Indications for Replantation

The level and extent of injury are the most important determinants in the decision to proceed with replantation. In replantation, observation of functional results at different anatomical levels guides our indications. Good candidates for replantation include patients with amputating injuries of the thumb, multiple digits, hand, and wrist. When the amputation occurs through the forearm, at the elbow, or at the arm, only sharp or moderately avulsed injuries are considered favorable candidates. Patients having guillotine-type amputations are the best candidates for replantation because of the limited zone of injury, but this mechanism of injury is also the least common. Most amputations occur by crushing or avulsion, which increases the zone of damaged tissues, makes the surgical repair more difficult, and lowers viabil-ity.19-21 The extent of the zone of injury generally determines whether a part can be replanted.

In general, thumb replantation should be attempted when it is technically pos-sible.22-26 The function of a replanted thumb with return of at least protective sensation is superior to that of a prosthesis for tasks requiring fine dexterity. The functional results improve with more distal thumb replantations (Figs. 4.1 and 4.2).

Traumas involving amputation of multiple digits are good candidates for replantation (Fig. 4.3). It is often the case that surgeons can replant only the least damaged parts. Digits can be transferred from their natural position to a more functional position or to a more suitable stump.27 When possible, it is more appropriate to

Reconstructive Microsurgery, edited by Konstantinos Malizos. ©2003 Landes Bioscience.

Fig. 4.2. Thumb replantation at metacarpophalangeal joint (MCP) level permits fine dextrous tasks difficult to perform with a nontactile prosthesis.

Fig. 4.3. A,B,C, Day of injury photographs of 8 finger amputations. D, Distal parts are dissected and prepared for replantation before the patient enters the operating room. E, Appearance of the digits just after replantation with the distal index amputations replanted onto the long finger stumps to preserve central digital function.

Fig. 4.3. A,B,C, Day of injury photographs of 8 finger amputations. D, Distal parts are dissected and prepared for replantation before the patient enters the operating room. E, Appearance of the digits just after replantation with the distal index amputations replanted onto the long finger stumps to preserve central digital function.

replant the central, middle and ring digits than the index and little fingers, which are border digits.

Replantation of injuries through the palm, wrist, and distal forearm generally provides better function than can be achieved with a prosthesis.28 Recovery of

Fig. 4.3, cont. F,G,H, Good cosmetic appearance, gross grasping, and fine dextrous function allowed this man to return to his former job, which would not have been possible with revision amputations.

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