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Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

Woo, Sang Hyun M.D., Ph.D.

Author Information
Plastic and Reconstructive Surgery: November 2019 - Volume 144 - Issue 5 - p 878e-911e
doi: 10.1097/PRS.0000000000006134


In traumatic amputation of digits, hands, or upper extremities, a decision whether to perform a microsurgical replantation depends on the condition of the stump and its amputated parts, the injury level, and the medical condition of the patient. Eastern and Western surgeons differ on indications for replantation. With recent advances of microsurgical techniques, virtually all levels of amputation—from the fingertip to the upper arm—can be considered candidates for replantation (Tables 1 and 2).1–162 The patient’s medical condition and replantation timing are also determining factors, as they impact on the complication rate and final functional outcomes. Emergent replantation is laborious for the plastic surgeon but should be performed with a sense of responsibility and pride in resurrecting the amputated tissue. The goal of this article is to provide practical tips to improve efficiency and success for replantation with absolute indications. Specific controversies involving replantation of a very distal digit, single zone 2 digit, multiple digits, ring avulsion, transmetacarpal level, and major limb replantation are discussed along with the issue of replantation timing.

Table 1. - Indications for Replantation
Absolute indications
 Multiple digits
 Single digit in children
 Individual digit distal to the flexor digitorum superficialis tendon insertion
Relative indications for replantation
 Distal to the distal interphalangeal joint
 Single digit proximal to the flexor digitorum superficialis tendon insertion
 Local crushing or clear avulsion
 Elbow and above elbow, sharply amputated or moderately avulsed
 Patients of advanced age

Table 2. - Contraindications to Replantation
Life-threatening associated injuries
Psychologically unstable patients
Systemic illness (e.g., severely arteriosclerotic vessels)
Severe crushing or avulsion
Multiple segmental injuries of the amputated part
Extreme contamination
Prolonged warm ischemia time in major limb amputation


Very distal digital replantation is defined as a replantation distal to the distal interphalangeal joint.1,2 The literature shows higher success rates and good functional and cosmetic results with replantation compared with revision amputation at this level, which raises the question of whether to consider it as a relative indication for replantation (Table 3).3–26 Absolute indications may include children, individuals concerned with the aesthetic appearance of their hands, and those for whom full-length restoration is advantageous, such as musicians (Level of Evidence: Therapeutic, IV).

Table 3. - Analysis of Dedicated Distal Digital Replantation Series Since 2000
Reference No. of Replantations Mean Age (Range) (yr) Level of Amputation Success Rate (%) Presence of PA/ND Author’s Conclusion
Lim et al., 20193 43 32 T1* 72 NC No significance of venous repair in distal replantation
Aksoy et al., 20174 94 35.4 (22–63) T1 84 NC Palmar venous repair did not show significant effect on venous congestion but reduced the rate and severity
Braig et al., 20175 11 T1/T2 73 38%/25% Successful distal digital replantation leads to high patient satisfaction with only minimal functional limitations; fingertip replantation should be attempted
Kim and Lee, 20156 46 45.5 (15–72) T1 91.3 4/NC Y-shaped vein grafting technique enable better aesthetic result and successful rate in distal replantation
Huang and Yeong, 20157 27 42.7 (5–68) T1–T2 81.5 10%/40.7% No significance of vein repair
Erken et al., 20138 24 31.8 (18–59) T1 (10)–T2 (14) 88 NC/45.8% Controlled nail bed bleeding after artery-only repair showed high success rate
Fufa et al., 20139 6 NC T2 57 NC Success rate of digit replantation (57%) at academic level-I trauma hospitals was lower than previously published rates
Cheng et al., 201310 30 29 (16.45) I2† 93.3 NC Palmar vein repair showed better results than artery-only repair
Chen et al., 201311 30 29.2 (2–61) T1–T3 90 NC Artery-only repair, 2-mm incision at fingertip and local injection of heparin showed good success rate of replantation
Mersa et al., 201412 193 NC P3 84.5 NC Volar vein repair is better than dorsal vein repair
Hsu et al., 201013 5 30.2 (4–51) T1 (3)–T2 (2) 100 NC Arterial and venous revascularization with bifurcation of a single central artery
Shi et al., 201014 12 6 (4–10) I2–I3 91 1/4 Artery-only repair; venous drainage with controlled bleeding technique showed successful result
Buntic and Brooks, 201015 19 28.8 (5–64) I2–I4 100 NC Artery-only repair showed successful results
Ito et al., 201016 67 41.7 (7–68) I1–I4 91%, 1; 85%, 2; 94%, 3; 79%, 4 NC No significant effect of venous repair up to I3
Yan et al., 200917 121 27.5 (3–62) T1 (66)–T2 (55) 90 37%/29% No significance of vein repair or vein graft
Hasuo et al., 200918 143 38 (1–69) I1–I4 93 NC/+ Successful venous anastomosis offers the best way to promote survival
Zhang et al., 200819 120 33 (3–54) T1 95.8 NC Delayed arterial ligation, no external bleeding showed successful result
Li et al., 200820 201 26.2 (1–67) T1 (90)–T2 (11) 79 NC Palmar or dorsal vein repair or venous drainage through medullary cavity in T2 and external bleeding in T1 showed successful result
Koshima et al., 200521 16 15–72 P3 81.3 NC Delayed venous repair showed high successful rate in distal replantation
Matsuzaki et al., 200422 15 38.9 (19–56) T1 86.7 1/0 External bleeding showed acceptable results without venous repair
Hattori et al., 200323 64 2-82 T1 85.9 22%/31% Venous anastomosis is important on distal replantation
Akyürek et al., 200124 21 26 (1–41) P3 76.2 NC Amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only
P3, distal phalanx; PA, pulp atrophy, ND, nail deformity; NC, not commented.
*T, Tamai zone.25
†I, Ishikawa zone.26

Replantation can be performed under either a brachial plexus or a local block. The central artery is the largest terminal branch from the distal transverse palmar arch in Ishikawa zone 2 (Fig. 1).26,28 When longer vessel length is required, a reliable source can be obtained by reversing the distal transverse palmar arch.29 Another source of a vein can be harvested from the proximal interphalangeal joint crease to the digitopalmar crease on the volar aspect or from the thenar area. Using this graft circumvents the arduous task of anastomosing under tension in the depths of the pulp fat, allowing a higher success rate.30,31

Fig. 1.
Fig. 1.:
Ishikawa subzone and Tamai zone of amputation and schematic view of the arterial and venous anatomy of the fingertip. (Left) Both proper digital arteries form the distal transverse arch and then the central artery with branches to the nail fold, nail bed, and then finger pad. The central artery courses close to the midline and just palmar to the distal phalanx. (Right) At the distal interphalangeal joint level, the vein goes distally, the larger vessels are palmar, and proximal to the distal interphalangeal joint, the dorsal veins tend to predominate. At the level of the proximal nail fold, the distal venous arch on just the lateral nail fold area can be found and anastomosed reliably.

Finding a suitable vein is challenging, and venous insufficiency is the most compromising cause of replantation failure. It should be noted that the digital veins distal to the distal interphalangeal joint tend to be larger on the palmar than on the dorsal aspect, and vice versa proximal to it. At the level of the eponychium, 63 percent of fingers have a vein 0.8 mm or larger.32 The distal venous arch lateral to the nail fold is reliably found and can be used for anastomosis (Fig. 2). When veins distal to the nail fold are impossible to repair, salvage procedures such as as external bleeding with “fishmouth” incision, removal of the nail bed, use of medical leech, continuous infusion with heparinized saline, and delayed venous repair can be used.7–10 [See Video 1 (online), which presents the author’s technique of replantation of the very distal amputation, showing central artery repair without vascular clamp and salvage procedure of venous drainage with medical leech and external bleeding.8,15,21,33] Aeromonas hydrophila, a bacterium found in the gastrointestinal tract of the leech species Hirudo medicinalis, can cause infection, and prophylaxis with fluoroquinolones is required.

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Fig. 2.
Fig. 2.:
(Left) Preoperative view of severe crushing amputation of the right long and small fingers at subzone I and the ring finger at subzone II according to the Ishikawa classification. (Center) On the small finger, one central artery and one dorsal vein on the lateral nail fold is repaired. (Right) Eight months after surgery.


A single-digit injury or any amputation at the proximal index finger alone or a level proximal to the insertion of flexor digitorum superficialis is generally regarded as relatively contraindicated for replantation, supposedly because of the loss of sensibility, stiff digital excursion, and overall functional downgrading. Revision amputation is simple and economical, with negligible functional impairment, and is considered as the “standard surgery,” except in patients with a strong need for a longer and more aesthetic digit or a cultural reason (Fig. 3). Zone 2 flexor tendon injury is no longer considered unapproachable with wide-awake tendon surgery, strong repair technique, and early rehabilitation.35,36 Repairing only the flexor digitorum profundus tendon will prevent adhesion between the flexor digitorum superficialis and the flexor digitorum profundus tendons. Attaching the proximal flexor digitorum profundus of an amputated part to the distal flexor digitorum superficialis tendon of the stump is an available option to achieve flexion where significant injury to the substance of the distal flexor digitorum profundus exists. Venting the sheath or pulley for a total of 1 cm in the area close to the amputation level allows smooth gliding of the repaired tendon. [See Video 2 (online), which presents the author’s technique of single-digit replantation, including bone fixation, tendon repair with venting of the pulley, and microanastomosis of the nerve and vessels.]

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Fig. 3.
Fig. 3.:
(Above, left) A 28-year-old guitarist sustained crushing amputation of the left index finger and laceration of the thumb. The left index finger was completely amputated at the proximal phalangeal bone. The ulnar digital artery and both digital nerves were microanastomosed. The flexor digitorum profundus was repaired with Tang’s technique, and the distal part of the A2 pulley was vented about 1 cm in length. (Above, right, and below, left) Appearance at 12 months after the operation. (Below, right) Preoperative and postoperative radiographs.

The sensation in the postreplantation index finger rarely matches that of the middle finger, which substitutes for the index finger in its place.36 If the radial digital nerve cannot be repaired, replantation is contraindicated. An unused replanted digit in an everyday setting impacts heavily on the functional outcome. Decreased hand dexterity after a single-digit replantation is significantly associated with older age and poor recovery of sensation.37 However, selected cases of single-index-finger amputation have the potential for satisfying survival and functional results (Table 4).37–47 From a medicoeconomic perspective, a single-digit replantation has a higher incremental cost-effectiveness ratio compared with revision amputation.40,43,44,48

Table 4. - Analysis of Dedicated Single-Digit Replantation Series
Study No. of Digits Mean Age (Range) (yr) Injury level Success Rate (%) Follow-Up (mo) Functional Outcome Indication (Pros/Cons) Authors’ Conclusions
Nakanishi et al., 201937 23 2.9 (1.1–5.7) T* I–V; thumb, 3; index, 11; long, 9 100 23 (13–25) TAM, 61%; SW test, 3.9; pinch†, 53% Pros Decreased hand dexterity after single-digit replantation by older age and poor recovery of sensation
Milone et al., 201938 54 <30 yr, 17; 30–50 yr, 24; >50 yr, 13 Distal to the midmetacarpal level <30 yr, 41%; 30–50 yr, 58%; >50 yr, 46% NC NC Pros Relationship between vein repairs and survival of single-digit replantation; more veins repaired is not necessarily to improve survival rate; two veins should be repaired for every arterial anastomosis
Wang et al., 201839 538 Success, 42; failure, 51.3 Distal to MPJ 91.4% NC NC NC A high level of D-dimer can be an independent factor predicting replantation failure
Zhu et al., 201840 354 39.7 T I–V 87.6 At least 12 TAM: thumb, 136 deg; fingers, 192 deg; protective sensation, 93.9% Pros/cons Relative contraindications; single amputation of small (T I–V), ring (I–III), and long (I) fingers; extra benefit from replantation; thumb (I–V), index (I–V), long (II–V), and ring (IV–V) fingers
Chen et al., 201841 30 44.2 (20–65) Thumb, 14, index, 12; long, 2; ring, 1; small, 1 Failure excluded 36 (19–50) TAM: thumb, 53%; fingers, 58%; grip‡, 90.5%; pinch, 81.5%; 2-PD, 10.4 mm; SW test, 3.7; DASH, 6.6 (0–39.2); CI, 53% Psychological result: depression, 2 patients; PTSD, 1 patient Pros Total grip strength is the most important factor positively related to subjective outcomes; the incidence rates of psychological symptoms after digit replantation are very low at long-term follow-up
Cho et al., 201842 1670 11.2% trial among 14,872 single-digit amputations 76–82% NC NC Pros Patients are more likely to undergo replantation if they had private insurance or a higher level of income; more single-digit amputations are treated by urban teaching hospitals with a higher likelihood of replantation
El-Diwany et al., 201543 17 41 Flexor zone II, 8 complete and 9 incomplete Failure excluded At least 24 DASH, 14; Beck depression score, 1.06; CI, 9 always and 5 often Pros Significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation; replantation of zone II amputated digits should be considered, as long as the patient desires replantation
Buntic et al., 200844 23 index 39 (17–67) Zone 1, 11; zone 2, 9 100% 11–12 TAM: zone 1, 170 deg; zone 2, 133 deg; mean QuickDASH, 14 Pros Selected cases of single-index-finger amputation have the potential for satisfying survival and functional results
Braga-Silva, 200145 85 24 (15–33) Guillotine, 60%, avulsion, 40% 85.9% After 8-hr stay, patients discharged with ambulatory protocol; in 15 patients, thrombosis was noted in the replanted segment; 12 of 85 patients (14.11%) lost the replanted digit completely
Soucacos et al., 199546 67 11–65 Complete, 31; incomplete, 36; MPJ distal Complete, 81%; incomplete, 89% NC ROM of PIPJ, 20–30 deg (proximal PIP group); 2-PD, 13 mm, adult Pros/cons The indications for replantation of a single-digit amputation: (1) amputation distal to the insertion of the FDS; (2) ring injuries type II and IIIa; (3) amputations at the level of or distal to the DIPJ
Urbaniak et al., 198547 59 22.7 Distal to FDS, 48; proximal to FDS, 11 86% 53 ROM of PIPJ: distal to FDS insertion, 82 deg; proximal to FDS, 35 deg Pros/cons Replantation of a single finger amputation distal to FDS insertion is justified; proximal to FDS insertion, seldom indicated
T, Tamai zone; TAM, total active range of motion; SW, Semmes-Weinstein; NC, not commented; MPJ, metacarpophalangeal joint; 2-PD, two-point discrimination; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; CI, cold intolerance; PTSD, posttraumatic stress disorder; ROM, range of motion; PIPJ, proximal interphalangeal joint; DIPJ, distal interphalangeal joint; MPJ, metacarpophalangeal joint; PIP, proximal interphalangeal; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; FPB, flexor pollicis brevis.
*Tamai zone25: I, distal to FDP or FPL insertion; II, distal interphalangeal joint to FDP insertion or interphalangeal joint to FPL insertion; III, middle phalanx distal to FDS insertion or proximal phalanx distal to FPB insertion; IV, proximal phalanx to middle phalanx FDS insertion; and V, metacarpophalangeal joint and proximal.
†Pinch: mean pinch strength percentage of the contralateral hand.
‡Grip: mean grip strength percentage of the contralateral hand.


Crush and avulsion injuries in children are common, and replantation survival is lower than in adults, but it should not be a contraindication for replantation. Diminutive vessels and their propensity for vasospasm make the replantation challenging, but the functional results are much better than in adults because of quicker soft-tissue healing, less scar formation, better nerve regeneration, enhanced tendon gliding, and easier joint mobilization.49 Bone shortening is minimized to preserve the epiphyseal plates. Simple fixation with Kirschner wire is the preferred method, with cautious exercised to not cross the growth plates; if necessary, a smooth Kirschner wire over a threaded one is preferred, to minimize injury (Fig. 4). Postoperatively, sedation to maintain calmness and somnolence helps in preventing vasospasm. Recovery of sensibility is as good as for the isolated digital nerve repair. Without significant epiphysial damage, digits can attain 81 to 90 percent of the normal length.50,51 Despite numerous complications related to venous congestion,52 the success rates of pediatric digital replantation have been reported to be as high as 95 percent (Table 5).50,53–61 The satisfaction level for both patient and parents are so high with a successful replantation that it justifies the comprehensive effort required.

Table 5. - Analysis of Dedicated Pediatric Hand and Upper-Extremity Replantation Series
Study No. of Digits Mean Age (Range) Success Rate (%) Functional Outcome Authors’ Conclusions
Lafosse et al., 201852 65 2.9 yr (1.1–5.7 yr) 47 TAM; 72%
Cold intolerance, 5/8 in unsuccessful cases and 1/7 in successful cases
Venous ischemia treated with controlled bleeding in 86%; venous blood flow is a key factor of success
Wen et al., 201753 21 39.9 mo (18–65 mo) 95.2 2-PD, 3.8 mm; ROM of DIPJ, 88–90 deg; pulp atrophy, 19% (3/16) Successful palmar venous anastomosis appears to promote the survival of pediatric fingertip replantation
Berlin et al., 201454 455 9.3 ± 6.2 yr 81.5 NC Lower likelihood of suffering a total complication, requiring amputation, and longer stay in the hospital; broad indication for performing digit replantation in children
Yildirim et al., 200855 17 4 mo–14 yr 58.7 Chen criteria61*: excellent, 7; good, 1; sensory recovery, satisfactory Postoperative sedation, immobilization; dressing changes under general anesthesia or sedation
Dautel et al., 200756 18 <16 yr 66.6 2-PD, 4.6 mm; cold intolerance, 25%; mild atrophy of pulp Excellent sensory return in the absence of any neural repair
Faivre et al., 200357 8 9.2 yr (3–15 yr) NC All mild pulp atrophy; cold intolerance, 25%; 2-PD, 4.6 mm Spontaneous neurotization in the absence of nerve repair in children; mechanism of injury/body weight were most influencing factors for survival; blood transfusion in 41%; importance of successful venous repair
Waikakul et al., 200058 36 <13 yr 94.4 Chen criteria: excellent, 30; good, 4; sensory recovery, satisfactory Type of injury was the most important factor determining both survival rate and final functional outcome; all replanted digits could grow nearly normally and none had significant deformity
Cheng et al., 199850 26 4 yr 79 Mean TAM of thumb, 120 deg; mean TAM of fingers, 151 deg; normal 2-PD, 88%; grip strength, 79% of contralateral; activities of daily living, 96% (excellent); bone growth, 88–93% In long-term follow-up, the ultimate hand function is successful and no unacceptable complications or sequelae remain
Baker and Kleinert, 199459 41 <36 mo 69 NC No relationship between ischemic time and growth rate; daily activity: important factor in promoting growth
Saies et al., 199460 Total, 162; complete, 73; incomplete, 89 3 days–16 yr Complete, 63%; incomplete, 88% Mean TAM of fingers; 155 deg; 13/17, 2-PD <5 mm Level of the injury did not influence survival; TAM was significantly better when the level of amputation had been distal to the insertion of the FDS tendon; the age of the patient, the mechanism of injury, the duration of ischemia, and the number of vessels repaired did not influence the functional outcome
TAM, total active range of motion; 2-PD, two-point discrimination; ROM, range of motion; DIPJ, distal interphalangeal joint; NC, not commented; FDS, flexor digitorum superficialis.
*Chen grade61: II, good; III, fair; IV, poor.

Fig. 4.
Fig. 4.:
(Above, left) An 8-year-old boy injured his right ring finger while inline skating. The digital artery and nerves are avulsed. Fracture involves distal interphalangeal bone and joint, which shows Salter-Harris type III epiphyseal separation. Fracture of the distal and middle phalangeal bone is fixed with two transverse Kirschner wires. (Above, right) Proximal radial digital artery is anastomosed to the distal ulnar digital artery. (Below, left) Nerve repair is carried out between the proximal ulnar digital nerve and the distal radial digital nerve. (Below, right) Postoperative view, 25 months later.


Replantation with arthrodesis at the distal interphalangeal joint amputation gives good function and appearance with minimal disabilities.62 One or two Kirschner wires are inserted through the medullary canal of the distal end of the amputated tip, just volar to the nail, and pushed up proximally into the phalanx but not crossing the proximal interphalangeal joint of the replantation finger. Damage to the proximal interphalangeal and metacarpophalangeal joints is detrimental to the functional recovery of the digit, which should be preserved at all cost.63 Preservation of the proximal interphalangeal joint in periarticular amputation is possible using a modified 90-90 wire with intraarticular loop wire in the anteroposterior direction and intraosseous loop running perpendicular to it in the coronal plane around the two fragments.64

Wrist arthrodesis is preferred for amputation around the radiocarpal joint with extensive bone fractures. Proximal carpal row carpectomy is recommended for amputation at the level of the intercarpal joint with or without fractures of proximal carpal bones.65 Amputation at the elbow joint with an intact joint surface and temporary use of a Kirschner wire with external fixator can preserve joint function. If the passive motion is maintained after replantation, free functioning muscle transfer reconstructs joint motion of the elbow. [See Video 3 (online), which demonstrates the author’s technique of joint salvage for replantation of amputation at the wrist and elbow joints.] The surgeon should always and foremost contemplate preserving the joint over fusion in periarticular amputations.

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In completely degloved finger skin without bone or tendon injuries, a suitable vessel for replantation can be seen only by turning the skin inside out. Otherwise, a zigzag volar incision is needed to find the vessels. When shortening or disarticulation of the distal phalangeal bone is present, the skin tension needs to be reduced before reattachment (Fig. 5). Digit avulsion with fracture or joint injury at a level distal to the insertion of the flexor digitorum superficialis but with an intact proximal interphalangeal joint can be considered to be the best indication for replantation.66,67 With the significant injury in the distal flexor digitorum profundus, repairing the proximal flexor digitorum profundus to distal flexor digitorum superficialis tendon is an option to obtain flexion. Arterial reconstruction requires either long venous interposition grafts or digital artery transfer from an adjacent digit. When suitable arteries are not available, arteriovenous shunting can be a useful alternative procedure.68 Flow-through venous flaps harvested from the distal forearm are very useful for reconstructing both vascular and soft-tissue defects.69–71

Fig. 5.
Fig. 5.:
(Above, left) A 10-year-old girl sustained avulsion amputation while participating in archery. The left index finger was completely avulsed, with the flexor digitorum profundus. The extensor tendon is repaired with the multiple figure-of-eight technique at zone II. The proximal flexor digitorum profundus is repaired to the flexor digitorum profundus with a modified Becker technique. The ulnar digital artery was anastomosed with a vein graft approximately 1.2 cm from the volar aspect of the proximal interphalangeal joint. Both digital nerves are anastomosed. After closure of the epiphyseal growth plates approximately 6 years later, the distal interphalangeal joint is fused because of extension lag of the joint. (Above, right) Appearance at approximately 8 years postoperatively demonstrates active motion of the proximal interphalangeal joint. (Below, left) Preoperative and (below, right) postoperative radiographs are shown.

It is not always possible to reconstruct both digital nerves. Single-digital-nerve reconstruction is mandatory to restore protective sensation of the pinch side of the digits. Nerve transfer from the intact proximal digital nerve to the distal digital nerve is preferred over a nerve graft from the intact portion of the avulsed nerve. The terminal branch of the posterior interosseous nerve or branch of the medial antebrachial cutaneous nerve is the last available graft source. Tension-free neurorrhaphy and wrapping them with a collagen conduit attenuates neuropathic pain in digit.72 Extensive soft-tissue necrosis oftentimes follows successful replantation because of the soft-tissue damage and disruption of the neurovascular structures. Additional flap coverage is often necessary for late necrosis (Fig. 6). Defatting of the degloved skin and converting it into a full-thickness skin graft is a reliable technique to decrease the risk of necrosis. Functional outcome after replantation (Table 6)9,58,61,67,68,69,73–86 in terms of sensibility and range of motion is better compared with what is historically cited in the literature (Level of Evidence: Diagnostic, III).87

Table 6. - Analysis of Dedicated Replantation Series of Avulsion Amputation
Study Mean Age (Range) (yr) No. of Replan tations Level of Amputation Vessel Repair Additional Procedure Success Rate Functional Results Authors’ Conclusions
Hamouya and Barbato, 201873 23.7 72 Kay 89 IV* Vein graft in 79.1% 57%; vein graft; 65%; direct repair, 27% TAM, 167 deg; 2-PD, 6 mm; CI, 2 cases Vein graft for arterial flow; replantation should be attempted
Kayalar et al., 201768 24 (17–40)† Complete, 9; incomplete, 3 P1–P2 Arteriovenous repair, 33%; vein graft, 22% Secondary amputation, 2; bone shortening, 2; skin graft, 4 66.7% NC Completely degloved skin survives in approximately 2 of 3 cases
Mersa et al., 201474 NC 28 NC Vein repair: dorsal veins, 2.4; volar veins, 1.7 Additional volar vein 68% NC More volar vein repair, greater possibility of survival
Crosby et al., 201475 40 33 Urbaniak classification91‡: class I, 8; class II, 13; class III, 12 II, vessel repair; III, 10 amputation revisions; 2 replanted 93.4% TAM/2-PD: I, 224 deg/5 mm; II, 175 deg/7–10 mm; III, NC/7–10 mm; CI, 9.1% (3/33) Replantation in class III is warranted only in select situations
Fufa et al., 20139 39 (17–79)† 18 NC Vein graft (needed) NC 56% NC Tobacco use/vein graft: significance (+)
Adani et al., 201367 36 (14–54) 39 Kay Vd, 28; IVp, 6; IVi, 5 Artery transfer, 54.5%; vein graft, 45.5% Vein graft or vein transfer for venous drainage 87.9% TAM, 185 deg; 2-PD, 8–15 mm; CI, 5 cases Resection of the avulsed digital artery and vein, vessel transfer from middle finger
Özaksar et al., 201276 29.7 (15–51) 37 Kay IVid Artery transfer, 56.8%; vein graft, 16.2%; end-to-end anastomosis, 27% Skin graft; amputation 83.8% TAM, 172 deg; 2-PD, 9 mm; CI, 46.2% (12/26) Radical resection of damaged zones of vessels and healthy vascular anastomosis
Brooks et al., 200777 35 (12–80) 59 Class I, 9; class II, 40; class III, 10 Primary artery repair, 37%; vascular graft, 56%; venous flap, 7% Partial necrosis, conservative, 1; late arterial anastomosis, 1 85.5% TAM/grip§: I, 210 deg/81%; II, 190 deg/70%; III, 174 deg/63% Excellent survival and good functional outcome after microsurgical treatment of selected ring avulsion injuries
Hyza et al., 200778 NC 6 Type III One artery with vein graft and two veins repair 100 TAM, 195 deg; 2-PD; 9 mm; grip, 37.4 kg Liberal resection of the “zone of contusion” of vessels and primary vein grafting for arterial repair
Sanmartin et al., 200479 34 (12–66) 105 (Kay I, 19; II, 18; III, 33; IV 35) Vein graft for artery and vein reconstruction (needed) Venous flap (needed) 81% TAM; 173 deg; 2-PD; 8 mm; grip; 37.4 kg Reconstruction of 2 or more veins resulted in higher survival rates
Akyürek et al., 200280 27 (20–44) 7 Urb class III All vein grafts for artery reconstruction 85% TAM, 194 deg; 2-PD, 7.8 mm Extended débridement of the avulsed digital artery and interposition with long venous grafts
Waikakul et al., 200058 3–51† 89 MPJ to DP† Artery or vein graft (needed) 78.6% Chen grade‖: II, 5; III, 18; IV, 47 Single avulsion amputation is not a good candidate for replantation
Beris et al., 199481 26 14 Urb class II, 1; class III, 13 One artery and one or two veins Staged flexor tendon reconstruction, 3 64.3% 2-PD, 9.4 mm Primary microsurgical repair is the treatment of choice for almost all ring avulsion injuries and especially for children
Weil et al., 198982 40 (13–81) 16 Urb class I, 2; class II, 7; class III, 7 One artery and one more veins 83.3% TAM/2-PD: I, 192 deg/8 mm; II, 224 deg/6 mm Subdivision of ring avulsions to class IIC
van der Horst et al., 198983 NC 48 Urb class II, 23; class III, 25 Vessel repair 12 cases in II; 9 cases in II; 90.5% Sensibility; S3+¶; CI, 39.3% (11/28) Immediate use of long venous interpositional grafts in all cases
Kay et al., 198969 35 55 Urb class I, 3; class II, 25; class III, 27 Use of vein graft, 61.1% in class II and 43.8% in III Secondary amputations, 9 79.5% TAM I, 128 deg; II, 103 deg; III, 92 deg; 2-PD, <10 mm in 47%; CI, 65.2% (15/23) Propose a new classification system including skeletal injury
Nissenbaum, 198484 36 7 Urb class IIA 5/7; end-to-end or vein graft; not revascularized, 2/7 Secondary Z-plasty 100%(5/5) TAM IIa, 236 deg; CI; 1 Revascularization of class IIA ring avulsion injury results in as close to a normal digit as possible
Tsai et al., 198485 40 7 Urb class III Vessel repair; 1.9 arteries/3.3 veins 85.7% (6/7) TAM: 159–174 deg; protective sensation; CI, 67% (4/6) Damaged PIP joint: completion of amputation; amputation distal to the PIP with a functional FDS: primary microsurgical repair
Urbaniak et al., 198186 NC 24 Urb class I, 2; class II, 9; class III, 13 Vessel repair, 67% (16/24); amputated, 6/24, 87.5% (14/16) TAM: II, 206 deg; III, 145 deg; sensory, good; CI, 0 In completely amputated or degloved finger, favor revision of the amputation
TAM, total active range of motion; 2-PD, two point discrimination; CI, cold intolerance; PN, partial necrosis; NC, not commented; MPJ, metacarpophalangeal joint; DP, distal phalanx; PIP, proximal interphalangeal joint; FDS, flexor digitorum superficialis.
*Kay (Kay classification84): I, circulation adequate; II, circulation inadequate without skeletal injury; III, circulation inadequate with skeletal injury; Vid, complete amputation distal to the insertion of FDS; Kay VIp, complete amputation proximal to the FDS insertion; Kay IVi, complete degloving injuries with intact tendons.
†The age of specific injury zone was not reported.
‡Urb (Urbaniak classification87): I, circulation adequate; class IIA, circulation inadequate with arterial damage; class IIB, circulation inadequate with bone, tendon, or nerve injury; class III, complete degloving or amputations.
§Grip: mean grip strength percentage of the normal hand.
‖Chen grade61: II, good; III, fair; IV, poor.
¶S3+: sensibility based on British Medical Research Council.

Fig. 6.
Fig. 6.:
(Above, left) A 19-year-old man had his right hand degloved in a rolling machine and sustained complete degloving of all fingers and thumb, including the palm and dorsal hand and distal wrist. The flexor pollicis longus and distal phalangeal bones of the thumb and other fingers are avulsed together with soft tissue. After complete débridement of the degloved skin and the proximal stumps, the fracture and dislocation are fixed with a longitudinal Kirschner wire. The princeps pollicis artery, second and fourth common digital arteries of the degloved skin, and the proximal stumps are anastomosed to each other for revascularization. Basilic vein and dorsal metacarpal vein anastomosis is performed in the proximal degloved skin to allow venous outflow. Vein graft from the volar aspect of the forearm is used to restore the venous flow. (Above, right) On the third week after first operation, soft-tissue necrosis of the palm and skin necrosis of the digits is covered with split-thickness skin graft. (Below, left) Three months later, contracture of the first web space and palm is released with adductor myotomy with transverse two-Kirschner-wire fixation. Reverse radial forearm fasciocutaneous flap covered the defect. (Below, right) Postoperative view, 16 years later.


Replantation is considered for all traumatically amputated thumbs, irrespective of type and level of amputation (Fig. 7 and Table 7).9,25,40,58,61,88–103 Bone shortening of the stump is kept to a minimum, and arthrodesis is more generously accepted for amputation near the interphalangeal or metacarpophalangeal joint. A thumb with interphalangeal fusion can still have useful motion through the metacarpophalangeal joint and carpometacarpal joint without flexor pollicis longus and extensor pollicis longus repair. Thumb with metacarpophalangeal joint fusion can still maintain the role of a post for opposition with digits.

Table 7. - Analysis of Dedicated Thumb Replantation Series
Study No. of Digits Mean Age (Range) (yr) Amputation Level (Tamai Zone25) Injury Mechanism Success Rate (%) Surgical Technique Functional Outcome Authors’ Conclusions
Zhu et al., 201840 112 39.7* T† I, 11; T II, 27; T III, 41; T IV, 33 Saw (40%)* 87.6% NC NC Replantation of thumb (I–V); extra benefit compared with revision amputation in functional outcome and therapeutic costs
Mahmoudi and Chung, 201788 773 Success, 39.9; failure, 40.4 Machinery > cut > others > auto > firearm 79% NC Regionalization of digit replantation procedures to high-volume centers can achieve the highest rate of successful revascularization
Wagner et al., 201789 8 42 (21–60) MPJ to IPJ Avulsion in all 8 cases 100% Bridge arterial graft ROM of MPJ, 46.5 deg; diminished 2-PD; no or mild pain Bridge grafting using a vein to bridge the dorsal radial artery to the ulnar digital artery of the avulsed thumb
Fufa et al., 20139 40 39 (17–69)* T III, IV Sharp, 69%*; crush, 16%; avulsion, 15% 68% Vein graft (if needed) The rate of success of digit replantation (57%) at two academic level I trauma hospitals was lower than previously published rates
Shale et al., 201390 550 NC NC Machinery, 73% 84.9% NC NC Teaching and high-volume hospitals attempt to replant a higher percentage of traumatic thumb amputations; success rates are similar across practice settings
Haas et al., 201191 34 43 (15–66) Complete, 20; incomplete;14; IPJ, 11; P1, 15; MPJ, 4; base of M1, 4 Sharp, 35%; saw, 35%; crushing, 30% 100% Classic form of replantation procedure Quick DASH, 11.3; Mayo score, 110; SW test, 4.32; TAM, 124 deg; pinch, 4.6 kg Functional results are independent of amputation level, length of ischemia, and patient age; mechanism of injury affects sensory recovery; return to previous occupations, 59%
Agarwal et al., 201092 52 42 (21–81) Zone I, distal to IPJ, 13; II, IPJ to PJ, 29; III, proximal to MPJ, 34 Sharp, 65% Total, 92%; zone I, 100%; II, 94%; III, 75%; sharp, 94%; avulsion, 89%; crush, 89% Artery repair:
UDA, 33; RDA, 10; both, 5; crossover repair, 3; vein graft, 9
Pinch‡/grip§; sharp, 65/75%; avulsion and crush, 38/56% High rate of survival; secondary surgery; related to zone of injury; pinch and grip strengths worse in crush or avulsion
Tian et al., 200793 6 31 (5–56)* IPJ, 1; MPJ, 3; CMCJ, 1; RCJ, 1 Sharp, 1; avulsion, 2; contusion, 1; crush with avulsion, 1; degloving, 1 100% Vessel repair; proximal artery to the vein of the amputated part and proximal veins to 2 or 3 veins in the amputated part MPJ, 28; IPJ, 53 deg; 2-PD, 7 mm; pinch, 2.9 kg; no CI in all cases after 2 yr Venous arterialization may salvage otherwise nonreplantable thumbs
Unglaub et al., 200694 24 39 (10–70) P2, 6; P1, 9; M1, 8; M1 base, 4 Crush/avulsion, 15; sharp, 9 100% Classic form of replantation procedure DASH score, 16.7; TAM, 56 deg; grip, 70%/pinch, 68% of contralateral
Sensation: normal, 4%; reduced, 25%; protective, 54%; loss of protective, 12%; non, 4%
Functional results; independent of amputation levels and patient age; returned to previous occupation, 66%
Sharma et al., 200595 103 35 (1–68)* Complete, 51; incomplete, 52; P2, 28; P1, 40; MPJ, 25; M, 10 Saw, 50; crush/avulsion, 32; guillotine, 21 91.3% Vein graft, 34%; 12 cases reexplored, 75% salvaged NC High survival rate regardless of the mechanism of injury or level of amputation; early reexploration for vascular problems; use of vein grafts in severe crush and avulsion injuries
Hattori et al., 200196 7 20–82 Distal to nail fold Clean, 57%; blunt, 29% 100% Interposition vein graft; no nerve suture SW test: 3.61, 5; 4.17, 2; nail deformity (positive), 3; pulp atrophy, (positive), 3; IPJ ROM, 45–90 deg Replantation of very distal thumb amputations with preosteosynthesis interpositional vein graft to terminal branch of the digital artery; subcutaneous vein repair near the midline of pulp
Waikakul et al., 200058 Single, 228; combined, 99 3–51* Complete, 212; incomplete, 16 Crushing, 68% 99.1% Arterial anastomosis, 2 (83%) Chen grade61‖: I, 184; II, 92; III, 37; IV, 4 The most important factor determining the survival rate, surgical technique, and functional outcome was the type or mechanism of injury
Aziz et al., 199897 27 33 (2–78) IPJ, 8; P1, 13; MPJ, 3; CMCJ, 3 All avulsion 48% Primary arthrodesis of IPJ, 4; tendon transfer, 6 Protective sensation, 11; 2-PD <10 mm, 2; TAM, 108 deg; grip, 48 lb Tendon transfers and primary arthrodesis in thumb avulsions replantation
Arakaki and Tsai, 199398 122 33 (2–78) P2, 24; IPJ, 36; P1,40; MPJ, 12; M, 6; CMCJ, 4 Guillotine, 81; avulsion, 24; combined, 17 Mean, 71%; guillotine, 88%; avulsion, 58%; combined, 12% Bone shortening, 7.8 mm; vein graft if needed NC Type of amputation influences the survival; age, smoking history, amputation level, no. of vessels reconstructed, not related to survival
Goldner et al., 199099 89 34 (3–81) P2, 3; IPJ, 19; P1, 21; P1 base, 22; MPJ, 4 Laceration, 55; avulsion or crush, 45% 78% Standard manner Compared to uninjured side, grip, 84%; lateral pinch, 68%, TAM, 42; 80% daily use; CI, 57% Demonstrate uniform superiority of replantation over revision
Bieber et al., 1987100 39 36 (6–73)* Avulsion IPJ, 26%; P1, 28%; MPJ 41%; CMCJ, 5% All avulsion 26% Vein graft, 67%; artery transfer, 8% All, 2-PD >10 mm The success rate of thumb replantation is low
Vlastou and Earle, 1986101 7 10–56 P2, 1; IPJ, 1; P1, 4; MPJ, 1 All avulsion 91.3% Use of vein graft; avulsed digital nerve anastomoses at the carpal tunnel Thumb amputation is the best single indication for a digital replantation attempt
Cheng et al., 1985102 15 22.9 (17–32) P1, 8; MPJ, 7 All avulsion 93% Artery/vein transfer; nerve transfer; fourth FDS to FPL and EIP to EPL tendon transfer TAM of IPJ, 10–60 deg; 2-PD, 6–12 mm By transfer of blood vessels, nerves, and tendons, all the tissues can be repaired primarily
TL; Tamai level; MPJ, metacarpophalangeal joint; IPJ, interphalangeal joint; CMCJ, carpometacarpal joint; ROM, range of motion; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; NC, not commented; RDA, radial distal artery; RCJ, radiocarpal joint; 2-PD, two-point discrimination; CI, cold intolerance; P1, proximal phalanx; M1, first metacarpal; SW test, Semmes-Weinstein monofilament test; FDS, flexor digitorum sublimis, FPL, flexor pollicis longus; FPB, flexor pollicis brevis; EIP, extensor indicis proprius; EPL, extensor pollicis longus.
*The age and injury mechanism were not subdivided.
†Tamai classification: TL I, distal to FPL insertion; II, interphalangeal joint to FPL insertion; III, proximal phalanx distal to FPB insertion; IV, proximal phalanx to metacarpal shaft.
‡Pinch: mean pinch strength percentage of contralateral hand.
§Grip: mean grip strength percentage of contralateral hand.
‖Chen grade61: II, good; III, fair; IV, poor.

Fig. 7.
Fig. 7.:
(Above, left) A 37-year-old man had segmental amputation and crushing injury of the left thumb. Both flexor and extensor tendon are repaired, and the first metacarpal artery is anastomosed to the distal segment of ulnar-side digital artery, and then the princeps pollicis artery is microanastomosed to the communicating artery branch at the metacarpal neck of the proximal segment. A very narrow skin bridge provides venous drainage between the amputation segments. (Above, right) Postoperative appearance approximately 5 years later. Key pinch and grip power of the left hand are 20 lb and 100 lb, respectively, which are 85 percent and 95 percent of the contralateral side. Active range of motion of the interphalangeal joint is 30 degrees. Static two-point discrimination of the thumb is 12 mm. (Below) Preoperative and postoperative radiographs.

The ulnar digital artery is the dominant artery in a thumb and is reliable for anastomosis. Proximally, the princeps pollicis artery can provide sufficient blood flow from the dorsum if no palmar arteries are suitable for repair. The easiest primary repair is anastomosis of the severed ends of both digital arteries after bone shortening. If not, an interposition can be performed with a short or long vein graft harvested from the volar aspect of the wrist or forearm. Microscope focusing while repairing the ulnar digital artery at various levels can be very challenging, as it requires extreme arm pronation or supination. It is easier to anastomose interpositional vein grafts to the terminal branch of the ulnar digital artery before osteosynthesis. The proximal anastomoses can be performed dorsally, proximal to the area of injury in the supine position.

At least one ulnar digital nerve must be repaired. If both digital nerves are severely damaged, the radial digital nerve could be used as a graft to reconstruct the ulnar digital nerve. Several surgical options are available for avulsed flexor pollicis longus and extensor pollicis longus, depending on the level of fracture, disarticulation, and severity of contamination. [See Video 4 (online), which demonstrates the author’s various techniques of replantation for avulsion amputation of the thumb according to the amputation level.]

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Replantation of three or more fingers may result in complications that are beyond the functional and cosmetic problems of hands. It is quintessential to pay meticulous attention to all aspects of surgery, including techniques, preservation of amputated parts, anesthesia, and postoperative care, to avoid compromising the digits’ survival and to maintain the patient’s vital signs (Table 8).61,104–115

Table 8. - Analysis of Dedicated Multiple Digit Replantation Series
Study No. of Digits in Each Case (no. of patients) Mean Age (Range) (yr) Ischemic Time Operative Time Success Rate (%) Follow-Up Functional Outcome Operative Method
Kwon et al., 2016104 4 (30); 5 (5) 41 275.4 min (150–510); WIT, 94.8 min (15–270) 313.2 min (170–530 min) 87.5% (PN, 2.8%; TN, 9.7%) 3.5 (1–6) yr TAM: >200 deg; 27.1%; 150–199 deg; 34.1%; 100–149 deg; 31.8%; <99 deg; 7%; S2-PD, 12.5 mm (6–18); grip*, 67%; Chen criteria61†: I, 32.3%; II, 39.0%; III, 22.6%; IV, 16.1% Structure-by-structure (2 or 3 applications of the tourniquet)
Kantarci et al., 2010105 10 34 NC 7 hr 100% (PN, 1 finger) 38 ROM of MPJ and IPJ:
Loss within 20–30 deg; S2-PD, 6.1 mm; D2-PD, 4.0 mm
Under axillary block; two-team approach; structure-by-structure
Cong et al., 2010106 10 23 NC 9 hr 20 min 100% 7 yr TAM: thumb, 135–145 deg; finger, 220–255 deg; S2-PD, 4–11 mm; grip*, 69–81 lb; pinch, 13–19 lb Under axillary block; four-team approach; no bone shortening and vein graft
Cheng et al., 2004107 5 32 12 hr 9 hr All 2 digit survived (only 2 fingers could be used for replantation) 2 yr Open palm span of 10 cm; pulp-to-pulp pinch function is satisfactory Double transpositional digital replantations (index to thumb, ring to small)
Schwabegger et al., 1999108 2–5 (13) 38 (16–69) NC NC All replanted digits survived 29 mo (12–74 mo) TAM: thumb, 60–130 deg; finger, 0–180 deg; adequate sensation (S3, S3+, S4‡), 91%; S2-PD, 2–10 mm Transpositional digital replantations
Kim et al., 1996109 9 (3); 10 (5) 29 (17–49) WIT, 10 min–15 hr; CIT; 3–29 hr 19–31 hr 92% 1–5 yr S2-PD, 3–22 mm; grip*, 13–65 lb (42%); pinch, 5–26 lb (50%); PPD, 0–7 cm Under general anesthesia; two-team approach; digit-by-digit
Qing-tai et al., 1996110 10 45 13–36 hr 100% 6 yr TAM: thumb, 50 deg; finger, 140–160 deg; S2-PD, 9–14 mm Under axillary block; one-team approach; structure-by-structure
Soucacos et al., 1994111 2–5 (34) NC NC NC Total, 82.3%; thumb, 100% NC S2-PD, 10–14 mm; cosmetic appearance of the hand with a transposed digit or thumb was acceptable to the patients Transpositional digital replantation
Chiu et al., 1994112 4–5 (19) 24 (2–48) 2–11.5 hr; WIT, 20 min–8 hr 9 hr 8 min (5 hr 10 min–15 hr 50 min) 93.7% 1–7 yr TAM: >200 deg, 30.6%; 150–199 deg, 44.4%; 100–149 deg, 22.2%; <99 deg, 2.8%
Tamai scoring system25§: excellent, 61.0%; good, 36.6%; fair, 2.4%
Structure-by-structure; transpositional digital replantation
Baek et al., 1992113 9 (2); 10 (2) 28 (17–49) WIT, 1 hr 30 min–4 hr; CIT, 3 hr 10 min–27 hr 25–31 hr 100% (PN 1 finger) 13–20 mo S2-PD, 7.8 mm; grip, 13–65 lb; pinch, 5–15 lb; PPD, 0.9–2.85 cm; no significant atrophy or deformity Under general anesthesia; four-team approach; digit-by-digit
May et al., 1986114 8 21 39 hr‖ 46.5 hr 87.5% 35 mo S2-PD, 6–15 mm; grip, 17–18 lb; pinch, 5–15 lb; PPD, 2.2 cm; no active PIP joint motion Under general anesthesia; digit-by-digit
Wei et al., 1984115 10 26 10.5–28 hr 26 70% NC TAM: thumb, 65–70 deg; finger, 115–160 deg; S2-PD, 4–15 mm; grip, 21–24 kg; pinch, 2.2–6.5 kg Under general anesthesia; two-team approach; structure-by-structure
WIT, warm ischemic time; PN, partial necrosis; TN, total necrosis; TAM, total active range of motion; S2-PD, static two-point discrimination; D2-PD, dynamic two-point discrimination; ROM, range of motion; MPJ, metacarpophalangeal joint; IPJ, interphalangeal joint; NC, not commented; CIT, cold ischemic time; PPD, palm to pulp distance; PIP, proximal interphalangeal joint.
*Mean grip strength percentage of the normal hand.
†Chen grade61: II, good; III, fair; IV, poor.
‡S3, S3+, S4, sensibility based on British Medical Research.
§Tamai scoring system: 0–39, poor; 40–59, fair; 60–79, good; 80–100, excellent.
‖Maximum ischemic time.

Regarding prolonged ischemic time, it is preferable to use a digit-by-digit replantation109,113,114 sequence rather than structure-by-structure. A structure-by-structure sequence, however, is more efficient, as prolonged cold ischemic time at this amputation level does not affect the survival rate and final functional outcomes of the replanted digits (Fig. 8).104,105,110,112,115

Fig. 8.
Fig. 8.:
A 38-year-old man suffered from a sharp cutting injury on the left hand by a machine saw. The left index finger was amputated at the proximal interphalangeal joint, and the long, ring, and small fingers are amputated at the proximal phalanx. According to the structure-by-structure sequence of replantation, all amputated stumps were débrided, and digital nerve and artery are tagged with 6-0 black silk. Perpendicular 90-90 degree intraosseous wires are passed on the fracture site. Total operation time for four-digit replantation is 7 hours 45 minutes, and total amount of transfusion is 3 units.

Because of the importance of the pinch and grasp functions of the hand, replantation order should be thumb first, followed by the middle finger, ring finger, index finger, and the small finger last. Postoperative digital length does not positively impact the overall function of the hand and thus any prolongation of operation time and efforts to preserve the digit length is discouraged. A need for vessel or nerve graft is avoided by bone shortening at the phalangeal bone.

When multiple digital amputations include a nonreplantable thumb, the least damaged digit is replanted in place of the mutilated thumb (Fig. 9). Transpositional replantation aims to achieve basic pinch, tripod pinch, and most importantly, opposition grip. With an intact thumb, the digit is replanted toward the ulnar side of the hand so the palm span width is preserved and grip power is increased.107,108,111 In case of bilateral multiple-digit amputations or bilateral multiple-digit and hand amputations, the replantation effort is directed at increasing the dexterity of the dominant hand or restoring basic hand function by transposing digits or hand from less injured parts. Cross-hand replantation or cross-arm replantation is aimed to save at least one hand or one limb used for pinch and grasp.

Fig 9.
Fig 9.:
(Left) After a devastating crush amputation injury caused by a press machine, the right thumb, index, and long fingers seem nonreplantable. (Center) The amputated part of the long finger is transposed to the thumb. (Right) Follow-up 27 months later after second- and third-ray amputation.


Poor functional results after replantation at this level have been mainly attributed to the poor recovery of intrinsic muscle function, caused by the direct injury to intrinsic muscle, ischemia, or postoperative scarring.116,117 Replantation at this level is not technically difficult, and the primary survival rate is reported at 67 to 100 percent (Table 9).58,61,116–125

Table 9. - Analysis of Dedicated Transmetacarpal Replantation Series
Study No. of Digits Mean Age (Range) (yr) Injury Mechanism Ischemic Time Success Rate (%) Bone Fixation Vessel Repair Functional Outcome (Chen Criteria61*) TAM (deg) 2-PD (mm) Cold Intolerance Authors’ Conclusions
Paavilainen et al., 2007116 44 34 (1–71) Circular saw laceration, 26; crush, 11; sharp cut, 3; avulsion, 2; explosion, 1; degloving, 1 NC 86 Compression wiring, 32 patients Vein graft, 16 I, 7; II, 8; III, 18; IV, 5 154 14.7 Half of patients The majority of transmetacarpal injuries with devascularized rays can be revascularized/replanted with a good subjective and satisfactory functional end result; most patients can resume their old occupations or be employed after reeducation
Yildirim et al., 2003118 1 32 Severe crush 7 100 K-wire Direct III 88 >15 Four finger Cross-hand replantation should be considered to obtain at least one functional extremity
Waikakul et al., 200058 24 NC NC NC 100 NC NC II, 2; III, 10; V, 12 NC NC NC Regular cigarette smoking may result in a poor survival rate; prolonged ischemia had a significant influence on the final functional outcome, although there was no significant effect on the survival rate
Weinzweig et al., 1996118 13 37 (17–62) Crush, 11; explosion, 1; guillotine, 1 NC NC NC NC II, 4; III, 4; IV, 15 109 >15 NC None of the manual laborers (11 patients) were able to return to their preinjury livelihood; despite these discouragingly poor results, all patients were satisfied with the surgery
Gerostathopoulos et al., 1995119 16 31 Guillotine, 9; crush, 5; avulsion, 2 10 (5–12) 87.5 NC NC NC 64 >15 NC The best return in sensibility was observed in a young patients in whom the nerves could be approximated without tension and following guillotine type of amputations
Scheker et al., 1995120 4 NC NC NC 100 NC NC I and II, 3; III, 1 189 5–10 NC Early protected mobilization preserves tendon gliding, muscle strength and excursion
Tark et al., 1989121 29 NC Guillotine or local crush, 23; diffuse crush or avulsion, 6 NC 96 NC NC NC NC 5 NC Return of intrinsic muscle function after hand replantation was poor; however, patient satisfaction with the procedures remained high
Tonkin et al., 1988122 3 44 (20–58) Guillotine, 1; crush, 1; avulsion, 1 8–16 67 K-wire Radial artery, direct; dorsal vein, Y shape vein graft NC NC NC NC Three transmetacarpal injuries are described in which the patency of one common digital vessel alone provided blood flow to all fingers
Russell et al., 1984123 8 36 (18–69) Guillotine, 5; crush, 1; avulsion, 2 9.5 100 NC NC II, 3; III, 3; IV, 1 94 15–30 NC Young patients with complete, sharply amputated extremities at the wrist level or those with incomplete injuries and uninjured peripheral nerves had the best functional results; multiple-level, diffuse crush, or avulsion injuries, even if the injuries were incomplete, and patients with high-level nerve injury had less return of function
Scott et al., 1981124 4 0 NC NC NC NC NC III 192 2 NC Restoration of tendon and joint function was aided by early and aggressive flexor tendon reconstruction and early digital motion
Zhong-Wei et al., 198161 54 54 NC NC NC NC NC NC 18 4 NC Evolution of a treatment plan requires careful consideration and synthesis of the many factors but always with a view toward what will be of greatest total benefit for our patients
Meyer et al., 1976125 1 28 Guillotine 9.5 (2.7, warm; 6.8, cold) 100 K-wire fixation; late, thumb End-to-end, radial artery; vein graft, ulnar artery I 70 12 Slight In the contracture of the intrinsic muscles in our case, tissue damage from ischemia was possibly of importance
TAM, total active motion; 2-PD, two-point discrimination (in mm); NC, not commented; K, Kirschner.
*Chen criteria61: I, excellent; II, good; III, fair; IV, poor.

At least 1 cm of bone shortening is recommended to prevent secondary intrinsic tightness in the fingers (Fig. 10). Careful bone fixation can prevent malrotation of a digit, which results in greater functional deficit than in other digits. At least three or four dorsal veins should be anastomosed, approximately two veins for each artery. It should be identified both in the distal amputated part and stump, then ligated to prevent postoperative hemorrhage from the branches of the deep metacarpal arteries, causing a hematoma after revascularization. The distal portions of devitalized and denervated interosseous muscles should be completely débrided, allowing the intrinsic tendons to tenodese in an intrinsic-plus position.

Fig. 10.
Fig. 10.:
(Above) A 46-year-old man working at a butcher’s shop sustained a guillotine-type amputation to his dominant hand. All intrinsic muscles are debrided and bone fixation is performed with multiple Kirschner wire and plates and screws after metacarpal shortening. All extensor and flexor tendon repair is followed by princeps pollicis artery; second, third, and fourth common digital arteries are microanatomosed and three dorsal veins are repaired. (Below, left) Postoperative 12 months later. (Below, center) Preoperative and (below, right) postoperative radiographs.

The postoperative protocol, which is initiated 72 hours postoperatively, consists of early protective active mobilization with anticlaw splinting. This helps to prevent intrinsic-minus deformity, provides a more serviceable grasping hand, and improves final functional results.120 Intrinsic muscle function and pinch and grip strengths are weak or absent in most patients.


Major limb amputations are defined as those occurring from the proximal radiocarpal joint to the shoulder. In more proximal amputation, there is a high possibility of associated life-threatening injuries that may preclude replantation altogether.

Even with the most efficient emergency room triage system in place, it may take at least 2 hours to reestablish arterial flow to the amputated part.126 If the total ischemic time extends beyond 6 hours, the operator should consider attempting replantation with caution, as the ischemic time and level of injury are important predictors of the success rate.127

The use of a “back table” during anesthetic induction is a valuable tool to prepare the amputated limb and to gain time. The preparation of the amputated part should be started on a back table with sterile drapes well before the patient is brought to the operating room. Débridement is a very critical step in preventing infection and is performed more radically at the muscles of the distal part because the most common complication of major limb replantation is infection. Acute infection postoperatively may lead to ruptured vessels or multiple organ system failures, with life-threatening complications.

Temporary ectopic banking of an amputated major limb is a creative and useful limb-saving technique.128–131 The surgeon might well consider carrying out temporary extraanatomical cross-limb shunting to reestablish the circulation rapidly and to test the survivability of the amputated limb.132 Extracorporeal limb perfusion with an electrolyte solution has the potential to prevent ischemia-related cell damage.133–135 This can be performed before fixing the bone if the time from amputation to arrival in the operating room is longer than 4 hours. Hypothermic perfusion with University of Wisconsin cold storage solution may allow longer periods of preservation, enabling surgeons to take more precise and confirmed preparation before arterial anastomosis.136,137 During the whole phase of surgery, a hypothermic condition is maintained by placing the amputated part on ice bags.

At the wrist and proximal forearm, aggressive bone shortening up to 2.5 to 5 cm of both radius and ulna or 6 to 8 cm in humerus is essential to make the functional restoration possible. Regarding vessel repair, two main arteries and their venae comitantes, and at least two subcutaneous veins, should be repaired. Venae comitantes of the radial and ulnar arteries seem small compared with subcutaneous veins but are capable of draining a significant quantity of blood. After establishing the arterial flow, the vein should be allowed to bleed for 5 minutes. Acute blood loss may cause transient hypovolemic shock, necessitating prompt management. If the ischemic time is over 6 hours and/or there is a considerable muscle mass, the venous blood causes metabolic acidosis, hyperkalemia, myoglobulinemia, and possibly reperfusion injury. With intensive electrocardiographic monitoring, sodium bicarbonate is slowly given intravenously over a period of 5 minutes before clamp release.

Where the nerves are avulsed or segmentally defected, cross-nerve suture between the proximal radial–to–distal median repair or proximal ulnar–to–distal median repair is an alternative method of providing protective sensation of radial digits. If not, the nerve ends must be tagged with 4-0 nylon sutures at an easily accessible plane for later nerve grafting.

In cases of large soft-tissue defects possibly exposing vital structures or plate, tentative coverage with artificial skin or thin-split skin graft should be replaced by flap surgery as early as possible, depending on the general condition of the patient. Negative-pressure wound therapy is less invasive, and improves wound healing and shortens the period before the start of physical therapy in the early period after replantation and revascularization.138–140

Major upper extremity replantation is successful in 70 to 100 percent of cases, depending on the level and mechanism of injury (Table 10).25,61,120,123,136,141–152 Secondary surgical management is mandatory to improve the remaining functional deficit in the surviving limb. Tenolysis is the most common secondary procedure for amputations of the distal forearm to the wrist. Free functioning muscle transfer for amputations between the elbow and midforearm (Fig. 11) and soft-tissue coverage for upper arm replantation is the most common secondary operation.153

Table 10. - Analysis of Dedicated Major Limb Replantation Series
Study Level of Amputation/No. of Cases Mean Age (Range) Mechanism of Injury IT Success Rate (%) Operative Procedure Secondary Procedures Functional Outcome Authors’ Conclusions
Mattiassich et al., 2017141 Total, 16; incomplete, 5; UA, 8; F, 5; W, 3 40.6 yr (14–61 yr) Machine, 6; saw, 7; TA, 2; stone, 1 1.58 hr NC NC FFMT, 5; SKP, 1; SNG, 3; SG, 1; tendon transfer, 1; joint arthrodesis, 2; tenolysis, 1 DASH, 41
Chen criteria61*: I, 6; II, 8; III, 1; IV, 1; CI, all patients; 15, protective sensation
Positive long-term (13.5 yr) results with high rates of subjective satisfaction
Larson et al., 2013142 Total, 20; complete, 15; incomplete, 5; shoulder, 1; UA, 4; F, 5; W, 10 39.8 ± 16.5 yr Crushing, 5; sharp, 15 (avulsion component, 4) 3.6 hr 70 NC Complete revision amputation, 6; SG, 6; flap coverage, 4; tenolysis, 2 NC Replantation attempt, 32.3% (20/62); Injury Severity Score ≥16 at presentation is associated with replantation failure
Leclere et al., 2012143 Total, 11; E, 2; proximal F, 2; mid-F, 4; distal F, 3 43.4 yr (19–76 yr) Guillotine, 2; crush, 4; crush-avulsion, 5 5.9 hr (4–7.5 hr) 90.9 Bone shortening, 5–8 cm; preliminary arterial shunting; routine fasciotomies if CIT/WIT >6 hr; immediate nerve repair Secondary amputation, 1; deep infection, 2; free flap coverage, 2; tenolysis, tendon transfer; nerve graft Chen criteria*: I, 4; II, 3; III, 2; IV, 1
The indications for limb salvage after amputation can be expanded; however, because of the rarity of these replantations, they should be performed at specialized replantation centers
Gulgonen et al., 2012144 Total, 9; FA, 4; E, 2; UA, 3 24 (18–57) Clean cut, 4; avulsion, 3; avulsion/crush, 2 3.5 hr (2–8 hr) NC Bone shortening, 7; primary nerve repair, 5 13 operations on six patients; tenolyses, 2; bone graft, 1; tendon transfer, 4; nerve graft, 4; wrist fusion, 2 Chen criteria*: I, 5; II, 2; III, 2
All protective sensation
Grip, 14.5 kg; pinch, 48% of contralateral
Mild CI, 7
Excellent functional outcomes on long-term follow-up; 18 yr (15–24 yr); grip strength, 2-PD, TAM, and Chen scale did not improve after 5 yr; however, SW test and CI continued to improve up to 10 and 12 yr; replantation of an upper extremity proximal to the wrist joint satisfactorily restored the upper extremity function
Laing et al., 2012145 Total, 20; UA, 5; E, 1; mid-F, 2; distal F, 5; W, 6 30 (2–50) Guillotine, 9; crush, 3; avulsion, 7; gunshot, 1 CIT, 4 (2–7.5) 90 Nerve repair
Primary, 13; secondary, 6; no repair, 1
Tendon repair
Primary, 9; graft, 5; tenolysis, 5; no repair
14, SG; 3, flap; 3, secondary NG; tenolysis, 4; tendon graft, 5, Tamai scoring system25†: good, 7 (41%); fair, 7 (41%); poor, 3 (18%)
Return to old job, 5 (30%); returned to different job, 6 (35%); unable to work, 6 (35%)
Major limb replantation demonstrates favorable or acceptable long-term functional outcomes; high patient satisfaction rates even where results were poor emphasize the positive psychological impact of successful replantation
Sabapathy et al., 2007126 Total, 22; UA, 4; E, 1; proximal F, 6; mid-F, 6; distal F, 1; W, 4 27 (12–56) Crush, 7; avulsion, 3; crush and avulsion, 10; gunshot, 2 300 min (200–600 min) 90.9 PRC, 4; bone shortening, 5–10 cm; brachial block on arrival Secondary nerve and tendon repairs at approximately 3 mo Chen criteria*: I, 3; II, 9; III, 6; IV, 2 Takes at least 2 hr to restore blood flow to the amputated part from the time of a patient’s arrival; very hesitant to attempt replantation if TIT >8 hr; spontaneous neurotization in the absence of nerve repair in children; mechanism of injury/body weight; most influencing factors for survival; blood transfusion in 41%; importance of successful venous repair
Graham et al., 19981 Total, 22; UA, 8; E, 1; F, 7; W, 6 23 (4–56) Crush, 1; avulsion, 4; guillotine, 7; crush and avulsion, 6; guillotine and crush, 3; NC, 1 6.6 hr (2–16 hr); NC, 4 cases 100 NC NC Carroll test123‡: excellent, 5; good, 3; fair, 7; poor, 7 Replantation produces superior functional results compared with amputation and a prosthesis; statistical association between a better outcome in younger patients with more distal injuries
Daoutis et al., 1995147 Total, 47; complete, 19; incomplete, 28; palm, 11; W, 3; F, 27; UA, 5 35 (5–55) NC NC Total, 89 (complete, 100%; incomplete, 74%) Bone shortening; stable fixation; direct repair of vessels, nerve, and tendons; soft-tissue débridement NC Chen criteria*: I, 15; II, 11; III, 16; IV, 5 The type and level of injury, the severity of soft-tissue damage, and the duration of ischemia are decisive factors in determining the functional results
Ipsen et al., 1990148 Total, 26; UA, 11; E, 4; F, 10; W, 1 30 (5–62) Crush, 7; avulsion, 7; sharp, 12 5 (1–15) 85 NC NC Tamai scoring system†: replantation/revascularization: excellent, 3/5; good, 6/7; fair, 8/4; poor, 2/3 To facilitate comparison of materials, a modified and more realistic version of the Tamai scoring system is recommended as a standard for evaluation of functional results following above-wrist replantation
Russell et al., 1984123 Total, 34; UA, 7; proximal F, 6; distal F and hand, 13; hemihand, 8; complete, 22; incomplete, 12 27 (30 mo–69 yr) Local crush, 5; diffuse crush, 8; avulsion, 11; guillotine, 10 9.5 (2–16) 88 NC NC Functional outcomes were described according to amputation levels Young patients with complete, sharply amputated extremities at the wrist level or those with incomplete injuries and uninjured peripheral nerves had the best functional results; multiple-level, diffuse crush, or avulsion injuries, even if the injuries were incomplete, and patients with high-level nerve injury had less return of function
Tamai, 198225 Total, 17; UA, 5; F, 12; complete, 8; incomplete, 7 NC NC NC NC Irrigation-bone shortening and fixation, artery repair, vein repair, muscle/tendon repair, nerve repair, skin suture SG, 6; bone graft, 4; MPJ capsulotomy, 9; NG, 2; tenolysis, 17; secondary flexor repair, 5 Tamai scoring system†: excellent, 13%; good, 27%; fair, 43%; poor, 27%
Wang et al., 1981149 Total, 91; UA, 12; proximal F, 4; distal F, 14; W, 28; palm, 26; lower limb, 7 28.8 (2–55) Clean cut, 33; crush, 24; avulsion, 34 12 hr (4–70 hr) in successful cases 77 NC NC Function nearly normal, 18; function fair and limb useful, 38; no function, 7 Injuries resulting in twisting and tearing trauma had the poorest outcome; no significant difference existed between the viability rates of replantations of complete or nearly complete severance
Zhong-Wei et al., 198161 129 NC NC Chen criteria*: I and II, 63%; III, 32%; IV, 5% Evolution of a treatment plan requires careful consideration and synthesis of the many factors but always with a view toward what will be of greatest total benefit for our patients
Chen et al. 1978150 190 NC NC NC for total cases, but over 10 hr in 21 cases, survival in 14 limb 83.2 Operative sequence: bony framework, blood circulation, muscle and tendons, nerves, skin NC Chen criteria*: I, 34.1%; II, 33.6%; III, 28%; IV, 3.9%) We believe that in replanting severed extremities of prolonged duration, preoperative refrigeration (2–4°C) and postoperative hyperbaric oxygen therapy are beneficial
Malt and McKhann, 1964151 Total, 2; UA, 2 12, 44 Crush, 2 NC 100 Two brachial venae comitantes and then of the artery; bone fixed by IM nail; nerve repair; muscle débridement and repair Split-thickness skin graft; neurolysis Amputation near the shoulder: biceps, pronator, opponens pollicis 30–40% of normal, flexor of finger and wrist >80% of normal The first upper limb replantation; special consideration: (1) preserving the limb by hypothermia until circulation is restored; (2) fixation of the bone; (3) the vascular anastomoses; and (4) management of soft-tissue injury
Kleinert et al., 1963152 Total, 4; E, 1; F, 1; W, 2 38 (23–67) Shotgun blast, 1; guillotine, 1; saw, 1; crush, 1 NC 100 Bone shortening, 2 inch; bone fixation with screw and two Rush nails; BA repair with GSV Flexor tenolysis; extensor muscle and radial nerve repair Arm, 30-deg motion of elbow; wrist, slight extension and flexion of the fingers and could oppose the thumb Infection is a major factor contributing to both thrombosis and secondary hemorrhage; more important than antibiotics was a thorough and extensive wound toilet; skeletal framework must be stabilized before vascular anastomosis (this prevents later kinking, trauma, or thrombosis, of the anastomotic site)
IT, ischemia time; UA, upper arm; F, forearm; W, wrist; TA, traffic accident; NC, not commented; FFMT, free functioning muscle transfer; SKP, Sauvé-Kapandji procedure; SNG, sural nerve graft; SG, skin graft; DASH, Disabilities of the Shoulder, Arm and Hand questionnaire; CI, cold intolerance; E, elbow; CIT, cold ischemic time; WIT, warm ischemic time; CRPS, complex regional pain syndrome; 2-PD, two-point discrimination; TAM, total active range of motion; SW test, Semmes-Weinstein monofilament test; NG, nerve graft; PRC, proximal row carpectomy; TIT, total ischemic time; MPJ, metacarpophalangeal joint; IM, intramedullary; BA, brachial artery; GSV, great saphenous vein.
*Chen criteria: I, excellent; II, good; III, fair; IV, poor.
†Tamai scoring system, score of 0–39, poor; 40–59, fair; 60–79, good; and 80–100, excellent.
‡Carroll test: excellent, >85; good, 75–84; fair, 51–74; poor, <51 (by Russell et al.123).

Fig. 11.
Fig. 11.:
(Above, left) A 23-year-old man sustained incomplete amputation of the left forearm caused by a punch-out machine. Both radial and ulnar arteries are completely ruptured, and all flexor and extensor muscles of the digits and wrist are ruptured. The ulnar nerve and superficial radial nerves are severely crushed, but continuity is intact. After radical débridement of crushed muscle and bone fragments, revascularization is performed. At postoperative week 3, the median nerve defect is reconstructed with a cable nerve graft from the sural nerve. Simultaneously, vascularized fibular bone is transferred for reconstruction of the ulnar bone, approximately 14 cm in length. (Above, right) Preoperative radiograph shows severe comminuted fractures with segmental defects of both forearm bones. (Below, right) Six months later, functioning gracilis muscle is transferred to reconstruct flexion of the thumb and all fingers. Four years later, pinch strength and grip power are approximately 16 lb and 34 lb, respectively. (Below, right) Postoperative radiograph.


The negative effects of ischemia can be minimized if the surgery takes place within 6 hours in the case of proximal amputation, and 12 or 24 hours in the case of digital amputation for warm and cold ischemia times, respectively.25,154 However, comparable survival rates and function compared to immediate replantation justifies the option of overnight-delayed and suspended replantation.155–158 In unusual cases of bilateral hand amputations or multiple-digit amputations, combined with unstable underlying ischemic heart disease, lung disease, or severe anemia, planned delayed or suspended replantation may be necessary. When a single-digit amputation presents at midnight, and the amputation stump is well preserved according to standard protocol, prolonged cold ischemic time does not affect the survival rate or final function of the replantation. This delayed replantation, however, is not the best option for amputation levels proximal to transmetacarpal amputation, because of the presence of intrinsic muscle in the hands that are not in digits.

A delayed and suspended replantation approach offers several advantages (Level of Evidence: Therapeutic, IV; and Diagnostic, IV).157,158 It relieves the pressure of overnight operations on the team staff and reduces the overall cost. It allows the operations to be performed fully staffed, and under optimal conditions with well-rested surgeons and staff (Fig. 12). This may, in part, explain the good results obtained in the delayed replantation group, in keeping with others reporting better survival of replantations performed during daylight hours.46 The cost to the hospital and the patient should also be considered. Maintaining all-night operations requires additional anesthesiologists and operating room personnel, which represents an economic burden.

Fig. 12.
Fig. 12.:
Schematic view of a timetable for suspended replantation. OP; operation, WIT; warm ischemia time, CIT; cold ischemia time, TIC; total ischemia time, DT; delayed time to operation, TDT; total delayed time to operation, BT; break time.


The circulatory status of the replanted digits is monitored using a pulse oximeter, implantable venous Doppler probe, digital thermometry, or laser Doppler imaging. Intensive monitoring of capillary refill, temperature, and color by experienced nursing staff is more reliable (Table 11). When either a venous or an arterial insufficiency is detected, reexploration of the occluded vessel with subsequent reanastomosis, cross-anastomosis, or vein grafting is necessary. Detecting venous problems is trickier, and they may be occult because of a compressive splint or tight skin suture.

Table 11. - Monitoring of Circulation in Replanted Digits
Characteristic Normal Arterial Occlusion Venous Insufficiency
Color Pink Pale or white pink Dark pink or purple
Capillary refilling Fast Very slow Very fast
Temperature Warm Cold Warm-cool
Turgor Full Hollow Swollen
Bleeding Bright red Minimal, only serum Dark red or purple

Intravenous anticoagulation is indicated in traction injuries, vascular grafts, and any intraoperative findings suggestive of increased risk for thrombosis. Following a regimen of anticoagulation is recommended for replantation.160 Enteric-coated aspirin is started preoperatively with a loading dose of 1.4 mg/kg, and the same dose is maintained for 2 weeks. Before releasing the microvascular clamps, a heparin bolus of 50 to 100 U/kg is given intravenously. Intraoperatively, dextran 40 is administered at a dose of 0.4 ml/kg per hour, and the dosage is halved on postoperative days 3 and 4; on postoperative day 5, the patient is weaned off. In our institution, we avoid dextran because of the potential allergic reaction and intravascular volume expansion. Although anticoagulants are a useful adjuvant modality, they can never substitute for a properly performed anastomosis.161,162


A detailed review of our institution’s experience on improving difficult replantation involving the amputation of digits, hands, and upper extremities is presented. This article provides a practical, clinically useful overview of the current best techniques and evidence available to the plastic surgeon.


The author thanks the staffs of the W Institute for Hand and Reconstructive Microsurgery for their sleepless endeavor for emergency replantation surgery; Jin Hee Choi, M.D., and Mr. Ki Young Bae for video editing; and Chul Moon, M.D., F.A.B.R., and Andrew Miller, M.S., for manuscript revision to this article.


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