What are the guidelines for replantation of the upper limb?

Guidelines for Upper Limb Replantation

In cases of upper limb trauma, limb salvage should be prioritized when the patient is hemodynamically stable, as psychological outcomes and quality of life are superior when limb reimplantation is successful. 1

Initial Assessment and Decision Making

• Evaluate overall systemic injury burden and patient physiology to determine if limb salvage is advisable 1
• Prioritize "life" over "limb" - if efforts at limb salvage would increase mortality risk, pursue damage-control measures or immediate amputation 1
• Consider the following factors when evaluating for replantation:
  • Hemodynamic and circulatory status 1
  • Associated organ injuries 1
  • Initial nerve damage 1
  • Major substance loss 1
  • Proximal vascular damage 1
  • Associated bone fractures 1
  • Delays in therapeutic management 1
  • Acute traumatic coagulopathy 1
  • Respiratory failure 1

Indications for Replantation vs. Amputation

Factors Favoring Replantation

• Hemodynamic stability 1
• Distal injury level (better outcomes with forearm replantations compared to more proximal injuries) 2
• Incomplete amputations with some tissue continuity 3

Factors Favoring Initial Amputation

• Complete traumatic amputation 1
• Large loss of substance making skin coverage impossible 1
• Major infectious risks 1
• Multiple fractures with bone loss or ischemic vascular lesions 1
• Severe crush or blast injuries with extensive tissue damage 1

Surgical Management Approach

For Hemodynamically Stable Patients

• Proceed with limb salvage when feasible 1
• Perform replantation within 2-6 hours after injury for optimal outcomes 4
• Surgical sequence typically includes:
  • External bone fixation 4
  • Vascular anastomoses 4
  • Nerve repair 4
  • Muscle repair 4

For Hemodynamically Unstable Patients

• Apply damage control strategy for patients with hemorrhagic shock, vascular injury, or mangled extremity 1
• Use temporary stabilization with external fixators rather than skeletal traction when definitive osteosynthesis is not anticipated within 24-36 hours 1
• Once stabilized, perform delayed definitive osteosynthesis as early as possible 1

Scoring Systems and Risk Assessment

• Mangled Extremity Severity Score (MESS) and Mangled Upper Extremity Injury (MESI) score may guide decision-making but should not be used in isolation 1
• MESI score above 20 has traditionally been considered a threshold for amputation, but recent evidence suggests these scores may not be definitive predictors of outcome 1

Post-Operative Management

• Administer anticoagulation treatment postoperatively to prevent thrombosis 4
• Monitor for early complications such as thrombosis at the anastomotic site 4
• Schedule frequent reassessments of hemodynamic and respiratory status 1
• Plan for potential secondary procedures (average of 2.4 secondary procedures may be required) 2

Expected Outcomes

• Functional outcomes correlate with level of injury:
  • Excellent to good outcomes for replants distal to elbow 2
  • Poor outcomes for replants at or proximal to elbow 2
• Return to work rates vary by level:
  • 65% for forearm replants 2
  • 43% for elbow replants 2
  • 32% for arm replants 2
• Overall limb survival rates can reach 93% despite severity of injuries 3
• Most patients (76%) can achieve good functional results according to Chen criteria 3

Rehabilitation Considerations

• Begin prosthetic limb fitting within 30 days following amputation if that route is chosen 5
• Implement multidisciplinary rehabilitation including physical and occupational therapy 1
• Evaluate for psychosocial risk factors affecting outcomes (PTSD, anxiety, low self-efficacy) 1
• Consider behavioral health interventions to improve psychological and functional outcomes 1

Common Pitfalls to Avoid

• Delaying transfer to a center with microsurgical capabilities 6
• Improper handling of amputated parts (should be wrapped in saline-soaked gauze, placed in sterile plastic bag, and put in ice-filled container) 6
• Using absence of plantar sensation or nerve transection as major decision factors for amputation 1
• Waiting too long for prosthetic fitting if amputation is performed 5
• Failing to consider patient preferences and surgeon expertise in decision-making 1