Complications of replantation: All complications of complex hand wounds can occur following replantation, including tendon adhesions, tendon rupture, neuroma, and delayed healing.  Replantation has additional risk for a number of other problems. Early vascular failure (replant2.htm) of replantation is influenced by mechanism of injury and patient selection. Early failure is more common in smokers (CU), more distal replantation level and in crush and avulsion injuries (DG). Following successful revascularization, venous problems are more likely to result in loss of replantation than arterial thrombosis (AQ, AW). The critical time for failure and for successful salvage is the first four postoperative days (AW). Marginal necrosis or interval gangrene (15050.htm), as with other wounds is due to inadequate debridement or inability to distinguish viable from nonviable tissues in a wide zone of injury. The most common complication of a successful replant is stiffness due to tendon adhesions (AQ). Cold intolerance is uncommon following pediatric replantation, but occurs in most adult replantations (AQ). Aesthetically disturbing fingertip atrophy occurs in nearly half of replanted digits (AQ), due to the effects of incomplete reinnervation and in some cases, late effects of prolonged ischemia (replant2.htm). Lack of sensory recovery is more common in adults than children, when both arteries have not been repaired (CB), and in avulsion injuries (DG). Local vascular complications such as pseudoaneurysm (AE),  arteriovenous fistula (BN), stricture, and late thrombosis may occur as with any vascular repair. Delayed union, nonunion, or avascular necrosis may occur, particularly when the replantation is performed at the phalangeal neck level (BU), because the phalangeal head is covered with cartilage, and has a primarily intramedullary blood supply. Fractures or osteotomies through this level are prone to this complication even out of the setting of replantation (CM). Prolonged incapacitation and multiple operations are typical, with the average patient requiring two or more additional procedures after replantation (CC).  Judgment regarding indications for replantation must include consideration that the poor results after replantation may be much disabling than primary amputation. Functional outcome is significantly worse when replantation involves prolonged ischemia (replant2.htm) or injury in flexor tendon zone II (CU).
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