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Page 2 of 7 Luthringer et al. Plast Aesthet Res 2020;7:42 I http://dx.doi.org/10.20517/2347-9264.2020.35

upper limb salvage. We also emphasize technical points that may lead to successful upper extremity major
limb replantation.

EVALUATION AND ASSESSMENT
Surgeons considering upper extremity replantation must take into account the injury’s devastating effect
[4,5]
on patient quality of life, functionality, and possible financial burden . Despite the profound nature of
this decision process, few substantiated algorithms delineating replantation versus revision amputation
[5]
exist in the current literature. Märdian et al. proposed an algorithm that took into account injury pattern,
patient risk factors, ischemia time, and contamination. Larson et al. expounded upon variables that
[6]
were significantly associated with choosing replantation: severity of systemic conditions, mechanism
and level of injury, ischemia time, and patient motivation comprised the foremost imperative factors
involved in management choice. Regardless, all algorithms should include a full initial patient evaluation
per conventional trauma standards. After going through the advanced trauma life support protocol, a
thorough exam, appropriate studies, and radiographic images of the proximal appendage and amputated
segment should be included in the initial assessment. Patients suffering high acuity systemic trauma
may demonstrate compromised ability for wound healing which is incompatible with replantation. Life
threatening injuries may absolutely preclude patients from undergoing long operations with sustained
[6,7]
[6]
general anesthesia . Larson et al. described in his retrospective study, spanning 11 years with 62 upper
extremity amputation patients, a significant association with the choice of revision amputation and an
Injury Severity Score of 16 or greater, indicating severe trauma. Further, those higher acuity patients who
did undergo replantation were more likely to experience replant failure .
[6]
The mechanism and level of injury plays a large role in anticipating the salvage probability of soft
tissue structures at amputation sites. Sharp or penetrating injuries, especially “guillotine” amputations,
demonstrate less extensive damage to sharply divided soft tissues. These injuries are associated with
[6]
significantly higher rates of attempted replantation over crush or avulsion events . Injuries that are
distally located may also encourage replantation attempts. On the other hand, proximal injuries may be
prone to increased effects of ischemia as more muscle mass and neuronal tissue are devoid of perfusion.
Additionally, this tissue is subsequently exposed to greater oxidative stress and reperfusion injury that can
sabotage microsurgical replantation efforts [6,8-10] . Therefore, the upper extremity amputation injury must be
considered when constructing an operative plan.

Furthermore, a close relationship between the surgeon and occupational therapist is invaluable to obtain
optimal function outcomes. Frequent communication of plans allows for real-time feedback, rehabilitative
protocol revision when needed, and can increase a patient’s faith in the treatment plan. Having a trusted
and reliable team of therapists available is vital when evaluating a patient for successful replantation. It is
also critical the patient be evaluated holistically to ensure appropriate candidacy for replantation. Patients
with injuries caused by multiple self-harm attempts may discourage replantation attempts unless post-
operative mental health care and constant monitoring are in place. When possible, the surgeon must assess the
patient’s occupation, physical demands, and motivation to endure a long and arduous rehabilitative course.

PROGNOSTIC FACTORS FOR UPPER EXTREMITY LIMB VIABILITY
One of the most crucial variables affecting limb salvage after replantation is the ischemia time of the
amputated segment. Replantation for wrist-proximal amputations should be attempted before 12 h of cold
[11]
ischemia time or 6 h of warm ischemia time . Prolonged warm ischemia time is particularly associated
with increased changes in cellular metabolism of susceptible muscle tissue. Damaging oxidative stress
renders the muscles dysfunctional, increases vessel permeability, and predisposes the patient to reperfusion
syndrome . Emergency personnel should be instructed to wrap the amputated extremity in gauze and
[11]