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Updated: Jun 12 2021



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Images amputation_moved.jpg
  • Summary
    • Replantation is the reconstruction of an amputated portion of the upper extremity secondary to trauma.
    • Diagnosis of an amputated digit is contingent on absence of blood supply (cold, white digit, without soft tissue attachment).
    • Treatment involves prompt transportation of the amputated tissue and stepwise reconstruction prior to tissue ischemia and meticulous post-operative care.
  • Epidemiology
    • Incidence
      • 90% of upper extremity amputation occurred after trauma
    • Demographics
      • 4:1 male-to-female ratio
    • Anatomic location
      • most amputations occur at the level of the digits
  • Etiology
    • Pathophysiology
      • mechanism of traumatic amputation
        • sharp dissection
        • blunt dissection
        • avulsion
        • crush
  • Presentation
    • History
      • timing of injury
      • type and location of amputation
        • number of digits involved
      • preservation of amputated tissue
      • associated injury
      • past medical history
    • Examination
      • stump examined for
        • zone of injury
        • tissue viability
        • supporting tissue structures
        • contamination
      • amputated portion inspected
        • segmental injury
        • bone and soft tissue envelope
        • contamination
  • Indications
    • Indications for replantation after trauma
      • primary indications
        • multiple digits
        • through the palm
        • wrist level or proximal to wrist
        • almost all parts in children
      • relative indications
        • individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I)
        • ring avulsion
        • through or above elbow
    • Contraindications to replantation
      • primary contraindications
        • severe vascular disorder
        • mangled limb or crush injury
        • segmental amputation
        • prolonged ischemia time with large muscle content (>6 hours)
      • relative contraindications
        • single digit proximal to FDS insertion (Zone II)
          • ring finger injuires in zone II have better cosmesis and grip strenth with 4th ray resection and 5th ray transposition
        • medically unstable patient
        • disabling psychiatric illness
        • tissue contamination
        • prolonged ischemia time with no muscle content (>12 hours)
  • Treatment
    • Transport of amputated tissue
      • indications
        • any salvageable tissue should be transported with the patient to hospital
      • modality
        • keep amputated tissue wrapped in moist gauze in lactate ringers solution
        • place in sealed plastic bag and place in ice water (avoid direct ice or dry ice)
        • wrap, cover and compress stump with moistened gauze
    • Operative
      • time to replantation
        • proximal to carpus
          • warm ischemia time < 6 hours
          • cold ischemia time < 12 hours
        • distal to carpus (digit)
          • warm ischemia time < 12 hours
          • cold ischemia time < 24 hours
      • general operative sequence of replantation
        • vascular shunt first (for proximal replantation with large muscle mass to minimize warm ischemia time)
        • bone fixation +/- shortening (after irrigation and debridement of soft-tissue and bone)
        • extensor tendon repair
        • artery repair (repair second after bone if ischemic time is >3-4 hours)
        • venous anastomoses
        • flexor tendon repair
        • nerve repair
        • skin +/- fasciotomy
      • finger order
        • thumb, long, ring, small, index
      • for multiple amputations structure-by-structure sequence is most efficient
        • digit-by-digit sequence takes the most time
  • Postoperative Care
    • Environment
      • keep patient in warm room (80°F)
      • avoid caffeine, chocolate, and nicotine
    • Replant monitoring
      • skin temperature most reliable
        • concerning changes include a > 2° drop in skin temp in less than one hour or a temperature below 30° celsius
      • pulse oximetry
        • < 94% indicates potential vascular compromise
    • Anticoagulation
      • adequate hydration
      • medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)
    • Arterial Insufficiency
      • treat with
        • release constricting bandages
        • place extremity in dependent position
        • consider heparinization
        • consider stellate ganglion blockade
        • early surgical exploration if previous measures unsuccessful
      • thrombosis secondary to vasospasm is most common cause of early replant failure
    • Venous congestion
      • treatment
        • elevate extremity
        • leech application
          • releases Hirudin (powerful anticoagulant)
          • Aeromonos hydrophila infection can occur
            • prophylaxis with Ciprofloxacin or Bactrim
        • heparin soaked pledgets if leeches not available
  • Complications
    • Replantation failure
      • most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm
      • decreased palmar width with ray resection
    • Stiffness
      • replanted digits have 50% of total motion
      • tenolysis is most common secondary surgery
    • Myonecrosis
      • greater concern in major limb replantation than in digit replantation
    • Myoglobinuria
      • caused by muscle necrosis in larger replants (forearm and arm)
      • can lead to renal failure and be fatal
    • Reperfusion injury
      • mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
      • allopurinol is the best adjunctive therapy agent to decrease xanthine production
    • Infection
    • Cold intolerance
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