Replant 4 FingersReplant 4 fingers post






Reattachment of body part that has been completely severed


Revascularisation of incomplete amputation


Vascular repair is necessary to prevent necrosis of the extremity

- retains some venous and lymphatic drainage albeit small

- revascularisation easier, quicker and better results


Mechanism of injury








Friedrich et al J Hand Surg Am 2011

- 9400 upper extremity amputations

- 14.5% underwent replantation

- 27% thumbs, 12% digits, 12% hands or forearms


Indications for surgery




Multiple digits


Individual digit distal to FDS insertion


Partial hand / through palm - replant far superior to prosthesis as lose sensation and power grasp


Almost any body part in child


Wrist or forearm


Above or below Elbow - only if sharply demarcated




Adult single digit proximal to FDS insertion

- poor results / stiffness


Ischaemic time distal to carpus

- > 12 hours warm ischaemia time

- > 24 hours cold ischaemia time


Ischaemic time proximal to carpus

- > 6 hours warm ischaemia time

- > 12 hours cold ischaemia time


Severe crush or mangled



- through elbow

- high arm


Multiple level / segmental injury


Other serious injuries / comorbidities


Transport of amputated part


4oC ideal


2 Methods


1. Wrapping the part in a moistened cloth of Ringer's or Saline

- placing in plastic bag and placing the bundle in ice water


2. Immersing the part in one of these solutions in a plastic bag 

- then putting on ice


No difference in outcome


Most important is to give clear and precise instructions to referring doctors




Key factor in success

Duration of allowed ischaemia varies from tissue to tissue


Recommended maximum


1.  Distal to carpus 


12 hours warm ischaemia time

24 hours cold ischaemia time


Digits consist of skin, bone and subcutaneous tissue

- no muscle

- warm ischaemia tolerated for long periods

- freezing not tolerated

- digits have survived for 12 hours or longer of warm ischaemia

- when cooled replants have been successfully performed at 36 hours


2.  Proximal to carpus 


6 hours warm ischaemia time

12 hours cold ischaemia time


Major limb replants contain large volume of muscle

- only tolerate 4-6 hours of ischaemia

- because of the size of the extremity only its outer part is adequately cooled 

- the deep muscle remains relatively warm

- the allowable 6 hours warm ischaemia time can't be extended


Patient factors


High demand professionals

- may push indications

- i.e. amputation at level of proximal phalanx


Patient must be aware of chance at viability, function, time off work etc


Premorbid conditions must be taken into account 

- diabetes, smoking, peripheral vascular disease

- patient compliance




Should be able to consistently achieve 90% patency rate in 1mm vessels in laboratory




Digit 1Digit 2Digit 3


Single digit


Distal to FDS tendon insertion replant

- outcomes good

- able to immediately mobilise of digit


Proximal to FDS tendon insertion replant

- useful function does not occur

- patient will bypass finger


Multiple digits



- replant best digit to most useful stump

- when thumb intact goal is to restore palm width


Kaneshiro et al J Plast Reconst Aesthet Surg 2020

- retrospective review of 12 patients undergoing multiple digit replantation

- mean 2.8 digits replanted, survival 87%






Shaterian et al J Hand Microsurg 2018

- systematic review of 32 studies with > 6000 digit replantations

- increased survival rates with 2 (90%) versus 1 (84%) arterial anastomoses

- increased survival rates with 2 (92%) versus 1 (73%) versus 0 (61%) venous anastomoses

- increased survival with sharp injuries (87%) versus crush (70%)




Shaterian et al Hand 2021

- systematic review of 28 studies with 618 digit replants

- average grip strength 80% contralateral limb

- average two point discrimination 8 mm (normal 2 mm)

- average DASH score 12 (0 - no disability, 100 - severe)


Operative technique for single digit



1. Locate and tag vessels and nerves

2. Debride

3. Shorten and fix the bone

4. Repair extensors

5. Repair flexors

6. Anastomose the arteries

7. Repair the nerves

8. Anastomose the veins

9. Obtain skin coverage




Set up

- maintain body temperature by warming the patient

- axillary block to block sympathetics

- ABx, tetanus prophylaxis

- in dwelling catheter



- longitudinal mid-lateral incisions for digital replants


Shorten bone

- get out of zone of injury 

- must have no tension on the grafts

- minimum 0.5 - 1 cm each side

- alternative is to vein graft but is easier to shorten bone

- shortening also helps with skin coverage

- ORIF proximal phalanx

- K wire DIPJ / distal phalanx


Extensor Tendons

- primary repair

- if inadequate extensor tendon for primary repair perform delayed repair


Flexor tendons 

- repaired primarily if at all possible

- otherwise 2 stage 


Arterial repair

- 9/0 or 10/0 nylon interrupted

- key is repair normal intima to normal intima

- adventitia is intensely thrombogenic so ensure none in repair

- strip adventitia for 1-2mm

- repair both arteries if possible otherwise consider reversed vein graft

- tourniquet acceptable

- micro-clips / bulldog clips should not be applied > 30 min due to intimal damage

- heparin boluses to maintain patency (5000IU in 500 mls)

- papaverine antispasmodics


Vein repair

- 2 veins for every artery

- can consider removing nail bed + heparin soaked dressings to allow bleeding


Nerve repair

- 10/0 interrupted epineural repair

- primary repair if possible

- primary nerve graft or conduit

- use medial cutaneous nerve of forearm 



- skin closed under no tension

- digital incisions often left open to decompress repairs


Postoperative management


Elevate in gallows

- high dependency area

- appropriate intravenous fluids

- anticoagulation controversial - usually heparin boluses given

- smoking strictly prohibited

- no caffeine

- warm ambient temperature

- observations hourly for 72h then q4h


Assessment of vascularity


Colour / capillary refill


Oxygen saturation probe


Surface temperature <30°C indicates that poor perfusion of the replant is certain



- bright red bleeding normal

- dark blue blood venous congestion


Failing replantation


If appears threatened immediate action is necessary

1. Relieve dressings or sutures

2. Either elevate or dependant position

3. Regional block for sympathetics

4. Relieve pain, fear and anxiety

5. Ensure patient warm and adequately hydrated

6. Intravenous heparin

7. Consider medical leeches for venous congestion

8. If return to OT is necessary then must be within 4-6 hours of ischaemia


Thumb replant


Thumb 1Thumb 2Thumb 3




Thumb has first priority


A successfully replanted thumb is always better than any reconstruction

- thumb provides 40% of hand function

- a fixed stump / post is very useful




Detipped thumb can be successful

- need dorsal veins in stump

- need 4mm of skin proximal to nail plate

- all efforts should be made to preserve thumb length 


Thumb detipThumb detip 2Thumb detip xray




Ulnar sided artery larger

Need to adduct shoulder / internally rotate arm

Can fuse IPJ




Lin et al Hand 2011

- systematic review of toe to thumb transfer for traumatic thumb replantation

- 25 studies, 450 cases

- 101 second toe transfers

- 196 great toe transfers

- similar outcomes


Ring Avulsions


Finger avulsion 1Ring avulsion 2Finger replant 3




Circumferential skin loss of finger caused by traumatic injury to ring


Urbaniak Classification


Bamba et al Hand 2018

- systematic review


Type I

- circulation adequate

- may involve damage to flexor / extensor tendons

- 9% of injuries

- typically good results


Type II

- circulation inadequate

- typically microvascular repair less simple

- can be large zone of injury

- vascular grafts or venous flaps may be required


Type III

- complete degloving or complete amputation

- 84% survival with replantation

- worse outcomes with regards range of motion and two-point discrimination


Midcarpal Replantation


Replant 4 FingersHand replant 1Hand replant 2


Replant 4 fingers postHand Replant 3


Major Limb Replantation




Proximal forearm / elbow joint / arm 




1. Usually avulsion or crush injuries types with extensive muscle injury


2. Amputations proximal to metacarpal level have significant muscle bulk

- high risk of myonecrosis and subsequent infection

- immediate arterial inflow is necessary

- need patient hydration and osmotic diuresis to protect kidneys


3. Functional outcome related to level of amputation




Rapid skeletal stabilisation

- at least one artery must be revascularised

- then follow sequence for digit

- extensive fasciotomies always indicated

- any exposed vessels must be covered by rotation flap etc




Ramji et al Plast Reconstr Surg Global Open 2020

- systematic review of 13 studies with 136 major limb replantation

- functional outcome related to level

- good to excellent outcome scores distal to elbow

- poor outcomes at or proximal to elbow