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THE JOURNAL OF SEPTEMBER 1983 VOLUME 8, NUMBER 5, PART 1 HAND SURGERY EDITORIAL Official journal AMERICAN SOCIETY FOR SURGERY OF THE HAND To replant or not to replant? That is not the question James R. Urbaniak, M.D., Durham, N. C. Successful replantation of amputated limbs has been possible for 20 years. This procedure has be- come commonplace over the past decade, perhaps to the extent that surgeons have been overly zealous in their efforts to reattach amputated fingers, hands, dig- its, and legs. Most replantation centers have reported greater than 80% viability rates in replantation surgery with "functional results generally better than achieved by prosthetic replacement. "1-6 Reports of these high success rates have encouraged a number of surgeons to attempt replantation of severely traumatized extremities even in cases where some other type of reconstruction would produce a more functional limb. Although the reports on number and success of replantations have been overwhelming in previous years, carefully docu- mented assessments of long-term functional results are scant. 1. 6. 7 Notably, no paper has been written on the failures of replantation. Because the ultimate functional result is unpredict- able, the decision of whether or not to replant an ampu- tated part is difficult even for the experienced recon- structive surgeon. Several factors may influence the physician when faced with the choice of replantation or amputation. The surgeon may feel he has to justify the high cost of the operating microscope and microsurgi- cal instruments. Replantation surgery is often a dra- matic event that attracts acclaim to the responsible Received for publication April 12. 1983; accepted in revised form April 23, 1983. Reprint requests: James R. Urbaniak, M.D., Professor of Ortho- paedic Surgery, Duke University Medical Center, Durham, NC 27710. physician. The reconstructive surgeon may feel pres- sured to participate in replantation surgery "to keep pace with neighboring micro surgeons , "and/or he may relish the challenge of attempting to restore a severed limb. The surgeon's judgment may be swayed by the expectations of the referring physician, the injured pa- tient, or his family. Some revascularizations have been performed for young surgeons to gain experience in microvascular anastomoses, a technique that must be developed in the microvascular laboratory before per- formed as part of patient care. The personal rewards of replantation surgery are counterbalanced by unfavorable conditions that may negate the election to replant. Most replantations re- quire many hours of surgery, usually at inconvenient times. These tedious procedures can be extremely dis- ruptive to the routine clinic hours, operating schedule, social activities, and sleep patterns. Compared with other reconstructive procedures, the surgeon's efforts are not remunerative. If the replanted part fails to survive, the surgeon's judgment and competence are immediately questioned. Ideally, the practice of replan- tation should be structured so that these extraneous fac- tors do not influence the surgeon's judgement. Many factors influence the indications for replanta- tion of amputated extremities such as the predicted morbidity to the patient, survival of the replanted part, functional outcome of the reconstructed limb, and the overall financial outlay of the patient, the insurance carrier, or society. Based on our team's experience with more than 700 attempted replantations over a 10- year period, we have developed criteria for proper pa- tient selection.2 Several other experienced replantation THE JOURNAL OF HAND SURGERY 507

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Page 1: To replant or not to replant? That is not the question

THE JOURNAL OF SEPTEMBER 1983

VOLUME 8, NUMBER 5, PART 1

HAND SURGERY

EDITORIAL

Official journal AMERICAN SOCIETY FOR SURGERY OF THE HAND

To replant or not to replant? That is not the question

James R. Urbaniak, M.D., Durham, N. C.

Successful replantation of amputated limbs has been possible for 20 years. This procedure has be­come commonplace over the past decade, perhaps to the extent that surgeons have been overly zealous in their efforts to reattach amputated fingers, hands, dig­its, and legs. Most replantation centers have reported greater than 80% viability rates in replantation surgery with "functional results generally better than achieved by prosthetic replacement. "1-6 Reports of these high success rates have encouraged a number of surgeons to attempt replantation of severely traumatized extremities even in cases where some other type of reconstruction would produce a more functional limb. Although the reports on number and success of replantations have been overwhelming in previous years, carefully docu­mented assessments of long-term functional results are scant. 1. 6. 7 Notably, no paper has been written on the failures of replantation.

Because the ultimate functional result is unpredict­able, the decision of whether or not to replant an ampu­tated part is difficult even for the experienced recon­structive surgeon. Several factors may influence the physician when faced with the choice of replantation or amputation. The surgeon may feel he has to justify the high cost of the operating microscope and microsurgi­cal instruments. Replantation surgery is often a dra­matic event that attracts acclaim to the responsible

Received for publication April 12. 1983; accepted in revised form April 23, 1983.

Reprint requests: James R. Urbaniak, M.D., Professor of Ortho­paedic Surgery, Duke University Medical Center, Durham, NC 27710.

physician. The reconstructive surgeon may feel pres­sured to participate in replantation surgery "to keep pace with neighboring micro surgeons , "and/or he may relish the challenge of attempting to restore a severed limb. The surgeon's judgment may be swayed by the expectations of the referring physician, the injured pa­tient, or his family. Some revascularizations have been performed for young surgeons to gain experience in microvascular anastomoses, a technique that must be developed in the microvascular laboratory before per­formed as part of patient care.

The personal rewards of replantation surgery are counterbalanced by unfavorable conditions that may negate the election to replant. Most replantations re­quire many hours of surgery, usually at inconvenient times. These tedious procedures can be extremely dis­ruptive to the routine clinic hours, operating schedule, social activities, and sleep patterns. Compared with other reconstructive procedures, the surgeon's efforts are not remunerative. If the replanted part fails to survive, the surgeon's judgment and competence are immediately questioned. Ideally, the practice of replan­tation should be structured so that these extraneous fac­tors do not influence the surgeon's judgement.

Many factors influence the indications for replanta­tion of amputated extremities such as the predicted morbidity to the patient, survival of the replanted part, functional outcome of the reconstructed limb, and the overall financial outlay of the patient, the insurance carrier, or society. Based on our team's experience with more than 700 attempted replantations over a 10-year period, we have developed criteria for proper pa­tient selection.2 Several other experienced replantation

THE JOURNAL OF HAND SURGERY 507

Page 2: To replant or not to replant? That is not the question

508 Urbaniak

surgeons have published similar indications. I, 8-10

None of these lists is rigid or absolute, and the criteria, although generally similar for all of the authors, do vary with the individual surgeon's or team's experience as they assess their results. Future experience may well dictate further changes in these criteria. It is hoped progress in technology of externally powered prosthe­ses will further influence the decision making in major limb replantation.

It is not the intent of this discussion to detail the criteria for proper patient selection for replantation. Nearly any amputated part can be reattached by an experienced replantation service and will remain via­ble. Warm and cold ischemia times and damage to the distal vessels of the amputated part are definite deter­minants. There is general agreement that the amputated thumb, multiple digits, hand, and distal forearm should be reattached when possible. Amputated parts in chil­dren and sharply severed major limbs are also reason­able candidates for reattachment.

The choice of management of an amputated digit or limb varies among surgeons or among replantation cen­ters just as the best management for a traumatic boutonniere deformity or flexor tendon laceration dif­fers among hand surgeons. There are certain amputated parts that most agree should be replanted. There will continue to be disagreement on replanting such parts as isolated digits other than the thumb and upper ex­tremities avulsed proximal to the forearm. Revascu­larization of severely damaged digits involving mul­tiple structures (for example ring avulsion injuries) may also be questioned. It is essential for physicians treating these injuries to have sufficient experience to be able to determine which replantations will have a reasonable chance of survival and satisfactory function. Generally, it is not wise to allow the patient or the family to make the decision for they will usually request replantation in cases in which there is little chance of survival or func­tion of the replanted part. There are, however, social, ethnic, and religious beliefs about the significance of the loss of an amputated part that influence the decision regarding replantation.

Although replantations of digits amputated distal to the superficial is insertion result in a high degree of viability (exceeding 85%) and provide good function, it is difficult to prove that the overall function to the hand is better than it would be with a good amputation revi­sion. I believe, however, that the experienced surgeon is justified in reattaching single digits in selected indi­viduals when he realizes function may not be im­proved, yet neither will it be impaired.

I am firmly convinced that the reconstructive surgeon who attempts lower limb salvage by revascularization

The Journal of HAND SURGERY

or replantation must be thoroughly knowledgeable about lower limb prosthetic fitting and function. I have not witnessed a patient with a limb replanted, above or below the knee, who could walk better or more efficiently than he could have walked with a satisfac­tory prosthesis at either level. Despite reports of "heroic efforts" or "gallant surgery" describing the reattachment of an amputated leg in an adult, the pa­tient rarely walks without a disabling limp, and the rehabilitation time is considerably shorter after ampu­tation and prosthetic replacement.

"The fate of the patient with the injured hand rests with the first doctor who treats him."l1 In most in­stances the choice of management of the patient with an amputated part is not difficult. Sometimes the decision cannot be determined until the condition of the vessels of the amputated part is examined under the operating microscope. Even after the surgeon has determined that replantation is possible, he must decide then if this is the best method of restoring function. The key question to be addressed is not "Should I replant or not?", but rather "How can I best restore useful function to the damaged limb?"

REFERENCES

I. Tarnai S: Twenty years' experience of limb replanta­tion-Review of 293 upper extremity replants. J HAND SURG 7:549-56, 1982

2. Urbaniak lR: Replantation. In Green DP, editor: Opera­tive hand surgery. New York, 1982, Churchill Living­stone, pp 811-27

3. Kleinert HE, luhala CA, Tsai T-M, Van Beek A: Digital replantation-Selection, technique, and results. Orthop Clin North Am 8:309-18, 1977

4. Morrison WA, O'Brien BM, MacLeod AM: Digital re­plantation and revascularisation: A long term review of one hundred cases. Hand 10:125-34, 1978

5. Biemer E: Replantation von fingern und extremitaten­teilen: Technik und ergebnisse. Chirurgie 48:353, 1977

6. Wang SH, Young KF, Wei IN: Replantation of severed limbs-clinical analysis of 91 cases. J HAND SURG 6:311-8, 1981

7. lones 1M, Schenck RR, Chesney RB: Digital replanta­tion and amputation-Comparison of function. 1 HAND SURG 7: 183-9, 1982

8. 0 'Brien BMcC: Microvascular reconstructive surgery. New York, 1977, Churchill Livingstone

9. Daniel E, Terzis 1: Reconstructive microsurgery. Bos­ton, 1977, Little, Brown & Co

10. Zong-Wei C, Meyer VE, Kleinert HE, Beasley RN: Present indications and contraindications for replantation as reflected by long-term functional results. Orthop Clin North Am 12:849-70, 1981

II. Murray JF: The patient with the injured hand. 1 HAND SURG 7:543-8, 1982