Upper extremity replantation: current concepts and patient selection

Dramatic advances in replantation and microsurgery have somewhat altered the criteria we use in selecting patients to be candidates for upper extremity replantation surgery. We suggest that contraindications for such replantation are: presence of associated life-threatening injuries; serious anesthetic risk; preexisting medical or psychiatric problems; previous injury or disease of the amputated part; warm ischemic time greater than 6-8 hours for extremities or greater than 10-12 hours for digits; and single-digit amputations (except thumb, for grasp). Replantation is feasible when: amputated part is properly preserved; injury type is sharp amputation, mild to moderate crush, or selected avulsion, and amputation is proximal to the DIP joint. Careful preservation of the amputated part, not in dry ice, is mandatory. On an individual basis, the decision to attempt replantation rests on the prediction that the patient may have better function with such surgery than with a prosthesis.