Is self-inflicted amputation to the upper extremity a contraindication to replantation?

Abstract

Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.