Proper preservation of amputated parts: A multi-level shortcoming

a b s t r a c t

Background: Successful replantation relies on proper preservation of traumatically amputated parts. The estab- lished protocol for preservation, however, is inconsistently adhered to. The objective of this study is to examine the rate of proper preservation in multiple patient populations.

Methods: A retrospective review of patients from 2015 to 2019 at a single academic institution was conducted. Patients were included if they suffered a traumatic amputation, the amputated part was present for evaluation by the hand surgery team, and modality of preservation was documented. Additional data including method of Patient transport, replantation attempt, and operative outcome were assessed. Patients were stratified based on whether proper preservation was employed and compared using chi-square tests.

Results: Ninety-one patients were included, thirty-one (34.1%) of whom had amputated parts which were prop- erly preserved. Patients from referring facilities were more likely to present with properly preserved parts (45.0%) than those presenting from home (25.5%), though this did not meet significance (P = .051). In total, 74 patients arrived via EMS with 35.1% adherence to preservation protocol. Of the 31 patients who had properly preserved parts, 58.1% underwent attempted replant; of the 60 patients who had improperly preserved parts, 23.3% underwent attempted replantation (P = .001).

Conclusions: The majority of patients who suffer traumatic amputations do not present with properly preserved amputated parts, limiting potential replantation. With a direct correlation to attempted replantation, proper preservation is a crucial aspect of care and should not be overlooked when seeking to optimize efforts and results. Level of evidence: Level IV.

Published by Elsevier Inc.

  1. Introduction

Successful replantation following traumatic amputation requires the alignment of many clinical, operative and systemic factors. Clinically, these include mechanism of injury, location and zone of injury, and patient suitability for an extended surgery and recovery period. These factors inherently cannot be controlled by the surgical team. Operative techniques, meanwhile, have been the target of much study and im- provement [1]. Microsurgical advances have allowed replantation with smaller vessels, improving outcomes for distal amputations [2,3]. Systemic factors, which include surgeon availability and annual hospital and surgeon case volume, play an important role in replanta- tion as well. These systemic factors correlate positively with attempts and success rates, and have spurred an effort to develop specific regional replantation centers [4]. It is critical that amputated parts are preserved in a specific manner to optimize their viability, regardless of

* Corresponding author.

E-mail address: [email protected] (H. Sinatro).

method of patient transportation. Advanced Trauma Life Support guide- lines dictate that standard preservation consists of wrapping the part in saline soaked gauze inside a watertight bag and placing it on ice [4-6]. This is a longstanding, proven modality that has both preoperative and post-reperfusion ramifications [7,8].

Adherence to this preservation modality, however, may be inconsis-

tent due to systemic variations. Patients present for evaluation follow- ing traumatic amputations through a number of channels. They can present from home or as transfers from community hospitals, via private vehicle or emergency ground services and even Air ambulance [9,10]. With the varying interfaces between the patient and the medical system, it is likely that each has a different level of adherence to protocol.

Many of the aforementioned factors and variables affect part viability, but improper preservation of amputated parts is the only fac- tor that can render a previously viable amputated part nonviable. It is therefore imperative that this factor be optimized. Several studies em- phasize the importance of proper preservation of amputated parts, but there is little literature to assess the adherence to these recommenda- tions. The aim of this study is to determine the rates of proper

https://doi.org/10.1016/j.ajem.2021.12.010 0735-6757/Published by Elsevier Inc.

preservation of amputated parts in patients arriving from home and from referring facilities, and how these rates correlate with treatment course and outcomes.

  1. Materials and methods
    1. Patient data

Approval was obtained from the institutional review board for retro- spective review of these data. Patient data was collected on 91 patients at a single, tertiary care medical center who experienced a traumatic amputation between the time of ICD-10 implementation, 2015, and the date of data collection, 2019. Captured data included injury charac- teristics, method of preservation of the amputated part, replantation attempt, and operative outcome. Cases were identified by ICD code and patient charts were reviewed by authors SM and HS. Information was captured in physician documentation from the emergency room, hand surgery team or EMS report. Any cases which did not have docu- mentation in any of the above were excluded.

Patients were screened for the following inclusion criteria: traumatic amputation of a digit or extremity, presence of the amputated part on evaluation by the hand surgery team, and electronic medical record documentation of the method by which the amputated part was pre- served. Patients were excluded if the amputation was not an acute in- jury, if it was non-traumatic such as surgical amputations for ischemia or infection, if it was partial in nature, if the amputated part was not brought for evaluation, or if clinical documentation did not describe the method by which the part was preserved. We define partial ampu- tation as still having soft tissue in place, whereas the ATLS protocol and adherence to it is specific to complete amputations in which the part is separate from the individual.

Proper preservation of the amputated part was defined as the part wrapped in saline moistened gauze and placed within a bag, which is then placed on ice. All other modalities were considered improper parts preservation.

    1. Statistical analysis

We provide the sample descriptive statistics including frequency and percentages stratified based on whether proper preservation was used or not. We used chi-square tests to examine subgroup differences by whether the amputated parts were properly preserved. We also examined the difference in operative outcomes by proper preservation among a subset of patients who had attempted replantation. We pro- vided frequency, percentages and the chi-square test result. All analyses were conducted SAS 9.4.

  1. Results

We identified 624 cases using ICD10 codes. Of these, 311 were excluded as incomplete amputations, 53 were excluded as non-acute amputations, 118 were excluded as surgical amputations, and 46 were excluded as no method of preservation documentation was available.

Ultimately, 91 patients were included, of which 73 (80.2%) were male. Anatomic locations are shown in Fig. 1. Of all included patients, thirty-one (34.1%) arrived to the emergency department with properly preserved amputated parts. Forty patients were transferred from a referring hospital, of which 18 (45%) arrived with amputated parts properly preserved. Fifty-one non-transfer patients arrived via air ambulance, ambulance or from a private vehicle. Of these patients, 13 (25.5%) arrived with properly preserved parts. 39 of 51 non-transfer patients arrived via EMS. Of these patients, 10 (25.6%) arrived with properly preserved parts. Replantation was attempted for 18 patients (58.1%) with properly preserved parts. Of those with improperly pre- served parts, 14 patients (23.3%) underwent attempted replantation

Image of Fig. 1

Fig. 1. Anatomic location of traumatic amputation. Lower extremity includes toes and proximal lower extremity. Proximal upper extremity encompasses all but upper extremity digit.

(P = .001). Replantation was successful in 33.3% of patients with prop- erly preserved parts, and 28.6% of patients with improperly preserved parts (P = .946). (Table 1) Replantation was not attempted for 60 pa- tients, 47 of which had documented reasoning for the decision to forego replantation. Of these patients, the majority (40.4%) did not undergo re- plantation due to “Other,” which included patient preference or medical indication based on surgeon opinion. Of the remaining patients, 14 pa- tients each (29.8%) did not undergo replantation due to the mechanism of injury and that the part was non-viable.

Techniques for preservation are described as follows: Parts that were marked as improperly preserved were most frequently placed in a bag on ice without gauze wrapping (16.5%), or directly on ice (21.2%). Modalities that fall under “other” were water or saline baths (4.4%) and wrapping with articles of clothing (4.4%), among others.

  1. Discussion

Replantation continues to be an integral Treatment modality for traumatic amputations. This is true not only for digital amputations, which comprised the majority of cases in our study, but also for proxi- mal upper and lower limb amputations [2,11,12]. Distal digital

Table 1

Patients stratified by proper and improper preservation modalities. Proper preservation correlated significantly with attempted replantation

Proper preservation of parts

Yes n = 31 No n = 60 p value

Sex 0.53


5 (16.1%)

13 (21.7%)


26 (83.9%)

47 (78.3%)

transport mode 0.79

Air Ambulance

5 (16.1%)

7 (11.7%)

Private Vehicle

5 (16.1%)

12 (20%)


21 (67.7%)

41 (68.3%)

Transfer status 0.05

Not hospital

13 (41.9%)

38 (63.3%)

Transferred from hospital

18 (58.1%)

22 (36.7%)

Replantation attempted 0.001


18 (58.1%)

14 (23.3%)


13 (41.9%)

46 (76.7%)

Among attempted replants

Operative outcome 0.95

Successful replant

6 (33.3%)

4 (28.6%)

Replant failure during operation

8 (44.4%)

7 (50.0%)

Replant failure post-operation

4 (22.2%)

3 (21.4%)

replantation especially has shown encouraging patient recorded out- comes and even cost efficacy [3,13]. As such, it is important that we op- timize the ability to offer replantation when appropriate [14].

Certain factors are out of the control of the surgical team and yet can influence the decision to attempt replant greatly. Specifically, mecha- nism of injury has been proven to be predictive of successful replanta- tion, with guillotine-type injuries achieving better outcomes than crush or avulsion injuries independent of anatomic location [15,16]. Intra-operative variables such as number of venous and arterial anasto- moses have also been correlated with outcomes [17]. Patient-specific factors that determine amenability to replantation include their physio- logic readiness to undergo a several hours-long operation, commitment and ability to receive therapy, occupation and time off of work, among others [5].

Cooling the amputated parts decreases oxygen requirements and si- multaneously improves diffusion of environmental oxygen [7,8]. Suppression of metabolism by hypothermia suggests that amputated digits stored in Low Temperatures had higher survival rates than com- mon temperature with applied bandages [15]. This suggests that low temperature is superior to common temperature for preservation of amputated digits. The target temperature should be acquired without direct contact with ice or liquid, which would cause direct thermal dam- age and maceration, respectively [22,23]. Using these principles, there have been multiple approaches to preserve amputated parts beyond the standard ATLS guideline which includes wrapping the part in saline moistened gauze, and placing indirectly on ice [5,23]. Ngaage et al. describe the Buncke protocol in which saline moistened gauze is re- placed with dry gauze, arguing that the saline too has potential to cause frostbite injury [6]. Others have borrowed from solid organ trans- plant techniques to develop modalities for active cooling and oxygena- tion by means of ex-vivo perfusion with hypothermic, oxygen carrying solutions [7,24]. Still, the ATLS protocol remains the gold standard.

Despite this being a longstanding standard of care, our results dem- onstrate that nearly two thirds of patients (65.9%) did not present with properly preserved parts. This poor adherence was true for all patient cohorts, as 80% of patients arriving via EMS services and 36.7% of patients transferred from a referring facility arrived with improperly preserved parts. The poorest adherence was found in non-transferred patients, as only 25% of both EMS presenting and private vehicle pre- senting cohorts arrived with properly preserved parts It is possible that this is secondary to a lack of awareness by patients, emergency ser- vices personnel, and transferring providers, providing us a clear target for potential intervention. Researchers in the U.K. found that only 18% of surveyed emergency department physicians could accurately describe the described protocol for preservation, with 42% stating the part could be stored directly on ice, and 32% stating it could be stored in a sterile saline bath [25]. The lack of education or prevalence of mis- information within this cohort of providers presents the best opportu- nity to improve adherence to proper preservation protocols. A health systems initiative to educate both emergency department providers, and EMS personnel on proper preservation of amputated parts could make a significant difference in part viability, and thus the attempt and success of replantation.

We found that replantation was offered at a significantly lower rate

(23.3%) to those who presented with improperly preserved parts than those who presented with properly preserved parts (58.1%) (p =

.001). While this may be a direct correlation in which improper preser- vation renders parts nonviable, it is possible that this difference is exag- gerated by potential biases. It may be that patients, EMS providers, and transferring providers are less meticulous in preservation of parts that are obviously nonviable, or also that documentation is more likely to explicitly describe preservation method if it played a significant role in the decision to proceed with replantation versus revision amputation. We do note certain other limitations to this study. Emergency depart- ment and specialty providers may also be more likely to document

non-standard modalities of parts preservation. Additionally, we note that ischemia time is a confounding variable and may be responsible for rendering parts nonviable and factor into the decision to attempt replantation. Of the 14 patients who did not undergo replantation, the average ischemia time for these amputated parts was 2 h and 55 min. Of these 14 samples, only two recorded a greater than 12-h ischemia time. While ischemia time certainly factors into the viability of an am- putated part, the majority of these samples endured far less ischemia time than the previously discussed 12-h ischemia mark. Lastly, we em- ploy a specific definition of proper preservation which some providers may choose to broaden. These limitations stem in part from the retro- spective nature of the study.

  1. Conclusion

In conclusion, the majority of patients who suffer a traumatic amputation do not present with properly preserved amputated parts for evaluation, making it difficult for surgeons to attempt replantation. This problem extends to patients arriving via EMS services and referring facilities, as well as patients arriving from home. Proper preservation is a critical component of the treatment course, in which an improvement might allow hand surgeons to more frequently offer replantation sur- gery. Systemic interventions to increase adherence to protocol warrant study for broader applicability.

Ethical approval

This study was approved by our institutional review board.

Statement of human and animal rights

This article is a meta-analysis of existing data and does not contain any additional studies with human or animal subjects.

Statement of informed consent

No identifying information about patients was included in this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


The author(s) received no financial support for the research, author- ship, and/or publication of this article.


  1. Ninkovic M, Voigt S, Dornseifer U, Lorenz S. Microsurgical advances in extremity sal- vage. Clin Plast Surg. 2012;39(4):491-505.
  2. Chung KC, Yoon AP, Malay S, et al. Patient-reported and functional outcomes after revision amputation and replantation of digit amputations: the FRANCHISE multi- center international retrospective cohort study. JAMA Surg. 2019;154(7):637-46.
  3. Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011;128(3):723-37.
  4. Johnson SP, Drolet BC. Revascularization and replantation in the hand: Presurgical preparation and patient transfer. Hand Clin. 2019;35(2):109-17.
  5. Bueno RA, Battiston B, Ciclamini D, Titolo P, Panero B, Tos P. Replantation: current concepts and outcomes. Clin Plast Surg. 2014;41(3):385-95.
  6. Ngaage LM, Oni G, Buntic R, Malata CM, Buncke G. Initial Management of Traumatic Digit Amputations: a retrospective study of functional outcomes. J Reconstr Microsurg. 2018;34(4):250-7.
  7. Dickey RM, Hembd AS, Fruge S, Haddock NT, Papas KK, Suszynski TM. Composite tis- sue preservation. Ann Plast Surg. 2020;84(6):711-6.
  8. Suszynski TM, Haddock NT. Theoretical implications of oxygenation in limb replant or transplant. J Reconstr Microsurg. 2017;33(6):452-4.
  9. Ozer K, Kramer W, Gillani S, Williams A, Smith W. Replantation versus revision of amputated fingers in patients air-transported to a level 1 trauma center. J Hand Surg Am. 2010;35(6):936-40.
  10. Nolte MT, Shauver MJ, Chung KC, Giladi AM. Effect of Policy change on the use of long-distance transport and follow-up care for patients with traumatic finger ampu- tations. J Hand Surg Am. 2017;42(8):610-617.e612.
  11. Pet MA, Morrison SD, Mack JS, et al. Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation versus prosthetic rehabilita- tion. Injury. 2016;47(12):2783-8.
  12. Bumbasirevic M, Lesic A, Palibrk T, et al. Lower limb replantation: 27 years follow up.

Injury. 2020;51(4):77-80 51 Suppl 4:S77-S80.

  1. Yoon AP, Mahajani T, Hutton DW, Chung KC. Finger replantation and amputation challenges in assessing impairment St, and effectiveness (FRANCHISE) group. Cost- effectiveness of finger replantation compared with revision amputation. JAMA Netw Open. 2019;2(12):e1916509.
  2. Levin LS. Commentary on “immediate versus overnight-delayed digital replantation: comparative retrospective cohort study of survival outcomes“. J Hand Surg Am. 2018;43(7):632-3.
  3. Yu H, Wei L, Liang B, Hou S, Wang J, Yang Y. Nonsurgical factors of digital replanta- tion and survival rate: a metaanalysis. Indian J Orthop. 2015;49(3):265-71.
  4. Ono S, Chung KC. Efficiency in digital and hand replantation. Clin Plast Surg. 2019;46


  1. Shaterian A, Rajaii R, Kanack M, Evans GRD, Leis A. Predictors of digit survival follow- ing replantation: quantitative review and Meta-analysis. J Hand Microsurg. 2018;10 (2):66-73.
  2. Li J, Guo Z, Zhu Q, et al. Fingertip replantation: determinants of survival. Plast Reconstr Surg. 2008;122(3):833-9.
  3. Lloyd MS, Teo TC, Pickford MA, Arnstein PM. Preoperative management of the am- putated limb. Emerg Med J. 2005;22(7):478-80.
  4. Kueckelhaus M, Dermietzel A, Alhefzi M, et al. Acellular hypothermic extracorporeal perfusion extends allowable ischemia time in a porcine whole limb replantation model. Plast Reconstr Surg. 2017;139(4):922e-32e.
  5. Azzopardi EA, Whitaker IS, Laing H. Perceptions of correct preoperative storage and transfer of amputated digits: a national survey of referring emergency departments. J Plast Reconstr Aesthet Surg. 2008;61(11):1418-9.