Improving the Early Outcome of Digital Replantation: Technical Tricks Learned in a US Fellowship

Abstract

Abstract Background Despite stable numbers of upper limb amputations there is a decline in replantation in Europe. This results in lacking experience, decreasing success rates, and fewer attempts. Training in high-volume centers is crucial for hand surgeons performing upper extremity replantation. Aims This abstract highlights the experience in a US microsurgery fellowship. Methods Upper extremity revascularization and replantation cases during a 10 month - period were retrospectively reviewed. Overall, the fellow was exposed to 29 cases: 2 hand, 5 thumb and 9 digitial replantations as well as 13 thumb and digital revascularizations. Primary outcome was the survival of the injured body part. Secondary outcomes were total case time, number of repaired arteries/veins, the use of vein grafts, and early free flap coverage. Whenever possible, all microsurgical steps including vessel debridement and anastomosis were performed under tourniquet. Results Success rate was 21/29 (72%). Failure was limited to avulsion or crush injuries. Mean surgery time for revascularization was 92 min (range, 45-134 min) per digit. Mean surgery time for thumb and single digit replantation was 133 min (range, 62-270 min) and for the two hand replantations 180 min and 300 min, respectively. Routinely, only 1 dominant artery was repaired. Forearm or saphenous vein grafts were used in 14/29 cases. Only in 3/23 cases > 1 vein was repaired and in 3 cases interpositional vein grafts were used for dorsal vein reconstruction. One venous flow-through flap was used and a dorsal hand soft tissue defect was covered with a fascio-cutaneous free flap 5 days after replantation. Conclusions Replantation remains a challenge for hand surgeons. The thoughtful use of a tourniquet with vessel debridement in a bloodless field is key to maximize the efficiency of replantation. Furthermore, the liberate use of vein grafts and venous flow-through flaps helps moving outside the trauma zone, thus increasing the likelihood of upper limb salvage.