Best Indications in Replantation Surgery in the Upper Extremity

The authors described their management and strategies in upper extremity replantation. This was a 35-year experience. Seven hundred patients have been operated on, their ages ranging from 2.5 years to 72 years.

Arm amputations are replanted when clean-cut or moderate crush injuries are involved, but successful replantations can be achieved after extensive multi-tissue debridment, thanks to the new possibility offered by Ilizarov secondary lengthening. Forearm amputations are also good indications, especially in the lower third. Transcarpal amputations lead to destruction of thenar muscle or the lower branch of the median nerve, as well as irreversible damage to the trapezometacarpal joint. Significant stiffness of the thumb can be expected, but good functional results are possible, provided that other fingers have recovered reasonable range of motion.

Transmetacarpal amputations deal with irreversible damage to the intrinsic muscles and the motor branch of the ulnar nerve. Joint stiffness and tendon adhesions are very common and preclude return of excellent function, but useful results can be achieved.

Multiple finger amputations constitute such an important functional loss that any effort to replant most of the fingers should be attempted, giving more attention to the radial side of the hand. Thumb replantation is one of the best indications, since some thumb stiffness or numbness does not preclude satisfactory use. Except in children, females, artists, and another few cases, there is no indication of replantation of a single finger proximal to the insertion of the superficial sublimis flexor tendon. Distal replantations, despite the technical difficulties, are worth attempting from both a functional and cosmetic point of view. If venous embarrasment occurs, the use of leeches provides a greater chance of success. Extensive use of vein grafts to bridge arterial or venous defects has significantly increased the rate of success in the replantation of severe crush injuries. Thrombosis is still a main concern, but early diagnosis can lead to successful reoperation.

In complex injuries, it is sometimes necessary to solve other problems as well. Localized skin defects and their coverage, bone grafts, nerve grafts, tendon grafts and even joint replacement have to be considered. Secondary procedures should be reserved for a few selected cases.

These guidelines are still being updated and have provided good results for the authors and their patients. The results were assessed by range of motion, return of sensation, and other academic criteria, but return to work and satisfactory daily use are the most reliable data.