Hand and Finger Replantation After Protracted Ischemia (More than 24 hours)

Author(s): Lin CH, Lin N, Aydyn YT, Lin CT, Hsu CH, Lin, and Yeh JT

Source: Ann Plastic Surg 2010; 64(3): 286-290

Summary:

The authors present their experience over an 8 year period performing digit and hand replantation in amputations over 24 hours old in 14 patients with 31 amputations.  Delays in replantation were due to attempted replantation at other institutions which failed and resulted in subsequent transfer for repeat replantation in 8 patients.  Of the 31 amputations, 2 had thumb amputations, 9 patients had 2-digit amputations, and 1 patient had a 3-digit amputation.  Two patients had wrist amputations that required life-saving resuscitation which delayed replantation.  Hands were placed in appropriate cold storage while awaiting replantation.  All amputations were guillotine or crush. 

Twenty-five of the 31 amputations were attempted, of these 16 survived and 9 failed resulting in a 64% success rate.  Of the two wrist level replantations, one survived and required revision surgery for tenolysis, 1st webspace contracture and opponensplasty.  The hand which did not survive suffered from significant venous congestion, profoundly affecting the intrinsic muscles.  Return of function varied from patient to patient with some recovering 2 point discrimination of 5 mm and some recovering no sensation.  Range of motion was not reported specifically but varied.  Power pinch of the involved digits averaged 41% of normal.
 
While ischemia tolerance of digits is higher than that of more proximal amputations with skeletal muscle involvement, a significant decrease in success of replantation after 10 hours has been demonstrated.  However, there are many case reports demonstrating success in significantly long cold ischemia times.  This case series demonstrates not only digit survival with extended ischemia due to multiple circumstances even including failed attempted replantation at previous hospitals, but successful replantation of a hand at the wrist level after 24 hours or more of cold ischemia with failure of another hand at the same level and ischemia time, for a salvage rate of 50% of this skeletal muscle containing amputation.  While the risks and benefits to patients must be balanced with every attempt at replantation, this case series demonstrates a higher level of success with replantation than one may expect.  Whether it is their technique, post-operative regimen of dextran, heparin, and prostaglandin infusion, or the shear fact that they attempted replantations that others may not consider feasible, the success rate of 64% is high enough that it causes one to think about current indications/contra-indications for replantation.