Replantation refers to the surgical reattachment of a body part (such as a finger, hand, or toe) that has been completely cut from the body. The goal of replantation is to reattach and restore function to as much of the injured part as possible.
Sometimes, for a variety of reasons, replantation of a lost body part is not possible. If the lost part cannot be reattached, a patient may have to use a prosthesis — a device that substitutes for a missing part of the body. In some cases, a prosthesis may give a person with a missing body part improved function and quality of life.
Replantation is usually recommended when the replanted part will work at least as well as a prosthesis. For example, a surgeon would not reattach an index finger if it was felt that the finger would be stiff, painful, and numb, getting in the way of the function of the other fingers. However, a surgeon may reattach a thumb knowing that this very important digit would be better than a prosthesis if the replantation is successful.
Before surgery, the doctor will explain the procedure and how much function is likely to return following replantation. The patient or family member must decide whether regaining use of the body part justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.
Unfortunately, replantation is time-sensitive, so decisions must be made quickly and decisively (you feel confident in the decision). It is important to note that while popular culture makes replantation seem routine (like they are easy and happen all the time), these are very complex procedures performed only at specialized centers. Also, as mentioned above, replantation is not always possible no matter how much it may be desired by the patient/family.
There are several steps in the replantation process, which typically takes several hours.
- First, the surgeon carefully removes damaged and contaminated (dirty) tissue on both the part and the stump.
- Then, the surgeon trims the bone ends. Trimming the ends before they are rejoined makes it easier to put together the soft tissue on either side of the wound.
- Next, the surgeon repairs the tendons and muscles, usually in a way that will allow for early movement of the part by the patient during recovery.
- Then, the surgeon attaches the arteries, veins, and nerves via microsurgery. This is often the most challenging part of the case, requiring skill, patience, and careful technique. The state (condition) of the vessels will often determine whether the part can live after surgery. If the trauma that caused the amputation is too great, it can permanently damage the blood vessels, making it impossible for them to carry blood to and from the part. This would result in failure of the replantation. If a surgeon is suspicious of the quality of the vessels in the part or the stump, they may advise you against attempting the replantation.
- At the end of the procedure, the surgeon loosely closes the skin to avoid compressing (pressing on) the newly repaired blood vessels. Sometimes, the surgeon may need to harvest (take) skin or other tissue from healthy parts of the patient's body to cover open areas on the replanted part. This may be done at the time of the replantation or several days/weeks later.
After a successful replantation, the patient often stays in the hospital for 1 week or more.
- The replanted part is closely monitored to ensure that it survives the procedure.
- There is often a lot of blood loss at the time of injury, surgery, and recovery, and patients often need blood transfusions (where donor blood is given to the patient).
- The patient usually takes blood thinners after surgery to prevent clots at the repaired vessels, which can cause further blood loss.
- Labs (blood tests) are drawn daily to make sure the patient's blood counts stay at safe levels.
- The room is kept warm to prevent spasms of the blood vessels.
- Patients are often denied caffeine and other foods/medications that can cause spasm of the vessels.
- The extremity (arm) is elevated to help blood drain out of the newly attached part.
- Leeches may be applied to the replanted part after surgery to help recovery of the vessels. If blood is getting into the part (via the arteries) but not getting out very well (via the veins), the replantation can fail. Leeches help thin the blood and draw old blood out of the part, allowing for fresh, oxygenated blood to enter and keep the tissues alive.
- When it seems like the replanted part is likely to survive, the patient may start therapy to get the part moving and prevent adhesions (bands of scar-like tissue) of the tendons.
Ultimate recovery of use often depends on regrowth of two types of nerves: sensory nerves and motor nerves. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. Motor nerves carry messages from the brain to muscles to make the body move.
- In a finger replantation, only sensory nerve recovery is necessary because the muscles that control the finger are located in the hand and forearm and are not typically injured by the amputation.
- In a hand or arm replantation, the motor nerves must also heal to allow for movement of the hand/wrist/elbow.
Nerves grow about 1 inch per month, and this fact helps doctors estimate the length of the recovery. For instance, in a fingertip injury, the number of inches from the injury to the tip of a finger provides an estimate of the minimum number of months after which the patient may begin to feel something with that fingertip.
Nerves almost never recover to full function after an amputation. While some sensation and motor signal will likely return, the replanted part will never function quite the same as it did before the injury.
Learn more: Nerve Injuries in the Hand and Fingers
Physical Therapy and Rehabilitation
Complete healing of the injury and the surgical wounds is only the beginning of a long process of rehabilitation. Physical therapy and temporary bracing are important to the recovery process.
- Braces are used from the beginning to protect the newly repaired tendons, and to allow the patient to move the replanted part.
- Physical therapy exercises are used to prevent the joints from becoming stiff, to keep the muscles moving, and to minimize the formation of scar tissue.
Even after a full recovery, replantation patients may find that they cannot do everything they wish to do or did before the injury and surgery. Tailor-made devices help many patients to do special activities or hobbies. A physician or therapist can provide more information about such devices.
Many replantation patients can 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.
The Patient's Role in Recovery
The patient has an important role in the recovery process, which is long and difficult. It requires a great deal of mental strength and may also require some lifestyle modifications (changes); for instance, smoking causes poor circulation and may cause a loss of blood flow to the replanted part, so if you smoke, your doctor may advise you to quit. Also, if the injury occurs in the hand, allowing the replanted part to hang below heart level for extended periods of time may also cause poor circulation to the replanted part and prevent or delay recovery.
Emotional Aspects of Recovery
Replantation can affect a patient's emotional life as well as their body. When bandages are removed, a patient may feel shock, grief, anger, disbelief, or disappointment because the replanted part simply does not look like it did before. Worries about the look of a replanted part and how it will work are common. Talking about these feelings with the doctor helps many patients come to terms with the outcome of the replantation. The doctor may also ask a counselor to help with this process.
When Additional Surgery Is Needed
Some patients who have fully recovered from replantation surgery may need additional surgery to regain full use of the part. Some of the most common procedures are:
- Tenolysis: frees tendons from scar tissue
- Capsulotomy: releases stiff, locked joints
- Tendon or muscle transfer: moves redundant (non-essential, or spare) tendons or muscles to an area that needs the tendon or muscle more
- Nerve grafting: replaces a scarred nerve or a gap in the nerves to improve how the nerve works
- Late amputation: removes the part later because it does not work or has become painful
The replanted part never regains 100% of its original use; most doctors consider 60 to 80% an excellent result. Generally, patients who have not injured the joints will get more movement back than those who have. A cleanly cut part usually works better after replantation than one that has been crushed or pulled off.
Younger patients have a better chance than adults of growing their nerves back. They may recover more feeling and may regain more movement in the replanted part.
Cold weather can be uncomfortable for patients with replanted body parts. It is a frequent complaint, even for those with an excellent recovery.
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AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.