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EARLY CHALLENGES
[11]
Following the first reported successful replantation, there was a surge of interest in replantation surgery .
Hand/microsurgeons attempted replantation with enthusiasm. However, replanted digits often lacked
[11]
function and sensation; some were even painful . Reattaching the amputated digit simply because it was
possible was not enough.

As it became clear that digit amputations were not all equal, hand surgeons first looked to case selection
as a means of improving success rates. The first consideration was if the digit was in suitable condition for
replantation. For instance, a severe crush injury causing comminuted fractures and significant soft tissue
disruption may not be eligible for replantation. Fingers that were stored improperly during transport, such
as in non-biologic solutions or on dry ice, were definite contraindications.

In 1978, a replantation team in Vienna compiled their three-year experience in replantation, which
[12]
included a set of indications . They stated replantation should always be attempted in any amputations
in young patients, especially children. Thumbs should always be replanted but not the other fingers except
in the case of multiple digit amputations causing loss of the ability to grip. They believed single finger
amputations should be performed only if the patient required that digit for their profession, skills, or
hobbies. In 1981, Dr. Zhong-Wei, Dr. Meyer, Dr. Kleinert, and Dr. Beasley, today regarded as pioneers in
replantation, together compiled the experiences from the authors’ home institutions in China, Switzerland,
[13]
and the United States . While they admit that firm indications for finger replantation are impossible, their
experiences largely matched those published by the Viennese replantation team. Since then, the indications
and contraindications have mostly remained unchanged [11,14,15] :
1. Thumb amputations
As the thumb is responsible for up to 40% of hand function, all thumb amputations should be considered
for replantation. Factors that may constitute contraindications in any other single digit amputation are
[16]
underemphasized relative to the importance of the thumb .
2. Multiple digit amputations
Unsurprisingly, the more digits that are successfully replanted, the greater is the final function. Replantation
is attempted starting with the digit with the greatest contribution to hand function and greatest chance of
[17]
recovery .
3. Mid-palm amputations
Amputations at the mid-palm level or more proximally are replanted more successfully than amputations
at the level of the digital arteries. Following successful replantations at this level, function is far superior to
[18]
any prosthetics .
4. Single digit amputation distal to FDS tendon insertion
Reported as early as 1981 by Dr. Zhong-Wei, amputations distal to insertion of the FDS tendon were found
to have superior outcomes .Replanting digits proximal to the insertion of the FDS tendon often results in
[13]
a stiff proximal interphalangeal joint.
5. Amputations in pediatric patients
Pediatric patients have superior healing potential compared to adults. However, their anatomy is even
smaller than that of adult patients and thus cases in pediatric patients may be even more challenging.

While these guidelines were a good place to start, the exact details of the injury and the patient were
determined to be equally, if not more, important. A detailed history - including the circumstances of
the injury, past medical history, and social history were found to be critical in order to determine if
replantation was worthwhile. Mechanism was also found to be a crucial component to the consideration
that directly affects the zone of injury and likelihood for a successful outcome.

While these guidelines were a good place to start, the exact details of the injury and the patient were
determined to be equally, if not more, important. A detailed history - including the circumstances of the