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The goal of all replantation surgery is to restore function to the part and return the patient as nearly as possible to his preinjury level of activity. In many cases, this is dramatically achieved with a single replantation effort such as replacing a scalp, an ear, a distal finger or a foot, but in other instances, the replanted part fails to function and the patient and surgeon become involved in a prolonged reconstructive effort that may last for years. The time, effort, debility, and money involved may or may not justify the final results, and experience and judgment are needed to organize a secondary reconstructive plan. Many variables must be considered in each individual case, and patients with severe or proximal level injuries must be made aware that secondary procedures may be necessary. Experience gained in many replantation centers has attested to the feasibility of replantation,1-7 and we are now entering a period of critical evaluation of functional results.2,8-l0
In our experience, more than 50% of all replant patients require a second procedure, and some as many as four, five or six. This is particularly true in patients suffering multiple-digit or proximal-level amputations. 2,11-13 Other centers report reoperations from 15% to 80%.1,2,4,6,9,14-21 The primary reasons for secondary operations are to improve bony stability and stable cover in the lower extremities 22-26 and range of motion, dexterity, and soft tissue coverage in the upper extremities. 1-4,27-31
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Both primary and secondary variables can affect the final outcome for patients requiring replantation. Primary variables, factors that cannot be completely controlled, include the preoperative mechanism and level of injury, the quality of healing with or without infection, and the severity of scar tissue formation. 2,8 Secondary variables that can be controlled or modified include warm or cold ischemia time,2 preoperative tissue handling, the quality of revascularization, methods of bony and soft tissue repair, postoperative therapy and rehabilitation, patient motivation, and the availability and coordination of all the services needed for secondary reconstruction.32,33
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