Arm, Hand and Finger Replantation

“Replantation” is the surgical reattachment of a finger, hand, or arm that has been completely separated from a person (see Figure 1). The goal of replantation surgery is to reconnect the separated part. This is done if it can give the patient back better function and appearance. This procedure is recommended if the replanted part is expected to be successful.

In some cases, replantation is not possible. The part or residual limb injury area can be too damaged. If the lost part cannot or should not be reattached, your surgeon may offer to clean, smooth, and cover the cut end. This is called a completion or revision amputation. In some cases, this option will give you a better and faster recovery than replantation. Therefore, even if replantation is possible, it is not always the best treatment.

Replantation surgery requires very specialized medical care. It requires the skills of a highly trained surgeon and an extensive support team in the emergency room, operating room, and hospital. Not every emergency room or hospital can provide this care. Therefore, it may require coordination of care to send the injured patient and part to a trauma center that has the capacity to take care of this type of injury.

The time elapsed from the injury to treatment is important. The separated part of the body does not have the blood supply, oxygen, or nutrients to support the tissue. Therefore, progressive tissue injury occurs over time. There are some options to help increase options for replantation. The separated part can be rinsed off quickly with water or saline. The part should then be wrapped in wet gauze and put in a sealed plastic bag. This bag can then be placed in ice water to keep the part cool.

It is important to try to be aware of how much time has passed since the injury, and there are several steps to measure time without blood flow (ischemia time). Record the time from the injury to the time when the separated part started cooling. This is called warm ischemia time. The time from cooling to replantation should also be recorded. This is called cold ischemia time. These times can affect treatment decisions and the success of surgery.

Procedure

There are three main steps in the replantation process:

• Step 1: Damaged tissue is carefully removed
• Step 2: Bone ends or fractured parts are reconnected with pins, wires, or plates and screws
• Step 3: Muscles, tendons, arteries, nerves, and veins are repaired; sometimes, grafts (from your own body or a tissue bank) or artificial spacers of bone, skin, tendons, and blood vessels are needed, too

Recovery

The initial recovery takes place in the hospital for days or weeks to monitor the reattached part to make sure it has good blood flow. There is sometimes the need to go back to the operating room to fix the blood flow. Often, transfusions or medicinal leeches are needed to assist in keeping the blood flowing to the reattached part.

Patients have a very important role in the recovery process after leaving the hospital. Generally, patients should:

• Avoid smoking, as it may cause loss of blood flow to the replanted part
• Avoid ice, which may decrease blood flow
• Keep the replanted part above heart level to increase circulation

Other factors that may affect recovery are:

• Age: Younger patients have a better chance of their nerves growing back, and they may regain more feeling and movement in the replanted part
• Area of injury: Generally, more use will return to the replanted part if it is further down the arm
• Joint vs. non-joint injury: More movement has a better chance of returning for patients who have not injured a joint
• Severed vs. crushed body part: A cleanly cut-off part usually regains better function after replantation than one that has been pulled off or crushed
• Weather: Cold weather may be uncomfortable during recovery, regardless of how well your recovery is going

Use of the replanted part depends partially on the re-growth of two types of nerves: sensory nerves, which let you feel, and motor nerves, which tell your muscles to move. Nerves grow about an inch per month. The number of inches from the injury to the tip of a finger gives the minimum number of months after which the patient may be able to feel something with that fingertip. The replanted part never regains 100% of its original use, and most doctors consider 60-80% of its original use an excellent result.

Rehabilitation

For replant patients

Physical therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons but allow the patient to move the replanted part. Therapy with limited motion helps to keep joints from getting stiff, keeps muscles mobile, and limits scar tissue.

Even after you have recovered, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients perform special activities or hobbies. Talk to your physician or therapist to find out more about such devices. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.

For amputees

If replantation is not possible and an amputation is chosen, therapy and rehabilitation also play a large part in recovery. For the missing part, a prosthesis (a device that substitutes for a missing part of the body) may be worn. There are also newer technologies that allow nerves to be repaired to existing muscles in an amputation. This can then be used to power a myoelectric prosthesis or “bionic arm” that can have very natural and meaningful function. This is called targeted motor reinnervation. The connection of sensory nerves to the muscles can reduce residual limb and phantom pain.

Emotional recovery

Replantation or amputation can affect your emotional life, as well as your body. When your bandages are removed and you see the replanted or amputated part for the first time, you may feel shock, grief, anger, disbelief, or disappointment because the body part does not look like it did before. These feelings are common. Talking about these feelings with your doctor often helps you come to terms with the outcome. Your doctor may also ask a counselor to assist with this process.

Long-term Symptoms

For replant patients

Sometimes, the replantation surgery is successful, and the reattached part survives. However, there may be residual pain, numbness, stiffness, cold sensitivity, and loss of use.

Over time, some of these symptoms may improve, yet some may be permanent. If the continuing symptoms are too severe, a late amputation of the part can be considered. This may reduce pain, improve the rest of the hand function, and allow for new prosthetic use.

© 2022 American Society for Surgery of the Hand

This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand.Find a hand surgeon near you.