Indications for replantation and factors that predict success

Abstract

Since the advent of replantation techniques, there has been uneven progress in terms of success—even considering whether success is defined as continued perfusion of the digit or long term functional outcomes. Early enthusiasm and success have not been maintained despite increasing familiarity with microsurgical techniques and greater understanding of how to optimize outcomes for the individual components of replantation such as tendon repair, nerve repair, and osteosynthesis. Practitioners participating in the care of patients undergoing replantation should be familiar with the history and current understanding of both the indications and contraindications for the procedure, post-operative rehabilitation, and factors contributing to functional outcomes. A review of the literature from the first publications on the topic demonstrates evolution in practice and understanding of which patients should be indicated for replantation. Indications can be considered in three broad categories: injury factors, patient factors, and care context factors. These factors intersect with one another and can inform the surgeon pre-operatively regarding the most likely outcome for a given patient. This insight is critical to discuss pre-operatively with the patient in order to make a shared decision about how to manage their injury.

Transmetacarpal Replantation. Eleven Years Later

“…In this case, the repair of the peripheral nerves is postponed for a secondary procedure because abnormal soft-tissue edema appeared during the second phase of replantation. Other additional operations such as tenolysis, arthrolysis, bone reconstruction for nonunion or malunion 5,7,29 have not been performed.…”

“…The K-wire fixation placed in an axial configuration, intramedullary, is quick, atraumatic, technically easier and ensuring sufficient stability so that early passive motions are not critical 8 . It is recommended as a method of first choice in transmetacarpal replantation 7,8,21,29 . Stable osteosynthesis by plates and screws, or intraosseous metal wire in combination with K-wires (Lister procedure) or by two intraosseous wires placed perpendicularly to each other (90-90 wire procedure) are alternative options 24,25,26 .…”

“…There is no uniform antithrombotic protocol for replantation in the hand area 3,27,28,29 . Opinions vary from total restraint from thromboprophylaxis to including Heparin as anticoagulant (appropriate type, Standard or LMW, dosage and timing) or drugs with antiplatelet effect (antiaggregant) such as Aspirin.…”

“…The indications and contraindications for replantation are specified, but they are not considered absolute 3,4,8,30,31 . Each case is subjected to a three-component analysis: trauma (exact time, mechanism of trauma, level of amputation and concomitant injuries, if present), amputated part (general view, state, significance for the hand function, contamination) and the patent himself with his/her specificities (in the first place age; children have better recovery prognosis than elders, health and psychical status at the moment, comorbidities now and in the past, harmful habits, profession and personal desires) 29 . The ischemia time is of exceptional significance (ischemia of more than 10 hours impacts negatively the outcome.)…”

“…For amputated parts which contain musculature the time of ischemia is a critical parameter (six hours without cooling and twelve hours with cooling) 4,8 . For a single finger the limitations are not so strict 4,8,29 . The requirement for a transmetacarpal replantation, as well as for all others, is storage of the amputated part by cooling, which extends the limits of the ischemia time.…”