Replantation may be contraindicated for reasons involving the patient or the digit.
Patients may decline on the basis that they want to return to work rapidly. Cosmetic concerns will determine many decisions. Age negatively affects the digit's capacity to recover, especially sensation, and it affects the patient's ability and will to rehabilitate. Sophisticated hand function and cosmetic considerations are less relevant in the elderly, and many will elect not to replant. On the other hand, elderly patients' hands are relatively stiff and compromised so that loss of digits will theoretically affect them more. Replanted digits in such hands, even if suboptimal, may closely approximate preinjury status and be highly prized. Medical fitness for prolonged anesthesia and prolonged rehabilitation also must be considered. Major associated injuries may mitigate against replantation as would uncooperative patients, for example, with mental retardation who may not tolerate postoperative care and rehabilitation.
Relatives, especially when a child is involved, ask if they could donate their finger, but rejection of course contraindicates this. Rejection was on the mind of surgeons who were confronted with a bizarre case in Argentina (Loda G, personal communication, 2004). In a tug of war, the rope broke leading to avulsion amputation of 20 or more digits from multiple participants. A well intentioned but unthinking bystander collected the digits, placed them on ice in a single plastic bag and proudly brought them to the emergency department where the spectacle was reported of amputees frantically squabbling over identification and ownership of their parts.
Grossly damaged digits or inappropriate proximal stumps are the usual contraindications for replantation. Multiple-level injuries and severe avulsions involving tendons and nerves will not function, and digits that have prolonged ischemia times or are frozen are unlikely to revascularize. Even though a digit may be judged nonreplant-able in the case of multiple amputation, a unique opportunity for improvisation exists where the least damaged amputated digits may be replanted on the most useful stump to provide a digit with better function than if replantation proceeded in its true position [25,26]. It may be better to obtain one finger functioning well in an optimal state than to have two less functional digits. A decision to replant often is not made until all structures have been identified and the extent of the damage recognized clearly. Besides digital transposition, digits unsuitable for replantation can provide vascularized small joints for transfer, nerves for grafting, and innervated or venous free flaps. In bilateral injuries, cross hand digital transfers can be considered to maximize function or be used to improve function in previously injured dominant digits .
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