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Dr. Levin (second from right) and part of the surgical team work toward completion of a bilateral forearm and hand transplantation, the first such procedure performed at the Hospital of the University of Pennyslvania, in September 2011. The team comprised 30 members, and the procedure took 11 and a half hours to complete.
Courtesy of David Cribb.

AAOS Now

Published 7/1/2012
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Terry Stanton

Issues Surround Replantation Services

Access to microvascular surgery still problematic

Thanks to advancements in microsurgery, limbs or fingers that have been accidentally severed can often be reattached. But replantation services are not readily available—even at Level 1 trauma centers.

According to L. Scott Levin, MD, FACS, only 60 percent of Level 1 trauma centers have replantation services available every day at all times, and the number of such centers has declined “precipitously” over the past decade. He addressed this and other issues during the American Society for Surgery of the Hand (ASSH)/American Association for Hand Surgery Specialty Day and in an interview afterward.

Dr. Levin, who is chairman of the department of orthopaedic surgery and a professor in the division of plastic surgery at the University of Pennsylvania, noted that the introduction of the microscope has had a significant impact on hand surgery. “I tell my residents that a day without a microscope is like a day without sunshine,” Dr. Levin said.

“During the past 25 years, the indications for replantation have changed and outcomes have improved,” he noted. Certain types of amputation injuries have become less common due to improvements in workplace safety and equipment. For example, circulating blades in modern lumber mill saws will stop spinning instantly when they contact the moisture and galvanic current of a finger.

Crush-avulsion and mutilation injuries, however, are more severe than guillotine amputations. “We know these patients do much worse,” he said. “They may also have metabolic issues and ischemia reprofusion issues that require you to save the life before the limb. The principles of shortening, fusion, and fasciotomy apply.”

Surgical workforce issues
Unfortunately, microsurgery is not a part of many orthopaedic training programs, so that many aspects of microsurgery are relegated to reconstructive plastic surgery. “The rigors of learning to be a microsurgeon have dissuaded many young people from doing replantation. Educational, social, economic, and generational issues are affecting care delivery,” said Dr. Levin.

“Most orthopaedic surgeons are supposed to learn the techniques and procedures in their hand fellowships, but many hand fellowships don’t include microsurgery or replantation,” Dr. Levin said. “It’s become something of a dying art.”

He acknowledged that training is an issue; learning to perform microsurgery might require more than a single-year fellowship.

“Major centers throughout the United States don’t even provide replantation. Our emergency room colleagues can spend hours on the phone trying to find somebody who will take a patient, often across state lines,” he continued.

Surgeons who opt not to perform replantations cite a variety of reasons, including liability concerns and uninsured patients.

Change is coming
Dr. Levin has spent a number of years addressing the issue. He has worked with the American College of Surgeons (ACS), the ASSH, and the AAOS to develop a plan for regional replantation service centers, similar to burn or trauma centers. That collaborative effort paid off when the ACS revised its trauma center policy and requirements to mandate that every Level 1 trauma center be able to deliver microvascular care at all times or have a transfer agreement with another center. The new requirement will go into effect with the publication of the next edition of Resources for Optimal Care of the Injured Patient—the “Green Book”—in the spring of 2013.

“That’s a huge achievement,” Dr. Levin said. He noted that hospitals might chafe in complying but that they need to face up to their obligation. Dr. Levin estimates that one or two replantation centers will be needed in each state and, on a national basis, 500 to 800 surgeons who are willing to take call one night a week would be needed. “We have an adequate workforce to provide this care in major centers, particularly in the teaching hospitals,” he said.

The future of replantation
Dr. Levin also covered the increasing appreciation for “spare-part” surgery and the concept of “never throwing anything away.”

“Sometimes extremities cannot be replanted but can be used to resurface a particular level,” he noted. “If an arm is severed just below the elbow and it’s not deemed replantable, it could be used to cover the elbow joint or extend the length of the residual limb. If multiple fingers are amputated, one or two may be replanted and the others used for their skin, vessels, and bone.”

Dr. Levin anticipates that, as immune-reaction issues are solved, allotransplantation may increase. Currently, patients receiving donor extremities must be on immune suppression therapy for their entire lives.

“If we cannot replant a limb, we should do everything we can to preserve the amputation level. Some day, when we have modulated the immune system, the patient may be a candidate for a vascularized composite allotransplantation,” Dr. Levin said.

Allotransplantation will be “the highest rung on the microsurgical reconstructive ladder,” he said. “It may provide promise for a whole category of patients who previously had no hope.”

Meanwhile, Dr. Levin will continue in his effort to ensure that replantation care is available to all patients in need.

“For me, this is a lifelong pursuit of protecting the public and providing care,” he said.

Disclosure information for Dr. Levin: KLS Martin, LP.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Patient access to replantation services may be limited by the number of surgeons trained in microsurgery and the number of centers offering such services.
  • Beginning in 2013, all Level 1 trauma centers will be required to have the ability to deliver microvascular care at all times or have a transfer agreement with another center.
  • The ability to address immune system issues may enable allotransplantation and increase the need for surgeons able to perform reconstructive microsurgery.