Hand Clin 23 (2007) 13–21

Wrist Level and Proximal–Upper ExtremityReplantation

Douglas P. Hanel, MD*, Simon H. Chin, MDSection of Hand and Microvascular Surgery, Department of Orthopaedics and Sports Medicine,

Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104-6499, USA

Since Malt and McKhann’s first successful arm

replantation in 1962, upper extremity replantationsurgery techniques have been refined and spreadworldwide [1–3]. Nevertheless, replantation at or

proximal to the wrist, referred to from here onas wrist-proximal replants, remains a dauntingchallenge that presents the hand surgeon with anarray of difficulties distinct from digital

replantation.The significance of undertaking a wrist-proxi-

mal replantation must be adequately assessed by

both the surgeon and cogently presented to thepatient. The graphic nature of a wrist-proximalamputation often dominates the concern of both

the patient and hospital personnel, but initialpriority must be given to the identification ofany other life-threatening associated injuries. The

latter must be appropriately addressed initiallyand, indeed, may preclude the possibility of limbreplantation.

Godina and colleagues [4] advocated tempo-

rary ectopic replantation using the thoracodorsalvessels in upper extremity amputees who couldnot tolerate a long replantation procedure because

of other life-threatening injuries. Wang and col-leagues [5] have extended this concept and re-ported a proximal wrist replant that took place

319 days after the initial injury by temporarilyperforming a quick ectopic implant of the severedhand and forearm into the groin. The authorscaution that the results of secondary replantation

are markedly inferior to primary replantation.

* Corresponding author.

E-mail address: dhanel@u.washington.edu

(D.P. Hanel).

0749-0712/07/$ - see front matter � 2007 Elsevier Inc. All r

doi:10.1016/j.hcl.2007.01.001

The practice of ectopic replantation is not wide-

spread and will not be discussed further.

Initial emergent care

The amputated extremity should be viewed asa distraction to initial evaluation. The patient’s

vital signs, general health assessment, and generalphysical examination should be assessed andaddressed first. Then the amputation stump is

wrapped in a gauze dressing. Bleeding, whenpresent, is addressed with compression. Tourni-quets are not used! Since wrist-proximal amputa-

tions involve muscle, ischemic time is particularlyimportant. Whereas digits may be routinely re-planted with up to 24 hours of cold ischemia timeand 12 hours of warm ischemia time, wrist-

proximal amputations should be performed be-fore 12 hours of cold ischemia time or 6 hours ofwarm ischemia time have elapsed [6]. Therefore,

as part of the initial treatment, ambulance person-nel and emergency physicians should be counseledto wrap the amputated part in gauze and cooled

on ice (Fig. 1). Once this is done, decisions regard-ing the feasibility of revascularization or replanta-tion are considered.

The description of the mechanism of the injuryis critical. Those patients with broad crush oravulsion injuries are typically poor candidates forreplantation (Fig. 2), whereas amputations result-

ing from sharp objects are the ideal candidates forreplantation because the zone of injury is largelyconfined to the amputated site. Sufficient bone

must be available for stable fixation, and thelacerated vessels, although frequently requiring in-terposition grafts, must have retained their distal

capillary integrity. In the absence of these

ights reserved.

hand.theclinics.com

14 HANEL & CHIN

conditions, successful replantation is impossible

and the patient should be informed of this reason-ing. In addition, the referring hospital and thepatient should be informed that those patients

with incomplete amputations fare better thancomplete amputations; Blomgren and colleagues[7] identified decreased operative time, reduced

postoperative morbidity, and a 92% successful re-construction in the former versus prolonged

Fig. 1. The amputated part is kept on ice until revascu-

larization. While the patient is being prepped for

surgery, the amputated part is prepared for replantation.

Core sutures are placed in the tendons and the nerves

and arteries are tagged.

Fig. 2. Sharp amputations, as seen in Fig. 1, that result

from knife lacerations or saws with a narrow kerf, are

ideal candidates for replantation. In contradistinction,

broad crush or avulsion injuries are not.

operative time, increased morbidity, and a 71%success rate in the latter.

A pertinent medical history must be obtained

during this process. Cardiac, pulmonary, andneurologic status must be weighed against thestress of transport and subsequent surgery. Forexample, a recent myocardial infarction or de-

mentia would serve as absolute contraindicationsfor replantation surgery. Strict guidelines forother conditions such as diabetes, renal failure,

or a prolonged history of nicotine consumptiondo not exist. The patient needs to be informedthat the complication rate is higher and the

success rate lower with these conditions anda lengthy operation and hospitalization may endin failure.

Social history is also relevant to the decision.

The patient’s age, occupation, and social situationinfluence the aggregate candidacy of the patientfor replantation. A return to gainful employment

is usually greater than 24 months in manuallaborers, a period of time that may be unaccept-able to a self-employed tool user such as a carpen-

ter, farmer, or rancher.Given no contraindications, expeditious trans-

port must then be arranged; air transport is the

standard method for long-distance referrals andground transport for more local referrals.

In those patients where the transport time isprolonged, a temporary vascular shunt may be

helpful. Shunts are particularly useful for patientswith incomplete amputations [6,8]. An intact skinbridge or a single intact vein is ideal, while arterial

flow is reconstituted with a carotid shunt or a largeintravascular catheter (Fig. 3). This procedureshould be performed in the controlled setting of

an operating room and once placed the shuntsshould be secured with silk sutures or ‘‘vesselhelpers’’ [8]. In cases of complete amputationsa venous and arterial shunt are essential or the pa-

tient may exsanguinate during the transportation.The risk of exsanguination even with arterial andvenous shunts is high enough that we advise using

this technique with caution. Patients with shuntprocedures will require blood transfusion andshould be transported with 4 units of typed and

cross-matched packed red blood cells (PRBCs).Most importantly, the efforts described aboveneed to be weighed against the overlying theme

that no single extremity is worth a patient’s lifeand these shunting efforts as well as replantationmay prove impractical. In addition, the time delayfor the shunt procedure may override the benefits

of revascularization. As a general guideline, the

15UPPER EXTREMITY REPLANTATION

authors consider emergent shunt procedures inpatients with transportation times greater than 6hours.

Upon arrival to the replantation center, thepatient is again evaluated for unrecognized in-juries to the head, chest, and abdomen. A concise

but thorough history of the incident is obtained.Radiographs of both the amputated and theremaining upper extremity are performed. Initial

laboratory values include hemoglobin, hemato-crit, serum electrolytes, blood urea nitrogen,creatinine, basic liver function, and a type andcross match for 4 units of PRBCs. For the next 5

days 4 units of PRBCs are always available.Finally, the expectations and risks associated

with the reconstructive effort must be thoroughly

Fig. 3. (A) Using an arterial shunt, the forearm of this

Montana farmer was kept vascularized during an 8-

hour transport to Seattle. His major nerves, the bra-

chioradialis, and the index and middle finger profundus

tendons were in continuity. A 3-cm skin bridge

was intact dorsally. (B) His radiographs reveal a fracture

dislocation of the elbow and a fracture of the radius and

ulna diaphysis. (C) The placement of the shunt allowed

us to perform meticulous debridement, stabilize the skel-

eton, (D), revascularize the limb, and perform immediate

soft tissue reconstruction with free tissue coverage.

explained to the patient. The immediate expecta-tion for patients with incomplete amputations isbetter than complete amputations; Blomgren andcolleagues [7] identified decreased operative time,

reduced postoperative morbidity, and a 92% suc-cessful reconstruction in the former versus pro-longed operative time, increased morbidity, and

a 71% success rate in the latter. The risk includesloss of limb, infection, multiple secondary proce-dures, and rarely loss of life. The shifts in fluid sta-

tus pre- and intraoperatively and the toxicity ofischemia-reperfusion of muscle tissue are welldocumented. Acidosis, hyperkalemia, production

of free radicals, and liberation of the inflamma-tion cascade follow. ICU monitoring is requiredwith administration of frequent blood products[9]. Informed consent is critical both to the patient

and the surgeon in this undertaking.

Operative techniques

Ideally, two teams are mobilized. One team

addresses the amputated part and the other teamaddresses the distal stump. A decision is maderegarding orientation of incisions on the stump

and the amputated part. While the patient is beingprepared for surgery, the amputated part isdebrided and cleansed. Vessels and nerves are

tagged. Locking sutures are placed in tendons andbone is prepared for fixation (see Fig. 1). This dis-section should be performed with the assistance of�3.5 loupe magnification at a minimum. If the

amputated part is considered to be favorable forreplantation, the replantation effort continues. Ifnot, the timing for revision amputation is less

urgent and the operative staff is appropriatelyinformed.

After anesthesia has been induced, and appro-

priate vascular access and monitoring has beenestablished, one lower extremity and the injuredextremity are isolated in the operative field. The

lower extremity serves as a potential donor site forvessels and nerve and skin grafts. The second teamreciprocates the identification and tagging ofstructures on the distal stump. Debridement is

the single most important step in reconstructionsfor two reasons. First, a thorough debridementperformed by the most senior member of the team

determines if the replantation effort is feasible.Second, if the replantation effort is deemed to beworthwhile, then the debridement will determine

what donor tissues may be necessary and whatmodifications will be needed. Both teams coordi-nate the bone shortening, essential to minimizing

16 HANEL & CHIN

tension on the reattached structures. With sharplycut tidy amputations, the amount of shortening isroutinely 2.5 to 3.5 cm, and with crush avulsion

injuries, even greater amounts of shortening arerequired.

Preliminary fixation with Kirschner wires,small plates, or simple external fixators is un-

dertaken while definitive fixation is determined bythe urgency for revascularization. Reestablish-ment of arterial inflow becomes the principal

concern as muscle death proceeds inexorably.Reestablishment of arterial inflow is performedstraightaway in those cases with ischemic times

greater than 6 hours, whereas in cases withischemic times less than 6 hours definitive rigidinternal fixation is performed before proceedingto revascularization.

Angiocatheters, ventriculoperitoneal shunts, orSundt’s carotid shunts can be used to cannulatethe ends of the transected arteries as a temporizing

conduit to reroute oxygenated blood to themuscles of the distal forearm and the hand. Thisminimizes the time of ischemia and also serves to

flush out toxins that have accumulated in theamputated part.

With shunts in place, attention is then directed

toward meticulous debridement followed by de-finitive bony fixation. Skin is cut back to bleedingedges. Similarly, muscles are debrided until bleed-ing is encountered in the stump. If the viability of

muscle cannot be determined because of broad

crush injury, the replantation effort is ill advised.In the amputated part, muscle attached to tendonalone is removed. Nerve ends are cut back to

identifiable fascicles. Vessels are cut back until theintima is free of injury, adherent to the muscu-laris, and clots can be easily removed from thelumen. The venae commitantes of wrist-proximal

amputations, although flimsy, are usually 2 to 3mm in diameter and should be identified for laterrepair. This is especially necessary when the dorsal

skin has been subjected to extensive crush. Thesevenae commitantes may represent the only reliablevenous outflow. The amputated part is flushed

with a dilute solution of heparin delivered throughone of the arteries using a small-bore catheter.Copious and frequent irrigation of the exposedtissues is repeated throughout the debridement

and the remainder of the procedure. We rarely usejet lavage irrigation, choosing instead to use 3-Lbags of normal saline elevated to 6 feet and

delivered through wide-bore ‘‘cysto’’ tubing. Para-phrasing their combined thoughts, Godina [10]and Rockwell and Lister [11] emphatically state

that ‘‘upon completion of a single aggressive de-bridement the wound should resemble that cre-ated for tumor resection.’’ If this axiom cannot

be met, then the replantation effort should beaborted. If the debridement leads to large openwounds, but a potentially functional limb, thenconsideration should be given to early if not im-

mediate free-tissue transfer.

Fig. 4. Illustrations of radiocarpal (A), forearm (B), and arm-level amputations (C) stabilized with the appropriate

length plates and screws. We prefer rigid internal fixation to other methods of fixation for this level of injury.

17UPPER EXTREMITY REPLANTATION

Temporary fixation is converted to rigid in-ternal fixation with plates and screws in deferenceto external fixation, K-wires, Steinmann pins, ortension bands [12]. We prefer wrist fusion plates

for radiocarpal level amputations, 3.5-mm dy-namic compression plates for forearm level ampu-tations, and 4.5-mm dynamic compression plates

for arm-level amputations (Figs. 4 and 5A, B).The sequence of repair from this point on is

from deep to superficial (Fig. 5C). Motor units are

repaired with braided nonabsorbable sutures, us-ing a locking four-strand technique. The profun-dus tendons of the fingers are tenodesed and

repaired to the profundus muscle belly of the mid-dle ring and small finger. The profundus to the in-dex may be added to these or used to power theflexor pollicus longus (FPL) tendon in cases where

the FPL muscle belly has been avulsed from theradius. Flexor digitorum superficialis tendons arerepaired to their respective muscle bellies as are

the wrist flexor tendons. The extensor tendons tothe fingers are tenodesed and sutured to proximalmuscle bellies as is the extensor pollicus longus. If

no motors are available, the tendons are left in thefloor of the wound with the anticipation of laterreconstruction using an innervated free muscle

transfer.In those cases where a temporary shunt was

not used, the operative microscope is now in-troduced into the field and final vessel preparation

is performed. If vessel grafts are deemed necessarythey are harvested at this time. Shunts, when used,are now removed and definitive anastomoses

performed. In major wrist-proximal replantationsarterial reconstruction should precede venous re-pair. The arterial repair is released and the

accumulated lactic acid and toxins are flushedout through the transected veins. The exact timethat an amputated part needs to be flushed isunknown but, from our experience, the time

required to set up and perform tendon repairsand complete the venous repair is adequate.Whenever possible the radial and ulnar arteries

are repaired as well as their venae commitantes. Ifthe venae commitantes repair was successful, thenthe median and ulnar nerve repairs are completed.

If the venae commitantes repair was not success-ful, then dorsal veins are anastomosed before themedian and ulnar nerves are repaired. There is

one exception to this sequence and that is in thecase of radiocarpal-level amputations, in whichthe ulnar nerve will be found deep to the ulnarartery in Guyon’s canal and repair of the nerve

should precede repair of the artery.

After arterial inflow has been reestablished,swelling of the hand and forearm should remindthe surgeon that fasciotomies of the hand, fore-arm, and possibly the arm may be required. We

perform hand and forearm fasciotomies straight-away in those patients with ischemia times greaterthan 8 hours and all arm-level replantations. The

forearm fasciotomies include release of the super-ficial and deep volar compartments and the dorsalcompartment. The hand fasciotomies include re-

lease of the hypothenar, thenar, and interosseimuscles as well as the carpal tunnel.

Wounds are closed loosely with transposition

flaps and skin grafts. If the outcome of thereplantation is questionable, allograft skin isused. If the limb survives, the allograft is replacedwith autograft after 5 days.

To prevent a first web space contracture,a two-pin fixator bridges the first web (Fig. 5D).This fixator is removed 4 weeks later. The extrem-

ity is immobilized with the elbow flexed at 90 de-grees, the forearm in neutral, and the wrist inslight extension. The fingers are blocked in slight

flexion at the metacarpophalangeal joints andthe interphalangeal joints are immobilized in ex-tension. Soft dressings are applied loosely and

the extremity immobilized with volar and dorsalsplints.

Postoperative care

After surgery, the patient is kept in a warm

room to promote vasodilation for 3 to 5 days.Hematocrit, parameters for disseminated intra-vascular coagulopathy (DIC), and electrolyte

balance are carefully monitored. An hematocritof 20 to 25 is ideal and electrolyte balance is keptclose to normal. Intravenous fluids are delivered

at a rate of twice maintenance rate for 3 days, thenroutine maintenance rates thereafter. As pointedout by Askari and colleagues [13], there are inad-

equate data to develop a rational evidence-basedapproach to anticoagulation in the setting of mi-crosurgery. We start low molecular weight dex-tran (Dextran-40) intraoperatively and if there

are no untoward reactions, the dextran is contin-ued for the next 3 to 5 days. One baby aspirin(85 mg) is given daily while subcutaneous heparin,

5000 units twice daily, are given to address poten-tial lower extremity deep venous thrombosis asso-ciated with bed rest. Therapeutic anticoagulation

with heparin and warfarin is reserved for themost desperate situations and is associated witha significantly larger blood loss and risk to the

18 HANEL & CHIN

Fig. 5. (A) Radiographs of the patient whose hand is shown in Fig. 1 demonstrate an oblique amputation of the distal

forearm reflecting the mechanism, a fine-toothed chop-saw used to cut crown molding and the position of the forearm at

the time of injury, pronation. (B) After debridement, the bone was shortened and rigid internal fixation was applied.

(C) Next, the soft tissues were repaired from deep to superficial, with nerves being done last. (D) A 2-pin fixator spans

the first web space preventing contracture and the wounds were closed with interposition flaps and skin grafts. (E) Post-

operative care included CPM for the digits, and intermittent passive motion of the thumb as pictured here from a similar

wrist-level replantation case. (F) Eighteen months after surgery the range of active motion is near complete and, (G) the

fractures have consolidated.

patient. Hourly monitoring with pulse-oximetry

and capillary refill is conducted until the patientis discharged.

In 48 to 72 hours the patient is returned to the

operating room for a dressing change and further

debridement if necessary and definitive soft tissue

closure, which may require skin grafting or the useof flaps. The patient is returned to the ward andmonitored for 3 to 4 days if no grafts or flaps are

necessary and 6 to 10 days if flaps are required.

19UPPER EXTREMITY REPLANTATION

Fig. 5 (continued)

Rehabilitation of these complex proceduresincludes edema management and early motion to

maintain joint pliability and prevent tendonadhesions. The former is initially controlled withstrict extremity elevation and the latter is initiated

as passive motion during the first 4 weeks fol-lowed by active exercises under the guidance ofa hand therapist. Digital continuous passive

motion (CPM) is started on the first postoperativeday for forearm and wrist-level replantations(Fig. 5E). A well-padded dorsal blocking splintis required to prevent hyperextension of the meta-

carpophalangeal joints and clawing of the digits.Unlike other authors, we do not advocate earlywrist active-assisted motion flexion and active ex-

tension during the first weeks postoperatively, in-stead postponing wrist flexion and extension for atleast 3 weeks [14,15]. Pressure wraps to control

edema are initiated during the third week. Gentleactive and active-assist wrist and digit motion isstarted during the fourth week. During the ensu-

ing period, strengthening exercises are added andactive motion increasingly used. Nerve recoveryreflects the mechanism of injury, with sharp

division providing better functional results thanavulsion injuries. Patients will often require super-

vised therapy up to the sixth postoperative monthbefore being released for self-maintenance regi-mens (Fig. 5F, G). The need for external protec-

tion for an insensate hand and the timing ofsecondary procedures is reflected by the mecha-nism of injury. Tendon transfers, tenolysis, and

scar revision are postponed for a minimum of 6months from injury and only when a 3-month in-terval has passed without functional improve-ment. In the authors’ limited experience of seven

forearm and two arm-level replantations, delayedtendon transfers were necessary in the two arm re-plantations, one for correction of a radial nerve

deficit and one for correction of an intrinsic mus-cle imbalance (Fig. 6).

Results

The case examples shown in Figs. 5 and 6 arefrom our experience with nine major limb replan-tations and represent the best possible outcomes

20 HANEL & CHIN

Fig. 6. (A) This 4-year-old boy sustained bilateral upper extremity amputations when his arms were caught in the power

winder of a fuel truck. The left upper extremity was avulsed from the roots of C5,6,7 and the ulnar nerve avulsed from

the forearm muscles. There were multiple fractures and the limb was not replanted. The right upper extremity had

a much narrower zone of injury, with the only irreparable injury being the radial nerve that was avulsed from the fore-

arm. Bony fixation is shown in Fig. 4C. Twenty-four months after injury he under went transfers for finger and wrist

extension. (B) Range of motion 3 years after injury.

from replantation surgery. The results attest more

to the patients, who were young and healthy thanto the expertise of the surgeons who followed thebasic tenets taught by their mentors, Kleinert and

colleagues [16], Lister and Scheker [17], and God-ina [10]. These individuals championed the basicprinciples of replantation, which are immediateaggressive debridement, rigid internal fixation,

limited warm ischemia, and a disciplined sequenceof soft tissue reconstruction.

Similar to these cases, Hoang [18] reported the

outcomes of five consecutive hand replants at thelevel of the radiocarpal joint. These all resultedfrom clean-cut amputations in young Vietnamese

males and were replanted within 9 to 14 hours ofinjury. With an average follow up of 33 months,the patients had 70% to 80% Total Active Mo-tion (TAM) of the digits and thumb opposition

compared with the contralateral hand and 8 to12 mm of two-point static discrimination. Meyerin 1985 [19] and Scheker and colleagues in 1995

[20] also reported good to excellent results in a ma-jority of wrist-proximal amputations, noting thatthe best results were seen in the more distal cases,

injured by a sharp object and subjected to earlyaggressive range of motion programs. The best

outcomes were of course in children, who were

found to recover 5 to 7 mm of static two-point dis-crimination and 90% of active range of motion[21]. These reports support the continued recom-

mendation for wrist-proximal replantation effortsfor patients in whom the mechanism allows ade-quate debridement, the ischemia time is less than12 hours, and whose general health and comorbi-

ties allow the patient to tolerate the rigors of sur-gery and postoperative recovery.

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21UPPER EXTREMITY REPLANTATION

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