Any surgeon trained in microsurgical technique and hand replantation may perform digit replantation. This training typically would include any attending orthopedic or plastic surgeon. However,  this procedure requires specialized equipment and personnel that are familiar with that equipment. These resources may not be available at all institutions. Orthopedic, plastic, or general surgeons with the Certificate of Added Qualifications (CAQ) in hand surgery are the best resources for performing replantation or referring to facilities where replantation is possible. 

Handling of Amputated Extremity Parts

Transportation of the amputated part is paramount in preserving viability. The most widely utilized and effective method of preservation is wrapping the amputated extremity in gauze moistened with a physiologic solution (normal saline or lactated ringers), placing the wrapped amputated part in a plastic bag, then putting this plastic bag on ice. Alternatively, the part may be immersed in a physiologic solution in one bag, which is then placed on ice. Amputated extremity parts should never be placed directly on ice, as this may result in frostbite or other soft tissue injuries to the amputated part. Such damage may preclude replantation altogether or compromise the achievable functional result of replantation.

Ischemia Time 

Timing is critical in replantation surgery. The amount of muscle in the amputated part determines the amount of ischemia time each part will tolerate. Digits contain no muscle, and the bone and soft tissue present in each digit have a relatively low metabolic rate and formation of toxic byproducts of ischemia. Therefore, digits amputated in Zone 1 and Zone 2 may tolerate up to 12 hours of warm ischemia time and up to 24 hours of cold ischemia time. In general, muscle makes up a substantial portion of the soft tissue in Zone 3 to 5 amputations. Extremities amputated at this level will tolerate no more than six hours of warm ischemia time or 12 hours of cold ischemia time. Because of this, vascular shunting to the amputated part may be necessary for forearm or elbow amputations before initiating the surgical repair.

Sequence of Repair

When possible, the amputated part should be taken to the operating room before the patient for thorough debridement and examination under the microscope. The quality of the tissue, specifically the nerves and blood vessels, are examined before committing to the replantation. Identifiable structures should be tagged with suture or microclips. The first step in replantation is bone shortening and fixation. The bone should be shortened enough to take all tension off of the subsequent soft tissue repairs. In the pediatric population, any bony shortening should take care not to sacrifice the physis. Bony fixation is followed by extensor tendon then flexor tendon repair. The surgeon should then initiate arterial repair. No matter the level of amputation, anastomosing intact and healthy arterial intima on each side of the repair is paramount to success. If this requires excessive debridement, vein grafts are necessary. Ample vein grafts are typically available from the ipsilateral extremity in the cephalic or basilic vein. However, lower extremity vein grafts may be necessary. Nerve repair is the next step, followed by vein repair. Lastly, the surgeon completes soft tissue coverage of the repair.[2][8][9][10]

In short:

1. Bone
2. Extensor tendon
3. Flexor tendon
4. Artery
5. Nerve
6. Vein
7. Soft tissue

Complications of flexor tendon injuries can include bleeding, infection, replant failure, and finger stiffness. Venous congestion of the finger is a common problem as anastomosis of damaged dorsal veins is often difficult. Various strategies to prevent or treat venous congestion exist, including removing the nail plate, fishmouth incisions over the fingertip with heparin pledget application, or application of leeches. Any patient begun on leech therapy should also be placed on ciprofloxacin therapy to prevent infection from Aeromonas hydrophilia.

If performed by an experienced hand and microsurgeon, viability rates of replants should be at least 80% following replantation. Motion at the affected joints depends on the level of amputation, mechanism of amputation, and compliance with postoperative therapy. Patients should receive counsel before surgery that the motion in replanted digits averages only approximately 50% of normal. Furthermore, patients undergoing replantation average ten days in the hospital and approximately seven months of time off of work. In general, the best results come from replantation of the thumb, hand, distal forearm, and fingers distal to the insertion of the flexor digitorum superficialis (Zone 1).

Digit reimplantation requires an interprofessional team that includes a hand surgeon, plastic surgeon, emergency department physician, and specialty trained nurses. Once the digit is reimplanted, close monitoring is required to ensure that no ischemia or infection occurs. Following the surgery, patients require prolonged physical therapy to regain joint function and strength. While digit reimplantation does have success, the procedure does not work in everyone.[11][12][13]