Hand and Finger Amputations (Replantation) in Ankara, Turkey

Hand and finger amputations are serious limb losses resulting from high-energy traumas. Replantation surgery aims to restore function by reattaching the severed limb. Success is directly related to the level of amputation, the duration, and the condition of the tissues.

Before the replantation procedure, the severed part should be wrapped in sterile gauze and preserved in a cold environment. In the initial evaluation, the condition of the vascular, nerve, tendon, and bone structures is analyzed. Multilayer repair is performed using microsurgical techniques.

The most critical step in hand and finger replantation is the restoration of vascular circulation. Blood flow is re-established with arterial and venous anastomoses; afterward, tendon, nerve, and bone structures are repaired. The procedure duration is long and requires an experienced team.

After surgery, intensive monitoring and rehabilitation are required. In the first days, monitoring circulation, infection control, and wound care are important. In the long term, hand grip strength, sensation, and mobility are improved with physical therapy. Early and appropriate intervention determines functional success.

What Are Hand and Finger Amputations (Replantation)?

Hand and finger amputations refer to the condition where the limb is completely or partially separated from the body as a result of trauma. Replantation is the procedure of reattaching the severed hand or finger using microsurgical techniques. In this surgical intervention, bone, tendon, vascular, and nerve structures are repaired to restore circulation and function. Success depends on the mechanism of injury, the preservation conditions of the severed part, and the patient’s overall health condition.

What is the difference between replantation and revascularization?

Although among the public every type of amputation and reattachment procedure is generally considered in the same category, for us plastic surgeons these two terms describe completely different scenarios both in terms of the course of the surgery and the recovery process. Understanding this distinction is very important for the patient to know what they will face. When we say replantation, we are referring to a complete amputation. In other words, the finger or limb has been completely separated from the body, has fallen to the ground, or remained inside a machine. In this case, the part is completely lifeless, blood circulation is zero, and it is outside the body.

Revascularization, however, presents a somewhat different picture. Here the limb has not been completely severed; it may still be attached to the body by a piece of skin, a tendon, or a crushed muscle group. However, the critical point is this: the main vessels supplying the part have been cut. In other words, even though the finger is still there, it is pale, cold, and medically left to die because blood is not reaching it. If intervention is not performed, that part will be lost. In both situations the techniques we apply are similar; however, in complete amputations (replantation), additional and difficult stages such as cleaning the severed part, finding the vessel ends, and adjusting bone length come into play.

Situations requiring revascularization are as follows:

• Deep glass cuts
• Partial limb amputations
• Fractures with vascular damage
• Gunshot injuries

Where do microsurgical methods stand in this surgery?

The heart, brain, and hands of these operations are microsurgery. It is not possible to connect vessel ends that appear like simple red dots to the naked eye with standard surgical instruments. In limbs such as fingers, vessel diameters are usually below 1 millimeter, and sometimes even below half a millimeter. The sutures we use to reestablish blood flow through such delicate structures and ensure that it continues without obstruction are so thin that if they fall to the ground you cannot find them, because they are much thinner than a human hair.

For this reason, we use massive surgical microscopes in the operating room. These microscopes enlarge our working area up to 40 times, providing us with a massive surgical field within that millimetric world. Microsurgery is not limited to suturing vessels. It also includes repairing the severed nerve ends one by one, fiber by fiber. In this way, the goal is not only for the finger to remain alive but also to regain sensation months later and distinguish between hot and cold. Therefore, replantation surgery is not a rough tissue attachment procedure but a restoration work that requires precision at the cellular level.

Special instruments included in the microsurgery set are:

• High-resolution microscope
• Micro needle holder
• Jeweler-type forceps
• Vascular clamps
• Micro scissors

Can every severed part always be reattached?

This is the question most frequently asked by patients’ relatives in the emergency department and the one whose answer is the most difficult to give. From an emotional perspective, everyone wants the part they lost to be restored. However, our medical reality and ethical approach are not based on “reattaching every part that can be sewn,” but on “reattaching the part that will be useful.” Because restoring blood flow to a lifeless tissue does not mean that it will become functional. If the finger we reattach becomes a structure that does not move, constantly causes pain, is numb, and becomes stiff like a stick when the healing process ends, this situation turns into more of a punishment than a reward for the patient.

At the decision-making stage, the mechanism of the injury is the most determining factor for us. Cuts we call “guillotine type,” meaning clean amputations caused by sharp objects such as knives, cleavers, or glass, are the group with the highest chance of surgical success. Because tissue loss is minimal, vessel ends are clear, and the wound is clean. However, in injuries caused by crushing, getting trapped in a press machine, caught in heavy machinery, or avulsion-type injuries, the situation is much more severe. In such cases, vessels are damaged not only from the point where they were severed but also from a much wider and deeper area. Since the inner wall of the vessel is damaged, no matter how well we suture it, the risk of clot formation inside the vessel is very high.

Some situations in which replantation is not recommended are:

• Multilevel injuries
• Severe crush damage
• Heavily contaminated wounds
• Prolonged waiting time
• Patients with life-threatening conditions

In which situations is replantation a priority?

There are some exceptional situations where we push the limits as much as possible, no matter how difficult the surgery may be. In scenarios where the possibility of “functional gain” is very high or where the loss of the limb would dramatically make the patient’s life more difficult, replantation becomes an absolute necessity. The foremost example of these is the thumb. Look at your hand and try to hold a glass without using your thumb; you will see how difficult it is. The thumb alone undertakes half of the hand’s functions. Thanks to its ability to oppose the other fingers, it is the center of the gripping and holding function. Therefore, in thumb amputations, no matter how bad the injury may appear, reattachment is always attempted.

Another unquestionable priority is pediatric patients. Children’s bodies have an incredible healing potential compared to adults. The capacity of nerves to regenerate in children is extraordinary. An injury that may result in sensory loss in an adult patient can return almost completely to normal in a child. In addition, the brain structure of children (neuroplasticity) adapts to the repaired limb much more quickly. Although their vessels are thinner and technically more challenging for us, the results obtained in children will affect their entire lifetime, so they are always prioritized.

Priority replantation indications are as follows:

• Thumb amputations
• Pediatric cases
• Wrist-level amputations
• Multiple finger losses
• Palm injuries

How should the severed part be transported and preserved at the time of the accident?

The success of replantation begins not in the operating room but at the accident site. Unfortunately, a finger that was cleanly cut and technically 100% salvageable can become “garbage” because of incorrect transport mistakes made while bringing it to the hospital. The most common mistake here is throwing the part directly into ice in panic. This is the biggest mistake that can be made. Freezing burns occur in tissues that come into direct contact with ice, cells crystallize, and the vascular structure is irreversibly damaged.

The correct transportation method saves lives and is actually quite simple. We can call it the “Three Bag Rule.” The aim is not to freeze the part but to slow its metabolism by keeping it cool. In this way, the tissue can withstand lack of oxygen for a longer time. If transported correctly, parts such as fingers that do not contain muscle tissue can remain viable for up to 24 hours, while larger parts containing muscle can remain viable for up to 6–8 hours. However, the shorter these periods are kept, the higher the chance of success.

The steps that should be followed are:

• Cleaning the part
• Wrapping it in a moist cloth
• Placing it in a dry bag
• Placing it in ice water
• Reaching the emergency department
• Substances that should not be used are:
• Direct ice
• Hydrogen peroxide
• Tincture of iodine
• Alcohol
• Milk

What is the surgical sequence followed during the operation?

When the patient lies on the operating table, while the anesthesia team tries to keep the patient’s general condition stable, we surgeons begin to play a chess game against time. Although it may appear like a trauma dominated by chaos, the operation actually has a very strict discipline and an unchanging order. We generally act according to the principle of “from bone to skin.” Just as you first build the foundation and columns when constructing a building, we first establish the framework of the hand.

The first stage is cleaning and debridement. Nonviable dead tissues are removed under the microscope. After that, the first task is to repair the skeleton. The severed bone ends are usually shortened slightly. This shortening provides us with room so that the severed vessels and nerves can meet end-to-end without tension. To fix the bones, we usually use thin wires or mini screws. After the skeleton becomes stable, we suture the motor units that will move the finger, namely the tendons.

When the skeleton and movement system are ready, we proceed to the most delicate part of the operation, which is vascular repair. First the arteries are sutured to allow blood to reach the part. When we release the tourniquet, seeing that pale and white finger suddenly turn pink is the happiest moment in the operating room. After blood flow is established, the veins that will carry the dirty blood back are repaired. In the final stage, the nerves that carry the sense of touch are sutured under the microscope and the skin is closed.

The surgical procedure sequence is as follows:

• Wound debridement
• Bone fixation
• Tendon repair
• Artery suturing
• Nerve repair
• Vein repair
• Skin closure

Is it necessary to take a graft from the body for vascular repair?

In an ideal world and in clean cuts, we prefer to suture the severed vessel ends directly to each other. However, accidents in real life usually do not occur this way. In crushing, avulsion, or fragmentation injuries, the vessel ends are also severely damaged. Suturing a damaged vessel end is an invitation to blockage. Therefore we have to cut away those crushed and deteriorated parts.

When we perform this cleaning, gaps sometimes of 2–3 centimeters and sometimes longer occur between the two healthy vessel ends. Vessels are not like rubber; you cannot pull and stretch them. If you suture them under tension, the vessel goes into spasm and blood flow stops. To fill this gap, we resort to the body’s “spare part” reservoirs. Usually, a superficial vein segment taken from the inner surface of the forearm or from the dorsum of the foot, which does not have vital importance, is sutured as a “patch” (graft) to the damaged area. This procedure prolongs the surgery time and increases technical difficulty, but it is often necessary for a healthy blood flow.

Regions from which vascular grafts can be taken are:

• Inner surface of the forearm
• Dorsum of the foot
• Leg region

What is the hospitalization process after surgery?

The completion of replantation surgery does not mean the work is finished. In fact, it would not be wrong to say that “the real process begins now.” The first 7–10 days after surgery are at least as critical as the surgery itself. Especially the first 72 hours are the risky process we call the “golden period,” during which vascular occlusions (thrombosis) occur most frequently. For this reason, we keep our patients under very close observation in the ward.

The temperature of the room is very important for us. Because cold air causes vessels to constrict, the patient’s room and body are kept warm at all times. Blood-thinning infusions and medications are administered to the patient. Doctors and nurses come every hour to check the color, temperature, and fullness of the finger. The finger being pink and warm indicates that things are going well, while turning white or purple indicates an urgent problem. During this period, the strictest rule the patient must follow is the smoking ban. Not only smoking themselves but even smoking near them is prohibited. Nicotine is a poison that instantly constricts vessels and may lead to the loss of the finger that has been sewn with so much effort.

The clinical findings that are monitored are:

• Skin color
• Finger temperature
• Capillary refill
• Tissue tension
• Bleeding control