  and  vasospasm.  In  these  cases,  cooling  the  amputated part 
(to  4° C)  can  dramatically  prolong  the  time  between  injury and 
successful  replantation.  Cooling  must  be  performed  to  the appropriate  level 
because  excessive  cooling  below  4° C  can  cause formation  of  intracellular 
crystals  that  can  cause  tissue  damage similar  to  frostbite. Properly  cooled 
parts  have  been  replanted  up  to  36  hours after  the  time  of  injury; 
however,  the  survival  rate  of  an  amputated  part  decreases  with  the 
delay  to  replantation. It  is  these  considerations  of  muscle  burden,  ischemia 
time, distance  of  required  nerve  regeneration,  and  degree  of  skeletal 
injury,  as  well  as  the  mechanism  of  injury,  that  need  to  be 
considered  in  every  case  of  major  replantation. Technical Considerations in
Preparing for Replantation Whether  at  the  digit  level  or  transhumeral  level, 
replantation  is best  performed  with  a  team  effort.  The  efficiency,  speed, 
and quality  of  replantation  are  enhanced  using  a  team  approach. Two 
teams enable  simultaneous  work  on  the  amputation  stump and  the 
amputated  parts.  In  lengthy  cases  (such  as  multipledigit  amputations),  the 
team  model  allows  surgeons  to  work  in shifts;  each  shift  of  well-rested 
surgeons  works  with  a  fresh perspective  and  relieves  the  fatigued 
surgeons  on  the  shift before  them. This  approach  should  be  used  as 
soon  as  the  decision  to operate  has  been  made. The amputated parts 
should  be brought to  the  operating  room  so  that  débridement,  dissection, 
and preparation  can  begin  before  the  patient  arrives  in  the  operating 
room.  This  will  minimize  the  patient’s  anesthesia  time  and allow  the 
surgical  team  to  assess  the  quality  of  the  part  and  thus the  likelihood 
of  replantation  or  technical  requirements.

INTRAOPERATIVE TECHNIQUE

Preparation of the Amputated Part The  amputated  parts  are  treated  with  a 
surgical  prep  solution and  placed  on  a  back  table  with  full  sterile 
technique.  Midaxial incisions  are  made  on  both  the  radial  and  ulnar  sides 
of  the digit.  The  volar  and  dorsal  skin  flaps  are  elevated.  The 
neurovascular  bundles  are  dissected  in  the  radial  and  ulnar  sides  and 
assessed  for  their  quality,  caliber,  and  length.  The  flexor  tendon is 
prepared  with  a  locking  3-0  suture,  with  the  loose  ends  protruding 
through  the  severed  end  of  the  tendon.  The  extensor tendon  is 
elevated  but  is  not  affixed  with  sutures.  The  bone is  shortened 
generously  to  enable  primary  nerve  coaptation. Osseous  shortening  is 
preferentially  performed  from  the  level of  the  amputated  part  so  that 
failure  of  the  replantation  would not  result  in  excessive  shortening  of 
the  amputation  stump.  If the  shortening  of  the  bony  structure  requires 
resection  back  to the  adjacent  joint,  the  joint  is  prepared  for 
arthrodesis  by removal  of  the  cartilage  and  subchondral  bone  and 
preparation for  a  cup-and-cone  relationship  between  the  amputated  part 
and  the  stump. Anticipated  osseous  fixation  is  prepared.  This  is  usually 
performed  with  longitudinal  nonparallel  Kirschner  wires  driven from  proximal 
to  distal  in  an  antegrade  fashion  through  the  tip of  the  digit  and 
then  recessed  to  the  level  of  the  proposed  osteosynthesis  site.  Pin  balls 
are  applied  to  the  Kirschner  wires  and protrude  through  the  tip  of 
the  digit  so  that  they  do  not  constitute  a  hazard  to  the  surgeon 
during  the  remainder  of  the operation.  The  pin  balls  will  later  be 
removed,  and  the  pins driven  retrograde  to  achieve  fixation. We usually 
remove  the  nail  plate  at  the  time  of  digit  preparation  and  discard  it. 
This  can  be  helpful  if  the  digit  demonstrates venous  insufficiency  following 
operation  and  requires  heparin pledget  application  in  the  nail  bed  or 
leech  application.  This will  avoid  the  need  for  nail  removal  at  the 
bedside  in  an  awake postoperative  patient. An  attempt  is  made  to 
separate  the  nerves  and  arteries  as minimally  as  necessary  for  assessment 
and  preparation.  Preserving  surrounding  subcutaneous  tissue  may  minimize 
desiccation  thoughout  the  case. The vessels  need  to  be  assessed  with  a 
microscope  to  evaluate the  intima  in  the  lumen.  Avulsive  injuries  will 
often  cause significant  dissection  of  the  vessel  wall  layers  or  fracturing 
of the  intima  near  the  zone  of  injury  (Figure  42.4).  This  will require 
resection  of  the  distal  vessel  until  a  normal  vessel  is observed.  If  a 
single  arterial  reconstruction  is  being  performed, the  distal  vessel  of 
better  quality  will  be  used.  This  can  be  performed  in  a  crossover 
fashion  to  the  contralateral  digital  artery if  length  and  caliber  facilitate 
it.  Additionally,  the  second  distal artery  could  be  considered  as  a  source 
of  venous  outflow  if  no dorsal  veins  are  available,  so  this  vessel 
should  be  preserved  in the  field,  and  both  vessels  should  be  dissected 
in  preparation for  replantation. In  the  dorsal  subcutaneous  fat,  the  veins 
are  assessed.  This  is also  performed  with  the  least  amount  of  initial 
dissection  of  the veins  possible.  The  quality  and  number  of  available 
veins  are assessed  under  the  microscope. Preparation  of  the  digit  can 
sometimes  be  difficult  if  the surgeon  does  not  have  an  assistant 
available.  Placement  of  the longitudinal  Kirschner  wires  can  facilitate 
unassisted  dissection. The  nonparallel  Kirschner  wires  protruding  through  the 
tip  of the  digit  can  be  held  stable  with  a  surgical  clamp  to  prohibit 
pronation/supination  of  the  part  during  dissection.

Preparation of the Hand

Information  about  the  osseous  level  of  shortening  is  shared  by the 
surgical  teams.  If  arthrodesis  of  either  the  proximal  interphalangeal  or 
distal  interphalangeal  joint  will  be  performed, the amputation  stump  is 
fashioned  into  a  convex  cone  configuration  in  preparation  for  the 
arthrodesis.  If  extraarticular  fixation is  planned,  the  bone  may  be 
prepared  so  that  it  is  aligned  to simplify  reduction.  The  simplest 
configuration  is  a  transverse osteosynthesis  site  so  that  fixation  and 
rotational  alignment  can most  easily  be  achieved. The proximal  tendon  is 
prepared  by  retrieving  it  through  the f ibroosseous  sheath,  resecting  the 
edge  back  to  a  healthy  transverse  tenotomy,  and  preparing  it  with  a  3-
0  locking  suture similar  to  the  preparation  of  the  distal  flexor  tendon.
The  dorsal  extensor  tendon  is  elevated  and  prepared  but does  not 
require  presuturing  for  preparation.  The  radial  and ulnar  neurovascular 
bundles  are  assessed  via  radial  and  ulnar midaxial  incisions,  and  the 
dorsal  skin  is  elevated  with  subcutaneous fat for preparation of  the veins. 
A microscope is brought into  the  field  at  this  point  to  assess  the 
vessels.  Considerations about  the  quality  of  the  proximal  vessels  are  the 
same  as  those described  for  the  distal  part. Ultimately, the  quality  of 
the  proximal  artery  will  be  determined  by  the  spurt  test,  which  is 
performed  after  the  tourniquet  is  released. The  digital  nerves  are  resected 
back  to  a  healthy  fascicular pattern  with  great  care  taken  to  attempt 
to  achieve  primary nerve  coaptation  after  osseous  shortening. Dorsally,  the 
veins  are  assessed.  The  proximal  veins  are usually  easier  to  find  and 
prepare  than  the  distal  veins  because of  their  larger  caliber.  If 
additional  length  is  needed  for  vein coaptation,  side  branches  may  be 
ligated  to  elongate  and  transpose  veins  to  reach  the  anastomosis  site 
(Figure  42.5). It  should  be  noted  that  the  preparation  of  the  amputated 
part  is  typically  done  under  tourniquet  control.  For  this  reason, all  of 
these  processes  in  preparation  of  the  amputation  stump and  ultimate 
replantation  should  be  done  as  efficiently  and rapidly  as  possible.  The 
surgeon  needs  to  assess,  prepare,  and plan  each  sequential  phase  with 
a  premium  placed  on  speed and  a  constant  awareness  of  the  duration 
of  tourniquet  time that  has  elapsed.

Replantation

Different  surgeons  favor  significant  variations  in  digital  replantation  technique. 

There  is  not  a  consensus  about  the  “correct” way  to  perform 
replantation  because  there  are  benefits  with many  different  strategies. 
Several  common  concepts  are  seen  in all  of  the  techniques,  however. If 
multiple  digits  have  been  amputated,  it  is  always  more efficient  to 
perform  the  replantations  sequentially.  For  example, the  osseous  structures 
in  all  digits  may  be  addressed  and replanted  prior  to  moving  forward 
with  the  tendinous  structures.  In  this  way,  structures  that  are  best 
repaired  during tourniquet  control  can  be  repaired  rapidly  digit  by  digit 
and structures  that  are  more easily  addressed  with tourniquet release can 
also  be  repaired  digit  by  digit. Structures  that  require  microscopic 
procedures  are  generally repaired  last  so  that  the  delicate  repairs  are 
not  damaged  by  the more  disruptive  tendon  or  bone  repairs. The 
tourniquet  time  also  influences  the  sequence  of  events because  some 
procedures  may  require  tourniquet  control and  others  are  easily  performed 
without  the  benefit  of  a tourniquet. In  our  center,  we  perform  digital 
replantations  in  the  following  sequence: Under  tourniquet  control  we  perform 
osseous  fixation, extensor  tendon  repairs,  flexor  tendon  repairs,  digital 
nerve repairs  under  the  microscope,  and  dorsal  vein  repairs  under  the 
microscope  if  time  permits. After  tourniquet  release  we  perform  any 
remaining  dorsal vein  repairs  that  have  not  been  performed  under 
tourniquet control,  arterial  repairs  under  the  microscope  after  adequate 
inflow  has  been  ensured,  and  loose  approximation  of  skin. There  are 
many  reported  variations  in  the  sequence  of  the structures  repaired  in 
digital  replantation. Some  surgeons  prefer to  repair  all  dorsal  structures 
(extensor  tendon  and  veins)  first, followed  by  all  volar  structures  (flexor 
tendons,  digital  nerves, and  arteries),  for  the  benefit  of  positioning 
efficiency.  Other surgeons  will  purposefully  plan  the  vein  repairs  last  in 
an  effort to  achieve  arterial  inflow  first.  Surgeons  who  advocate  this 
technique  have  reported  the  benefit  of  arterial  inflow  in  assessing and 
locating  dorsal  veins  with  the  engorgement  of  venous return.  Lastly,  some 
surgeons  have  advocated  repairing  flexor tendons  before  extensor  tendons 
because  they  feel  they  are better  able  to  reproduce  the  position  of 
the  replanted  digit within  the  cascade  of  the  hand. A  particular  note 
should  be  made  of  the  sequence  of  events for  major  replantation. When 
a  significant  muscle  burden  exists in  the  amputated part, the  degree  of 
urgency in achieving  perfusion  is  significantly  more  acute  than  with  a 
digital  replantation. In  this  case,  most  surgeons  would  advocate  moving 
toward arterial  repair  as  quickly  as  possible.  In  our  center,  if  we  feel 
that the  part  was  managed  with  appropriate  cooling  and  has  been 
brought  to  the  operating  room  with  a  very  short  ischemia  time, we 
will  perform  osseous  fixation  first  in  an  efficient  and  rapid manner and 
then move toward arterial reconstruction. However, if  either  ischemia  time 
or  temperature  has  been  compromised and  we  feel  that  there  is 
extreme  urgency  in  achieving  revascularization,  we  will  elect  to  use  an 
artificial  arterial  shunt.  Shunts rapidly  achieve  distal  perfusion  by  cannulating 
both  the  proximal  and  distal  ends  of  the  vessel(s)  requiring  repair 
(Figure 42.6).  In  this  setting,  a  catheter  is  placed  both  proximally  and 
distally  and  is  secured, usually  with  insufflation  of  balloon  cuffs. This  can 
be  further  secured  with  an  exterior  suture  ligation  of the  vessel  on 
top  of  the  shunt  to  achieve  a  watertight  seal.  After arterial  inflow  is 
established,  the  extent  of  venous  bleeding  is assessed.  A  second  shunt 
may  be  used  in  the  venous  system  so as  to  minimize  the  amount 
of  blood  loss.  If  the  muscle  burden of  the  amputated  part  is 
significant,  the  anesthesiologist  must be  prepared  to  address  this  with 
appropriate  hydration  and f luid  cardiovascular  monitoring. We  attempt  to 
reperfuse  for  20  minutes  for  every  hour  of ischemia  sustained  prior  to 
reperfusion.  When  this  is  achieved, one  can  consider  removal  of  the 
shunts,  exsanguination,  and tourniquet  application  so  as  to  move  forward 
with  the  rest  of the  replantation  procedure  under  tourniquet  control. 
Within this  time  frame,  the  team  may  rapidly  achieve  osseous  fixation 
(typically,  plating  of  the  radius,  ulna,  or  humerus  or  external f ixation  if 
there  is  a  significantly  complex  intraarticular  amputation  through  the 
elbow).  The  surgeon  may  proceed  with repair  of  additional  structures 
such  as  tendons  and  nerves  with the  shunts  in  place  as  reperfusion 
time  requires. Flexor Tendon Repairs 1481 Flexor  tendons  are  repaired  using  the 
preaffixed  locking  sutures. This  configuration  will  leave  two  3-0  caliber 
suture  ends  protruding  through  the  tenorrhaphy  site  distally  and  an 
additional two  suture  ends  protruding  through  the  tenorrhaphy  site 
proximally.  This  will  result  in  two  knots  within  the  repair  site.  If  the 
sutures  have  been tied  with this  configuration, a  two-core  suture tendon 
repair  would  be  achieved.  Alternatively,  a  four-core repair  can  be 
achieved  by  passing  the  needle  from  each  of  the protruding  sutures 
through  the  opposite  tendon  with  a  locking suture  technique,  returning  to 
the  tenorrhaphy  site,  and  completing  the  suture  knots.  This  results  in  a 
four-core,  two-knot tendon  repair  that  can  be  augmented  with  an 
epitendinous suture  if  desired  by  the  surgeon.

Osseous Fixation

At  the  level  of  the  digit,  osseous  fixation  has  often  been  performed 
with  nonparallel  longitudinal  Kirschner  wires  driven retrograde  after  they 
had  previously  been  placed  in  the  prepared amputated  digit.  They  can 
be  driven  across  an  osteosynthesis site  in  a  phalanx  or  across  a 
planned  arthrodesis  site.  Although there  is  a  sense  of  the  need  for 
speed  and  urgency  in  these  cases, one  should  always  take  great  care 
to  assess  for  malrotation  or angulation.  A  successful  replantation  can  be 
made  a  functional failure  with  poor  osseous  alignment. Other  techniques 
that  have  been  advocated  include  interosseous  wiring,  screw  fixation,  and 
plate  fixation.  Although  these techniques  provide  a  more  stable  construct 
than  longitudinal Kirschner  wires,  they  also  require  more  operative  time 
and, more  importantly,  more  significant  osseous  exposure. Attempts should 
be  made  to  minimize  soft  tissue  stripping  of  the  area surrounding  the 
osteosynthesis  site.  A  useful  technique  that provides  stability  with  minimal 
stripping  is  interosseous  wire f ixation.  This  is  particularly  useful  when 
replantation  is  performed  very  close  to  the  proximal  interphalangeal  joint 
line. Interosseous  wire  technique,  although  somewhat  more  timeconsuming 
than Kirschner  wire  fixation, can  enable  the  surgeon to  avoid  hardware 
crossing  the  proximal  interphalangeal  joint. When  performing  thumb 
replantation,  the  longitudinal Kirschner  wire  technique  may  also  provide 
additional  benefits. These  amputations  commonly  occur  in  the  region  of 
the metacarpophalangeal  joint  where  the  ulnar  digital  vessels  are difficult 
to  visualize  with  the  microscope  regardless  of  hand positioning.  In  this 
setting,  initial  fixation  is  achieved  by  driving one  of  the  two  prepared 
Kirschner  wires  across  the  osteosynthesis  site  and  leaving  the  second 
wire  in  position  at  the  margin of  the  osteosynthesis  site.  This  permits 
the  surgeon  to  temporarily  hyperpronate  the  distal  thumb.  The  surgeon 
may  elect  to access  the  distal  ulnar  digital  artery  for  primary 
anastomosis  or vein  graft  distal  anastomosis  in  this  position. When  this 
is  complete,  the  thumb  may  be  rotated  into  anatomic  position  on  the 
single  wire.  When  rotation  is  deemed  accurate,  the  perched second  wire 
may  be  cautiously  driven  across  the  osteosynthesis site,  completing  the 
fixation  and  controlling  rotation.

Extensor Tendon Repairs

Extensor  tendon  repairs  are  rapidly  performed  with  figure-ofeight  3-0 

braided  permanent  sutures.  This  is  usually  performed in  an  attempt  to 
coapt  the  tendons  tightly  so  as  to  diminish  the degree  of  extensor  lag 
experienced  postoperatively.

Flexor Tendon Repairs

1481 Flexor  tendons  are  repaired  using  the  preaffixed  locking  sutures. This 
configuration  will  leave  two  3-0  caliber  suture  ends  protruding  through 
the  tenorrhaphy  site  distally  and  an  additional two  suture  ends  protruding 
through  the  tenorrhaphy  site  proximally.  This  will  result  in  two  knots 
within  the  repair  site.  If  the sutures  have  been tied  with this 
configuration, a  two-core  suture tendon  repair  would  be  achieved. 
Alternatively,  a  four-core repair  can  be  achieved  by  passing  the  needle 
from  each  of  the protruding  sutures  through  the  opposite  tendon  with 
a  locking suture  technique,  returning  to  the  tenorrhaphy  site,  and 
completing  the  suture  knots.  This  results  in  a  four-core,  two-knot tendon 
repair  that  can  be  augmented  with  an  epitendinous suture  if  desired  by 
the  surgeon.Management  of  the  flexor  digitorum  superficialis  tendon  in 
zone  2  replantations  is  optional.  We  typically  perform  digit replantations 
using  FDP  tendon  repairs  only.

Digital Nerve Repairs

Under  microscope  control,  the  digital  nerves  are  assessed.  We prefer  to 
perform  this  with  the  benefit  of  tourniquet  control. The  nerves  are 
resected  back  to  healthy  fascicles  and  primarily coapted  if  possible. 
Primary  coaptation  of  the  nerves  is  an important  benefit  of  osseous 
shortening. The  functional  success of  a  successfully  replanted  part  will 
often  be  determined  by  the level  of  sensation  that  is  regained.  For 
this  reason,  this  step should  be  performed  carefully  and  all  attempts 
should  be  made to  achieve  primary  nerve  repair. Great  emphasis  should 
be  given  to  primary  nerve  coaptation in  the  setting  of  major 
replantation.  At  the  transhumeral, transelbow,  or  transforearm  level,  bony 
shortening  should  be pursued  if  possible  to  focus  on  primary  nerve 
coaptation because  this  will  play  an  even  more  critical  role  in  the 
ultimate functional  success  or  failure  of  the  replantation.

Digital Vein Repairs

Venous  repair  is  often  the  most  technically  challenging  and critical  aspect 
of  digital  replantation.  As  many  venous  anastomoses as possible should be 
performed in a tension-free manner without  the  need  for  interpositional 
vein  grafts.  In  zone  1 replantations,  this  is  particularly  challenging.  Finding 
dorsal veins  of  reasonable  quality  may  be  impossible,  and  one  should 
consider  assessment  of  the  volar  pulp  for  superficial  volar  veins as  well 
as  use  of  the  second  digital  artery  for  venous  outflow  if no  distal 
veins  can  be  located.

Arterial Repairs

Even  with  adequate  microscopic  investigation  of  the  proximal artery,  it 

can  be  difficult  to  determine  the  adequacy  of  ultimate inflow  from  an 
artery  without  releasing  the  tourniquet  and checking  a  spurt  test.  If  the 
spurt  test  is  inadequate,  the  artery can  be  resected  proximally  to  a 
less  damaged  vessel.  Prior  to excessive  resection,  however,  the  surgeon 
should  always  consider  topical  vasodilators,  including  warm  saline, 
papaverine, and  lidocaine,  to  relieve  vasospasm  and  provide  an  adequate 
assessment  of  the  inflow  capability  of  the  proposed  artery. Primary  arterial 
coaptation  can  be  performed  in  an  anatomic  fashion  from  the  proximal-to-
distal  artery  as  existed prior  to  injury,  or  it  can  be  performed  in  a 
“crossover”  fashion (i.e.,  the  ulnar  digital  artery  to  the  digit  may  be 
anastomosed  to the  radial  digital  artery  distally).  This  technique  may  be 
problematic,  however,  if  the  patient  requires  further  surgery  (i.e., tenolysis) 
in  the  future  which  could  interrupt  the  vascular supply  to  the  finger. 
Interpositional  grafting  of  the  artery  reconstruction  permits  the  surgeon  to 
resect  out  of  the  zone  of  injury and  perform  a  tension-free  repair. 
The  caliber  of  the  veins  on the  volar  aspect  of  the  distal  forearm  is 
a  good  match  for  the caliber  of  the  digital  arteries.  The  dorsal  hand 
veins  and  dorsal forearm  veins  are  usually  quite  large  for  this  task,  as 
are  the greater  saphenous  or  lesser  saphenous  veins. When performing  an 
interpositional  arterial  or  venous  graft for  the  artery,  it  is  technically 
easier  to  perform  the  distal  anastomosis  first.  This  is  a  smaller-caliber 
anastomosis  and  may have  less  dissectible  length  of  distal  artery  and 
thus  less  mobility for  the  distal  anastomosis.  If  performed  first,  the 
distal  anastomosis  may  be  more  freely  rotated  to  access  the  front  and 
back vessel  walls,  and  the  vein  graft  may  also  be  flipped  distally  after 
completing  the  front  wall  suturing  to  access  the  back  vessel  wall. Once 
the  distal  anastomosis  has  been  performed,  the  vein  graft can  be 
repositioned  into  its  anatomic  location  and  the  proximal anastomosis 
performed  with  relative  ease.

Reperfusion

Prior  to  releasing  the  clamps,  we  will  typically  apply  topical vasodilators, 
including  warm  saline,  lidocaine,  and  papaverine, to  the  arteries  and 
veins.  The  clamps  are  released  on  the  artery f irst.  If  a  vein  graft  is 
used,  the  distal  clamps  are  removed  first and  the  proximal  clamps 
second.  This  allows  rapid  passage  of the  blood  through  the  anastomoses 
and  into  the  digit.  Great vigilance  should  be  used  here  in  preserving  a 
warm  and  nondesiccated  environment  for  the  recovering  vessel  because  it 
will tend  to  go  into  vasospasm  if  traumatized. We usually  await  substantial 
engorgement  of  the  distal  veins prior  to  releasing  the  clamps  on  the 
venous  anastomoses. Venous  thrombosis  is  in  part  instigated  by  stasis  of 
blood underneath  an  area  of  intimal  damage.  In  this  regard,  any 
passage  of  blood  underneath  the  newly  performed  anastomoses would  best 
be  permitted  when  there  is  rapid  flow  of  venous return.  With  all 
clamps  released,  the  digit  is  continually warmed  and  kept  moist.  The 
digital  tip  is  assessed  for  a  Doppler  signal  as  well  as  color  and 
turgor.  It  is  not  uncommon  for the  digit  not  to  demonstrate  a 
Doppler  signal  in  the  operating room,  but  it  will  often  develop  an 
audible  signal  while  the patient  is  recovering  on  the  evening  following 
surgery  or  the following  day.

Skin Closure

It  is  of  utmost  importance  that  the  skin  closure  be  performed loosely. 
The  dorsal  and  volar  skin  can  be  loosely  approximated. With  skeletal 
shortening,  this  can  usually  be  performed  without any  difficulty.  However, 
we  typically  leave  the  midaxial  incisions wide  open,  even  in  the  setting 
of  exposure  of  the  neurovascular structures.  This  technique  will  result  in 
surprisingly  successful delayed  healing  with  minimal  scarring.  The  tension 
provided by  skin  closure  will  place  undue  pressure  on  arterial  and 
venous repairs  in  the  postoperative  period, particularly  with  postoperative 
swelling.

POSTOPERATIVE PROTOCOL

There  are  many  postoperative  protocols  used  by  replantation surgeons.  The 

frequency  and  vigilance  of  postoperative  monitoring  should  depend  on  the 
surgeon’s  threshold  for  surgical reexploration  or  alterations  in  postoperative 
medical  management.  The  surgeon,  patient,  and  patient’s  family  should 
have  an extensive  discussion  postoperatively  regarding  the  intraoperative 
findings,  potential  postoperative  outcomes,  and  future plans.  If  the  surgeon 
feels  that  if  a  thrombosis  develops  revision surgery  would  probably  not 
be successful  (because  of  the  condition  of  the  amputated  part),  the 
surgeon  may  elect  to  minimize postoperative  monitoring  and  discuss  the 
plan  for  postoperative  success  or  failure  quite  clearly  with  the  family 
and  the patient.  If  a  thrombosis  were  to  develop  and  surgical 
reexploration  would  not  be  warranted,  hourly  vascular  assessment would 
likely  not  be  indicated.  On  the  other  hand,  if  the  situation  warrants 
exploration  regardless  of  the  difficulty  of  the initial  operation  (as  with 
pediatric  replantation,  major  replantation,  or  multiple-digit  replantation),  the 
surgeon  may  request frequent  monitoring  postoperatively  so  that  if  a 
thrombosis  is detected,  emergent  reexploration  can  be  performed  rapidly 
and efficiently. Postoperative  adjuvant  treatment  varies  in  different  centers. 
Use of  topical  heat  (i.e., warming  blanket, heat  lamp, and  heated room), 
as  well  as  daily  aspirin  therapy, is  nearly  universal.  Other antithrombotic 
medications  such  as  dextran,  heparin,  or  warfarin  have  not  had 
significant  efficacy,  and  their  use  is  quite variable  among  replantation 
surgeons.2,10,24,32 Management  of  a  failing  replantation  depends  on  the 
appearance  and  acuity  of  the  changes  seen  during  postoperative 
monitoring.  If  the  changes  in  appearance,  Doppler  signal,  or temperature 
are  subtle  and  vasospasm  is  suspected,  surgeons may  try  to  control 
these  influences  nonsurgically.  Indwelling analgesic  catheters,  release  of 
constructive  dressings,  environmental warming, and pain control can provide 
limited improvement  if  vessel  thrombosis  has  not  occurred. Arterial  ischemia 
due  to  microvascular  thrombosis  requires emergent  reexploration  and  revision 
anastomosis  if  salvage  is to  be  pursued.  Resection  of  the  thrombosed 
segment  and  vein grafting  of  the  artery  are  usually  required  in  this 
setting. Venous  congestion  of  a  replanted  digit  may  be  discovered while 
arterial  inflow  is  still  present.  The  surgeon  may  elect  to use  heparin-
soaked  pledgets  or  leeches  applied  to  the  nailbed to  diminish  the 
venous  pressure  and  maintain  arterial  patency. The  patient  and  replantation 
team  should  anticipate  using leeches  for  several  days  until  the  digit 
establishes  new  venous drainage  channels.  This  will  require  antibiotic  therapy 
to  cover Aeromonas hydrophila,  a  gram-negative  bacteria  that  is  normal 
intestinal  flora  in  leeches.  Blood  transfusions  are  often  needed after 
lengthy  periods  of  treatment  with  leeches.

EXPECTED OUTCOMES

Reported  survival  rates  of  replanted  digits  have  varied  widely from  57 
to  90%.4,15,30,34,43,44  Factors  with  a  negative  impact  on survival  rates 
include  mechanism  of  amputation  (crush  injuries faring  poorly  compared 
with  sharp  amputations),  patient  age, and  smoking  history.  Surgical 
performance  of  more  than  one arterial  anastomosis  and  more  than  one 
venous  anastomosis also  increases  survival  rates.27,43,44 Functional  outcomes 
are  most  affected  by  the  mechanism  of injury  (crush  injuries  faring  least 
well),  level  of  injury,  and ischemia  time.  Replantations  within  zone  2  of 
the  flexor  tendon sheath  have  been  shown  to  achieve  dramatically  less 
range  of motion  than  those  performed  distal  to  the  flexor  digitorum 
superficialis  insertion.36,41  In  a  study  of  more  than  400  digital 
replantations,  sensory  recovery  of  8  mm  was  reported  with replanted 
sharp  amputations  and  two-point  discrimination  of 15  mm  was  reported 
with  replanted  crush  avulsion  injuries.16 Overall,  useful  two-point 
discrimination  was  achieved  in  61% of  thumb  replantations  and  54%  of 
digital  replantations. 1483 distinct  as  the  medical  considerations.  Because  an 
amputated limb  can  be  replaced  with  a  nontraumatized  part  without 
compromised  or  absent  skin/bone/nerve/vessel  segments,  some  of the 
difficult  aspects  of  replantation  surgery  that  limit  functional outcomes  can 
be  eliminated. Many issues  have been pivotal  in  the  growth of VCA for 
hand surgery.13  The  first  was  the  successful  control  of  the  immunogenic 
response  to  allotransplantation  of  skin;  earlier-generation transplantation 
immunotherapy  protocols  had  indicated  that this  was  not  achievable.  The 
second  has  been  unexpectedly favorable  results  of  sensory  and  motor 
nerve  recovery  in transplantation.  It  has  been  confirmed  experimentally  that 
a commonly  employed  immunosuppressive  medication,  FK-506 (tacrolimus), 
accelerates  nerve  regeneration.26,40  This  may  have contributed  to 
encouraging  reports  of  motor  and  sensory recovery  of  transplanted  limbs.
Functional  outcomes  as  measured  by  the  Disabilities  of  the Arm,  Shoulder, 
and  Hand  (DASH)  scores  have  been  surprisingly  good,  with  one  study 
reporting  average  scores  of  10  for thumb  replantation,  11.2  for  single-
finger  replantation,  and 16.1  for  multiple  amputations  where  at  least  one 
digit  was replanted.11  DASH  scores  have  also  been  better  among 
replantation  patients  than  amputation  patients.19 Several  studies  have 
attempted  to  provide  objective  means  of estimating  outcomes  and 
approaching  the  initial  decision  to pursue  limb  replantation  proximal  to 
the  wrist.  One  large  study demonstrated  the  functional  superiority  of 
replanted  limbs over  prosthetics.18  Objective  sensibility  testing,  however,  was 
excluded  as  a  measured  outcome.  Studies  have  demonstrated that  younger 
age  and  replantation  at  more  distal  levels  yielded significantly  improved 
functional  scores.  The  mechanism  of injury  and  ischemic  time  have  also 
been  shown  to  be  strongly predictive  of  functional  outcome.8,44

FUTURE DIRECTIONS: VASCULARIZED COMPOSITE TISSUE ALLOTRANSPLANTATION

Since  its  origins  in  the  1960s,  replantation  surgery  has  been focused  on 
improvement  in  microsurgical  technique,  postoperative  vascular  monitoring 
technologies,  thrombosis  prevention  and  management,  and  nerve 
repair/reconstruction  and recovery.  These  improvements  have  been  associated 
with  small gains  for  a  procedure  still  greatly  limited  in  its  reliability 
and functional  results. Our  specialty,  which  has  had  astounding  growth,  is 
the promising  new  field  of  vascularized  composite  tissue  allotransplantation 
(VCA).20,23,31  Since  the  first  modern-day  hand  transplantation  in  1998, 
numerous  transplantation  teams  have  been assembled,  with  over  100  upper 
extremity  transplantations  performed  in  over  70  patients  worldwide. Although 
the  field  seems similar  to  that  of  replantation  surgery,  the  techniques 
are  as distinct  as  the  medical  considerations.  Because  an  amputated limb 
can  be  replaced  with  a  nontraumatized  part  without  compromised  or 
absent  skin/bone/nerve/vessel  segments,  some  of the  difficult  aspects  of 
replantation  surgery  that  limit  functional outcomes  can  be  eliminated. Many 
issues  have been pivotal  in  the  growth of VCA for hand surgery.13  The 
first  was  the  successful  control  of  the  immunogenic  response  to 
allotransplantation  of  skin;  earlier-generation transplantation  immunotherapy 
protocols  had  indicated  that this  was  not  achievable.  The  second  has 
been  unexpectedly favorable  results  of  sensory  and  motor  nerve  recovery 
in transplantation.  It  has  been  confirmed  experimentally  that  a commonly 
employed  immunosuppressive  medication,  FK-506 (tacrolimus),  accelerates  nerve 
regeneration.26,40  This  may  have contributed  to  encouraging  reports  of 
motor  and  sensory recovery  of  transplanted  limbs. Many  centers  for  upper 
limb  transplantation  have  been established  worldwide.  Efforts  have  been 
made  to  provide improved  communication  and  exchange  of  experience  and 
data among  these  centers.  Scientific  societies  have  been  established for 
the  advancement  of  the  field.  Despite  these  collaborations, the  functional 
outcomes  and  risks  of  these  endeavors  remain poorly  defined.  Centers 
around  the  globe  are  not  uniform  in their  methods  of  measuring 
success  or  their  transparency  in reporting.  Furthermore,  the  field  is  so 
new  that  only  speculative predictions  can  be  made  about  long-term 
outcomes  and  lifetime  risks. In  a  recent  comprehensive  review  of  the 
worldwide  upper extremity  transplantation  experience  to  date,  Shores  and 
colleagues  provided  an  assessment  of  mortality  rates, limb  survival rates, 
and  functional  outcomes.39  The  overall  limb  survival  rate is  77.6%.  In 
close  assessment  of  all  of  the  databases,  however,  it appears  that  rates 
of  limb  loss  and/or  mortality  are  especially high  in  Chinese  transplantation 
centers  (7  losses  of  15  transplanted  limbs).  The  authors  speculate  that 
this  is  due  to  lack  of patient  access  to  immunosuppressive  medications 
or  to  noncompliance.  They  also  note  that  multisite  transplantations  (e.g., 
of  the  hand  and  face  or  the  hand  and  lower  limb)  accounted for 
eight  of  the  limb  losses  and  three  of  the  four  reported  surgical 
deaths  worldwide  in  cases  involving  upper  extremity  VCA. These  two 
subgroups  accounted  for  62.5%  of  the  upper  limb transplant  losses. 
Excluding  these  two  subgroups,  the  authors state  that  in  cases  of 
isolated  upper  limb  transplantations  (i.e., bilateral  and  unilateral  cases 
without  concomitant  face  or  lower limb  transplantations)  in  western  Europe, 
Australia,  and  the United  States,  there  have  been  no  deaths  and  the 
limb  survival rate  has  been  90.5%  so  far  (7  limbs  acutely  or 
chronically  lost or  amputated  of  74  transplanted  limbs). Assessment  of 
global  functional  outcomes  is  limited  by the  multitude  of  grading  systems 
employed  by  the  different centers  and  the  lack  of  applicability  of  these 
measures  to  hand transplantation.  In  attempting  to  correlate  these  outcome 
reports,  Shores  and  associates39  found  that  patients  who  had undergone 
distal  forearm  level  transplantation  had  the  best overall  results,  with 
measurable  sensory  discrimination,  some intrinsic  motor  recovery,  and  the 
most  rapid  recovery  times. Patients  who  had  undergone  midforearm  and 
proximal  forearm  level  transplantation  had  little  or  no  intrinsic  recovery, 
had  protective  and  sometimes  discriminative  sensation,  and had  weaker 
overall  grip  strength.  Finally,  the  smaller  cohort  of transhumeral 
transplanted  limb  patients  has  had  less  return  of extrinsic  function  than 
the  cohort  that  underwent  forearm level  transplantation,  and  they  cannot 
expect  intrinsic  recovery. Thus,  functional  results  have  diminished  at  more 
proximal levels,  as  would  be  expected.  Interpretation  of  the  value  of 
these endeavors  is  subject  to  debate.  Those  in  favor  of  the  more 
proximal  transplantations  view  the  outcomes  as  favorable  when compared 
with  prosthetic  function,  use,  and  durability  and view  the  functional 
results  as  markedly  improved  over  the patient’s  presurgical  state.  Critics 
of  proximal  transplantation question  the  risk  and  benefit  balance  in  light 
of  the  speculated long-term  risks  of  immunosuppression. The  evolution  of 
immunosuppressive  medication  regimens is  directed  toward  the  goal  of 
minimizing  morbidity.  Experimental  efforts  are  focused  on  achievement  of 
immunotolerance with  less  medication  or  no  lifelong  medication.12,35,37  If 
the  side effect  risk  profile  of  the  immunosuppressive  medications  is 
minimized,  a  more  widespread  acceptance  and  incorporation of  this 
modality  will  be  likely. The  success  of  these  strategies  will dictate  the 
pace  and  success  of  this  field  in  years  to  come.