This 2015 JAAOS review by Wolfe and Wang covers the full spectrum of upper extremity replantation. It addresses indications, contraindications, ischemia time limits, operative sequencing, postoperative monitoring, rehabilitation milestones, outcomes data, and ongoing controversies. The central question: who should be replanted, how should it be done, and what can realistically be expected?
The decision to replant is not just a surgical question — it is a counseling and triage question that starts the moment a patient arrives.
When you see a thumb amputation, multiple digit amputation, proximal amputation, or any pediatric digit loss, replantation is indicated. For a single digit through zone II (especially a border digit), the calculus shifts: weaker grip, longer rehab, and a 60% chance of needing a second operation often favor revision amputation.
Ischemia time governs the transfer decision. Digits buy you 12 hours warm and 24 hours cold. Proximal injuries give you only 6 hours warm and 12 hours cold before myonecrosis risk becomes prohibitive. Know these numbers before you call the referral center.
The 57% modern survival rate and the cost and return-to-work data ($42,561 vs $27,541; 125 vs 60 days) are not academic. They are the framework for an honest informed consent discussion. Patients who smoke, have diabetes, or sustained avulsion or degloving injuries should receive a frank conversation about the likelihood of failure and the near-certainty of secondary procedures.
This 2015 JAAOS review by Wolfe and Wang covers the full spectrum of upper extremity replantation. It addresses indications, contraindications, ischemia time limits, operative sequencing, postoperative monitoring, rehabilitation milestones, outcomes data, and ongoing controversies. The central question: who should be replanted, how should it be done, and what can realistically be expected?
The decision to replant is not just a surgical question — it is a counseling and triage question that starts the moment a patient arrives.
When you see a thumb amputation, multiple digit amputation, proximal amputation, or any pediatric digit loss, replantation is indicated. For a single digit through zone II (especially a border digit), the calculus shifts: weaker grip, longer rehab, and a 60% chance of needing a second operation often favor revision amputation.
Ischemia time governs the transfer decision. Digits buy you 12 hours warm and 24 hours cold. Proximal injuries give you only 6 hours warm and 12 hours cold before myonecrosis risk becomes prohibitive. Know these numbers before you call the referral center.
The 57% modern survival rate and the cost and return-to-work data ($42,561 vs $27,541; 125 vs 60 days) are not academic. They are the framework for an honest informed consent discussion. Patients who smoke, have diabetes, or sustained avulsion or degloving injuries should receive a frank conversation about the likelihood of failure and the near-certainty of secondary procedures.