Replantation Outcomes

doi:10.1016/j.cps.2006.11.003

Clinics in Plastic Surgery

Volume 34, Issue 2, April 2007, Pages 177-185

https://doi.org/10.1016/j.cps.2006.11.003 Get rights and content

Replantation aims to restore the amputated part to its anatomical site, preserving function and appearance. Outcome depends on factors intrinsic to the patient and to the nature of the injury. Young patients who have distal, cleanly amputated extremities have the best return of function; multiple levels of injury, crush, or avulsing injuries have less. Patients must be fully informed about the commitment to rehabilitation and the possibility of multiple surgeries needed for best results. Similarly, patient and surgeon expectations should be evaluated and addressed before replantation. Meticulous microsurgical technique, comprehensive occupational therapy, and perseverance are needed for success. Addressing these issues promotes a team rehabilitation to restore function while getting the amputation patient back to productive position in society.

Section snippets

Clinical outcomes

The hand is notorious for being the most commonly injured body part. It follows, then, that the fingers and thumbs are the most commonly amputated parts presenting for replantation. The final functional outcome is determined not only by the injury itself, but also the patient's age, underlying health, overall expectations, compliance with rehabilitation, and psychosocial disposition. The nature of the injury introduces variables that have an enormous influence on the functional outcomes of an

Upper extremity

The functional outcome of body part replantation can be evaluated as the isolated part, or as relative to the function of the remaining parts, or to amputation and prosthesis fitting. In the upper extremity, the premise that salvage of a sensate limb is preferable to prosthesis guides many hand surgeons to their decision to perform the replantation. The thumb is said to account for 40% to 50% of the function of the hand, and therefore mandates an aggressive approach to replantation [16]. Even a

Lower extremity

The indication for lower limb replantation is still controversial. Salvage of function through the primary or secondary reconstruction of amputations of the hand and upper extremity differentiates these from those of the lower extremity. Attempts at salvage and replantation of an amputated or mangled foot may be better served by amputation and functional lower leg prosthesis. This does not mean that lower limb replantation cannot be successful. An ideal candidate would be a young, healthy

Summary

The goal of replantation is to restore the amputated part to its native anatomical site, preserving function and appearance. The functional outcome depends on many factors, including those intrinsic to the patient and those intrinsic to the nature of the injury. Young patients who have distal, cleanly amputated extremities have the best return of function. Multiple levels of injury, crush, or avulsing injuries have less return of function. Patients must be fully informed about the commitment to

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Cited by (34)

Secondary Surgery Following Replantation and Revascularization
2019, Hand Clinics
Citation Excerpt :
Through improved microsurgical techniques, successful digital replantation and revascularization has improved over time, with greater than 80% digital survival in many series.1,2
Functional assessment and quality of life in patients following replantation of the distal half of the forearm (except fingers): A review of 11 cases
2017, Hand Surgery and Rehabilitation
Citation Excerpt :
Chen performed the first hand replantation in 1963 [23]. The outcome of replantation depends on several factors [13,24–37]: the injury itself [25–27], i.e. mechanism (with avulsion being the most damaging), amputation level (single or multiple), association of other injuries in the amputated segment and the proximal segment [28];
The aims of this study were to evaluate the function and quality of life in patients who have undergone replantation of the hand or forearm. We carried out a retrospective single-center study of cases performed between 1977 and 2015. Our hospital's database was searched for patients who underwent replantation of the distal half of the forearm and hand (except the fingers). The evaluation included sensitivity, joint mobility, strength and quality of life. Conventional functional scores were used. Seventeen replantation cases were identified. Four patients were lost to follow-up. Of the 13 available patients, two suffered a replantation failure. Ultimately 11 patients were included in the study. Three patients were evaluated based on their medical records and eight were reviewed in person. The mean patient age was 31 ± 11.8 years. The sensory evaluation resulted in five patients being classified as S1 and one as S3+. The mean Kapandji score was 4.3 ± 2.3 [0–6]. The mean grip strength was 39.4 ± 20% [0–80], and the pinch strength was 36.2 ± 16% [0–60] compared to the healthy contralateral side. The mean DASH was 36.2 ± 30.4 [4.5–79.5]. According to Chen's classification, two patients were at stage IV. For 50% of patients, the overall quality of life was at least equivalent to that of the general population. Replantation of the distal half of the forearm and hand should be attempted whenever possible. Although replantation causes some disability, good quality of life seems to be maintained.
Notre étude avait pour objectif l’évaluation fonctionnelle et de la qualité de vie des patients ayant bénéficié d’une replantation de la main. Nous avons réalisé une étude rétrospective monocentrique sur la base de données collectées entre 1977 et 2015. Les replantations de la moitié distale de l’avant-bras et de la main à l’exception des doigts ont été cherchées. L’évaluation portait sur la sensibilité, la mobilité articulaire, la force et la qualité de vie. Les scores fonctionnels classiques ont été utilisés. Dix-sept replantations ont été réalisées. Quatre dossiers ont été perdus. Parmi les 13 dossiers retrouvés, on dénombrait deux échecs de replantation. Finalement, 11 patients ont été inclus. Trois patients ont été évalués sur dossier et huit ont été revus en consultation. L’âge moyen était de 31 ± 11,8 ans [16–58]. L’évaluation sensitive a trouvé cinq patients classé S1 et un classé S3+. Le score de Kapandji moyen était de 4,3 ± 2,3 [0–6]. Le score moyen de la force de poigne était de 39,4 ± 20 % [0–80], et de 36,2 ± 16 % [0–60] de la force de pince par rapport au côté sain controlatéral. Le score DASH moyen était de 36,2 ± 30,4 [4,5–79,5]. Selon la classification de Chen deux patients était stade IV. Pour 50 % des patients la qualité de vie globale était au moins équivalente à celle de la population générale. La replantation de la moitie distale de l’avant-bras et de la main doit être tentée chaque fois qu’elle est possible. La replantation engendre une invalidité, cependant une bonne qualité de vie semble être conservée.
The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success
2016, Hand Clinics
Citation Excerpt :
With a multidigit amputation scenario, resection of the second ray will address the contracted web and the index may even be appropriate for thumb reconstruction or contribute to soft tissue coverage for a thumb reconstruction. Partial or complete digit amputation are commonly cited as having poor functional outcomes after replantation or revascularization, especially in the case of complete amputation or when there is damage to the interphalangeal joints or MCP joints.86,87 Concern regarding poor function with joint involvement leads many investigators to recommend revision amputation, as the severity of the trauma precludes any anatomic restoration of the joint surface.88
Major upper limb trauma: Patients' outcomes. about 22cases
2013, Chirurgie de la Main
Lors d’une macro-amputation, faut-il tout faire pour conserver un membre supérieur parfois peu fonctionnel ? Cette étude avait pour but d’évaluer et de comparer à long terme sur le plan fonctionnel, psychologique et social, des patients ayant été victime d’une macro-amputation du membre supérieur, qu’ils aient été replantés ou amputés. Il s’agissait d’une étude rétrospective monocentrique incluant 22 patients, victimes d’une macro-amputation du membre supérieur. Les caractéristiques du patient, du traumatisme et de la prise en charge initiale ont été analysées. Au recul, 16 patients ont pu être revus avec évaluation des résultats fonctionnels (Score DASH, score de Chen), de l’autonomie (activités de la vie quotidienne, travail, conduite, loisirs), du retentissement psychologique et de la qualité de vie (NHP, EVA, score de Russel). Vingt-deux patients ont été pris en charge. Onze replantations ont été réalisées avec six régularisations secondaires. Au recul moyen de 12 ans et cinq mois, 16 patients ont été revus, dont cinq replantés et 11 amputés. Tous les patients étaient autonomes. Le score DASH moyen et le NHP étaient moins bons chez les patients replantés, sans différence significative. Le délai de retour au travail et à la conduite n’était pas significativement supérieur chez ces patients. Le score de Russel révélait cependant que les patients replantés étaient satisfaits d’avoir conservé leur membre et recommanderaient cette prise en charge. Même si les résultats fonctionnels des macro-replantations du membre supérieur sont parfois décevants, la satisfaction pour ces patients d’avoir conservé leur membre et leur intégrité corporelle semble justifier de tenter, lorsqu’elles sont techniquement possibles, ces replantations.
In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.
Temporary catheter first perfusion during hand replantation with prolonged warm ischaemia
2012, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
The incidence of upper limb amputation in industrialised countries is estimated at 1-10 cases per 100,000 inhabitants,1 the first successful upper limb replantation was reported by Malt and McKhann.2 Many technical refinements have subsequently been described, and reported viability rates for macroreplantation have risen from 80% to 95%.1,3,4 Amputation level distal or proximal to the wrist distinguishes macro- from microreplantation,5 the key difference being the need to protect muscle from ischaemic necrosis, and the difficulty of effectively cooling large amputated parts during transfer.
Since the first successful arm replantation reported by Malt and McKhann in 1962, developments and refinements to upper extremity replantation techniques have led to higher success rates with better functional outcomes. One of the most important determinants of a successful macroreplantation is the ischaemic time of the amputated part, as irreversible muscle necrosis begins after 6 hours of warm ischaemia. With major trauma and plastic surgery units usually covering a wide geographical area, it is often difficult to ensure patient injury to revascularization time is less than 6 hours. In 1981, Nunley et al described the temporary catheter perfusion technique in upper limb replantation surgery to reduce ischaemia time without any significant complications. When used in appropriate cases this technique can reduce complication rates in upper limb replantation surgeries.
Temporary catheter first perfusion was used in a hand replantation after 6 hours of warm ischaemia, with preservation of the intrinsic muscles, as evidenced by return of function. The technique used is described, along with relevant literature.
Temporary catheter perfusion allowed early reperfusion of the amputated hand, improving the chance of intrinsic muscle preservation despite delayed presentation. It allowed better wound evaluation and debridement, and facilitated better bone stabilisation prior to vascular repair.
Temporary catheter perfusion is well described in proximal upper limb replantation procedures. This case shows that it is also a useful adjunct for hand replantation, particularly when the patient presents with a critical duration of warm ischaemia.
Patient satisfaction after lower limb replantation surgery for traumatic amputation - a qualitative study
2024, BMC Musculoskeletal Disorders

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Replantation Outcomes

Section snippets

Clinical outcomes

Upper extremity

Lower extremity

Summary

Lancet

Clin Plast Surg

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

Clin Plast Surg

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Am]

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

Upper extremity replantation

Curr Probl Surg

Problematic aspects of major limb replantation

Replantation of severed arms

JAMA

Salvage of the forearm following complete traumatic amputation: report of a successful case

Chin Med J

Significant factors in the reimplantation of an amputated hand

Bulletin de la Societe Internationale de Chirurgie

Replantation of amputated extremities

Annals of Surgery

Sixth People's Hospital, Shanghai. Reattachment of traumatic amputations. A summing up of experience

Chinese Med J

Successful replantation of a completely cut-off thumb: case report

Plast Reconstr Surg