Major upper limb replantation: a review of clinical pearls

Abstract

Replantation of major segments of the extremities can be a formidable task. Adequate debridement of crushed tissues is a prerequisite for successful major limb replantation. This article serves to elucidate the important situational and patient factors a surgeon must consider when choosing between replantation or revision amputation for upper limb salvage.

Keywords

Limb salvage / major limb replantation / microsurgery / upper extremity / reconstruction

References

[1] Hanel DP.Wrist level and proximal-upper extremity replantation..Hand Clin2007;23:13-21

[2] Ziegler-Graham K,Ephraim PL,Brookmeyer R.Estimating the prevalence of limb loss in the United States: 2005 to 2050..Arch Phys Med Rehabil2008;89:422-9

[3] Yueh JH,Liao EC.Major limb replantation..Eplasty2011;11:ic1 PMCID:PMC3020791

[4] Prucz RB.Upper extremity replantation: current concepts..Plast Reconstr Surg2014;133:333-42

[5] Märdian S,Roffeis J,Schaser KD.Complete major amputation of the upper extremity: early results and initial treatment algorithm..J Trauma Acute Care Surg2015;78:586-93

[6] Larson JV,Cederna PS,Urbanchek MG.Clinical factors associated with replantation after traumatic major upper extremity amputation..Plast Reconstr Surg2013;132:911-9

[7] Chung KC.Replantation of the upper extremity: indications and outcomes..J Am Soc Surg Hand2002;2:78-94

[8] Waikakul S,Unnanuntana A.Prognostic factors for major limb re-implantation at both immediate and long-term follow-up..J Bone Joint Surg Br1998;80:1024-30

[9] Tantry TP,Shenoy SP,Adappa KK.Perioperative evaluation and outcomes of major limb replantations with ischemia periods of more than 6 hours..J Reconstr Microsurg2013;29:165-72

[10] Atkins SE,Kay SP.(v) Upper limb amputations: where, when and how to replant..Curr Orthopaed2008;22:31-41

[11] Carden DL.Mechanisms of postischemic vascular dysfunction in skeletal muscle: implications for therapeutic intervention..Microcirc Endothelium Lymphatics1989;5:277-98

[12] Wolfe VM.Replantation of the upper extremity: current concepts..J Am Acad Orthop Surg2015;23:373-81

[13] Woo SH.Practical tips to improve efficiency and success in upper limb replantation..Plast Reconstr Surg2019;144:878e-911

[14] Pet MA.Indications for replantation and revascularization in the hand..Hand Clin2019;35:119-30

[15] Maricevich M,Mardini S.Upper extremity and digital replantation..Hand (N Y)2011;6:356-63 PMCID:PMC3213257

[16] Cavadas PC.Salvage of replanted upper extremities with major soft-tissue complications..J Plast Reconstr Aesthet Surg2007;60:769-75

[17] Dzwierzynski WW.Neligan P.Replantation and revascularization..Plastic Surgery. Vol 6.2017;3 ed.Elsevier

[18] Ahuja NK.Biobrane in the management of critical microsurgical wounds of the upper extremity..Microsurgery2012;32:196-200

[19] Axelrod TS.Severe complex injuries to the upper extremity: revascularization and replantation..J Hand Surg Am1991;16:574-84

[20] Daoutis NK,Efstathopoulos D,Bouchlis G.Major amputation of the upper extremity. Functional results after replantation/revascularization in 47 cases..Acta Orthop Scand Suppl1995;264:7-8

[21] Battiston B,Clemente A.Actualities in big segments replantation surgery..J Plast Reconstr Aesthet Surg2007;60:849-55

[22] Leclère FM,Juon B,Unglaub F.Macroreplantations of the upper extremity: a series of 11 patients..Arch Orthop Trauma Surg2012;132:1797-805

[23] Godina M,Baraga A.Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part..Plast Reconstr Surg1986;78:295-9

[24] Higgins JP.Ectopic banking of amputated parts: a clinical review..J Hand Surg Am2011;36:1868-76

[25] Li J,Guo Z,Cong R.Salvage of amputated thumbs by temporary ectopic implantation..Microsurgery2008;28:559-64

[26] Fufa D,Lin YT,Chuang CC.Secondary reconstructive surgery following major upper extremity replantation..Plast Reconstr Surg2014;134:713-20

[27] Venkatramani H,Sabapathy SR.Role of free functioning muscle transfer in improving the functional outcomes following replantation of crush avulsion amputations of the forearm..Injury.2019;50 Suppl 5:S105-10

[28] Askari M,Weniger FG,Lee WP.Anticoagulation therapy in microsurgery: a review..J Hand Surg Am2006;31:836-46

[29] Ketchum LD.Pharmacological alterations in the clotting mechanism: use in microvascular surgery..J Hand Surg Am1978;3:407-15

[30] Hemker HC,Kakkar VV.Can the haemorrhagic component of heparin be identified? Or an attempt at clean thinking on a dirty drug..Haemostasis1996;26:117-26

[31] Levin LS.Clinical use of anticoagulants following replantation surgery..J Hand Surg Am2008;33:1437-9

[32] Veravuthipakorn L.Microsurgical free flap and replantation without antithrombotic agents..J Med Assoc Thai2004;87:665-9

[33] Pet MA,Mack JS,Wright T.Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation versus prosthetic rehabilitation..Injury2016;47:2783-8

[34] Pierrie SN,Loeffler BJ.Current concepts in upper-extremity amputation..J Hand Surg Am2018;43:657-67

[35] Yoon AP,Hutton DW.Cost-effectiveness of finger replantation compared with revision amputation..JAMA Netw Open2019;2:e1916509 PMCID:PMC6902751

[36] Cancio JM,Barnicott SL,Alderete JF.Upper extremity amputation and prosthetics care across the active duty military and veteran populations..Phys Med Rehabil Clin N Am2019;30:73-87