Historically, the amputated fingertip, distal phalanx, or the entire digit was the first to be replanted. With the advent of microsurgery 50 years ago, the reattachment success rate was increased and thus the salvage rate improved. Function and sensation were enhanced with restoration of circulation (arterial and venous), bone stabilization, tendon repair, nerve connection, and skin closure. Attention to the preoperative, operative, and postoperative care has all led to improved function [1].

Simultaneously, larger amputated structures were being replanted in an effort to provide a functional and viable arm or leg. In the early 1960s, replantation of the arm was attempted and accomplished by a number of surgical programs throughout the USA. In January 1963, a 15-year-old Eskimo male accidentally caused the amputation of his right arm just below the shoulder while playing a game with friends using a commercial washing machine. The arm had been amputated just below the shoulder, due to the rotary motion of the machine. Feeling he would bleed massively, all automobile speed limits were broken by me when the ER nurse contacted me. On my arrival, the boy was reading a comic book in no distress at the nurse’s desk. Ten minutes later another boy brought the arm wrapped in a towel to me at the hospital outpatient clinic. After laboratory, blood typing, proper surgical preparation, and repair of the nasal injuries while using a pHisoHex prep, the mangled arm was reattached focusing primarily on the vascular supply. Following several hours of surgery, we then elected to remove the arm due to its condition and close the upper arm stump approximately 4–6 inches below the shoulder. Later, after consultation with other centers, the consensus was that the brachial plexus twisting and avulsion along with the mangled multiply fractured distal arm wounds incurred by the arm would not have allowed function in the future, even if viable, and that no replantation and that arm removal was the best option. His wounds healed well and he was referred for outpatient physical therapy and rehabilitation.

Unfortunately, functionality of these extremities was and remains a major concern for the treating physician and the patient. Viability did not guarantee usability of the replanted extremity nor was the patient free from complications and further health risks. Later, when Professor Harold Haley and I attended a trauma meeting in San Antonio, two patients were presented. One had an upper arm amputation without replantation. He was happy, outgoing, and employed. The other had a surviving upper arm replantation without return of function. He was depressed, withdrawn, and not working—thus a concern as to whether the arm should have been reattached was expressed.

Some time later, we then encountered the near-total amputation of a leg except for a few inches of skin. He represents a viable replant but with minimal function. After reconstructive boney, muscular, vascular, and neural component surgery, his leg was viable. But a decade later, he requested amputation of the near-functionless but viable extremity due to multiple problems, including infection, with the replanted extremity.

With experience over the years, physicians and surgeons learned more about the multiple aspects of extremity amputation and salvage reattachment. The factors concerning preoperative preparation, surgery, and postsurgical care all became of importance if one wished to salvage the amputated extremity or a part thereof of the body Table 54.1.

As listed above, a number of factors concerning the incident, its location, the cause, and the condition of the injured patient are all relevant to the possible salvage and replantation of an extremity. Obviously, the part amputated must be salvageable and potentially viable without undue risk of life while obtaining a viable replant. The harmed individual must be potentially salvageable and transportable to a facility where the amputated part and amputee may receive appropriate care without undue delay. Infection potential and time delay must be managed appropriately and safely.

At the treating facility, evaluation of the tissue for crush, mangling, or inappropriate contamination with infectious or noxious agents will be performed. Antibiotic and resuscitation steps will be initiated. Simultaneously, determination as to the patient’s acute and possibly chronic health condition will be taken into consideration. Checking for other major ancillary injuries will be important—especially of the cranial, thoracic, and abdominopelvic organs. Cleanliness and patient temperature concerns will be important determinants in the decision process.

In surgery , appropriate anesthesia and multisystem monitoring will be maintained before, during, and after the reattachment. Blood loss, body and extremity temperature, heart rate, and urine volume will require consideration. Certainly the ability to locate and label appropriate structures will require adequate time after boney stabilization. Tendon, neural, and vascular (venous and arterial) anastomoses will follow with appropriate identification and surgical techniques [1]. The closure of skin over the exposed structures without tension will aid in tissue survival and avoidance of infection. All of this care will require a long period of anesthesia, maintenance of vitals, and multiple personnel—including surgical specialties or subspecialties.

Postoperatively , depending on the condition of the patient and the amputated structure, the use of the intensive care facilities and staff may be necessary. Laboratory, vital signs, and patient-extremity monitoring will all be of value. Complete blood count (CBC), electrolyte, x-ray, and urine volume will be followed as appropriate. Patient alertness and responsiveness will affect one’s evaluation as well as color and temperature of the amputated tissue replanted. With time, dietary and ambulatory options will be advanced. With more stabilization, short-term physical and occupational rehab programs will be initiated and the longer programs introduced. Reasonable early onset of such programs will aide in the eventual rehab of the patient.

As presented above, the number and type of personnel involved in the patient’s care vary from the local accident scene to the long-term post-discharge rehab staff. At the scene of the trauma, there may be only the patient, a few bystanders, or a crowd. Many times the paramedics or emergency personnel will arrive at the scene and monitor the situation. With our first patient, he and his friends walked to the clinic. Later, two friends carried the arm in to the clinic.

At the hospital, the emergency staff (nurses, LPNs, secretaries, transport team, and physicians) will all become involved (Table 54.2). Diagnostic personnel including x-ray and laboratory individuals will perform necessary testing. The surgical team then provides the necessary anesthesia; nurses; orthopedists; general, vascular, neural, or hand surgeons as well as circulators; and other OR staff. Then the patient is transferred to the recovery, regular ward, or intensive care staff for 24 h care depending on the patient’s condition and level of amputation (Table 54.3). After stability, the regular floor or ward staff and inpatient physical or occupational therapy programs will be initiated. The long-term posthospital rehabilitation program and staff will then follow, as well as the posthospital medical staff, to monitor for complications and possible need for repeat interventions.