Digital Replantation Research Articles

Digital replantation in forward surgical units: a cases study.

Introduction: Noncombat-related hand injuries are common in current theatres of operations. Crushing is one of the most frequent mechanisms that may cause traumatic amputations of digits. In the military setting, management of these digital amputations is challenging regarding limitation in microsurgical means in medical treatment facilities and aeromedical evacuation delays out of the combat zone.Methods: Two cases of digital replantation performed in French forward surgical units are described. The first case was a complete distal amputation of the medius which was successfully replanted in the operating theatre of an aircraft carrier. No complication was observed after evacuation. Functional and aesthetic results were excellent. The second case was a ring finger avulsion revascularized in a role 2 facility in Central African Republic. Unfortunately, revascularization failed due to arterial thrombosis during evacuation.Results: Digital, hand or more proximal upper extremity replantation may be considered for isolated amputations due to work-related accidents within the combat zone. For a surgeon trained to microsurgery, a microsurgical set and magnification loupes enable to attempt such procedures in austere conditions.Discussion: The authors propose an algorithm of management in the field according to the type and level of amputation.

The Rubber Glove Osteotomy Method for Soft Tissue Retraction in Digital Replantation

The Rubber Glove Osteotomy Method for Soft Tissue Retraction in Digital Replantation

Measures for Blood Congestion after Replantation of Digits Amputated at the Distal Phalanx Level -Usefulness of Medical Leeches-

Measures for Blood Congestion after Replantation of Digits Amputated at the Distal Phalanx Level -Usefulness of Medical Leeches-

Multiple venous anastomoses decrease the need for intensive postoperative management in tamai zone I replantations.

BackgroundVenous anastomosis is an important component of digital replantation, but is not always feasible, as some cases require external bleeding to treat venous congestion in the replanted tissue. In the present study, we evaluated the relationship between the number of vein anastomoses and the survival rate of Tamai zone I replantations.MethodsA retrospective review was performed of all patients who underwent replantation of a fingertip amputation between 2014 and 2016. Patient charts were reviewed for demographic information, the mechanism of injury, the number of venous anastomoses, and the use of anticoagulation, external bleeding, and/or leeches. The cohort was divided into 3 groups depending on the number of venous anastomoses: no veins (group 1), a single vein (group 2), and 2 or more veins (group 3). Survival rates and external bleeding rates were analyzed across the groups.ResultsThe review identified 143 fingertip replantations among 134 patients. The overall survival rate was 94% (135 of 143). Failures were due equally to venous complications (n=4, 50%) and to arterial complications (n=4, 50%). Our analysis did not identify any correlation between the number of veins anastomosed and the replant survival rate (P=0.689). However, a greater number of anastomoses was associated with a significantly lower frequency of external bleeding (P=0.017).ConclusionsThe number of venous anastomoses was not correlated with the survival rate. However, a greater number of venous anastomoses was associated with a decreased need for external bleeding, corresponding to a significant decrease in the need for postoperative monitoring and leech therapy.

Correlation of volumetric flow rate and skin blood flow with cold intolerance in digital replantation

Cold intolerance is a common complication of digital replantation. The exact etiology is unclear, but it is considered to be multifactorial, including nonsurgical characteristics, vascular, and neurologic conditions. Blood flow may play a significant role in cold intolerance. This study was designed to evaluate the correlation of digital blood flow, including volumetric flow rate (VFR) and skin blood flow (SkBF), with cold intolerance in replanted fingers.A retrospective study was conducted among patients who underwent digital replantation between 2010 and 2013. Patients were selected into study cohort based on the inclusion criteria. Surgical data was collected on each patient, including age, sex, injury mechanism, amputation level, ischemia time, number of arteries repaired, and whether or not vascular crisis occurred. Patients were included as study cohort with both nerves repaired and without chronic disease. Cold intolerance was defined as a Cold Intolerance Symptom Severity (CISS) score over 30. The arterial flow velocity and caliber were measured by Color Doppler Ultrasound and the digital VFR was calculated. The SkBF was measured by Laser Speckle Imager. Both VFR and SkBF were calculated as a percentage of the contralateral fingers. Comparative study of surgical data and blood flow was performed between the patient with and without cold intolerance. Correlation between VFR and SkBF was also analyzed.A total of 93 patients met inclusion criteria for the study. Approximately, 42 patients were identified as having cold intolerance. Fingers that survived vascular crisis had a higher incidence of cold intolerance with a lower VFR and SkBF. The VFR was higher in 2-artery replantation, but the SkBF and incidence of cold intolerance did not differ significantly. No differences were found in age, sex, injury mechanism, amputation level, or ischemia time. Furthermore, no correlation was found between VFR and SkBF.Cold intolerance of digital replantation is associated with decreased SkBF and VFR in the replanted fingers, which survived vascular crisis. Further work will be focused on how vascular crisis cause the decreasing of SkBF and VFR and the increasing chance of cold intolerance.

Use of an Intra-Arterial Catheter as a Provisional Conduit for Regulated Outflow Management in the Setting of Artery-Only Digital Replantation.

Successful replantation of distal digital segments necessitates the establishment of sufficient outflow to minimize congestion and progressive tissue necrosis. In cases where only arterial anastomosis is feasible, an artificial outlet must be provided to maintain physiological requirements until microvenous circulation regenerates. This can be accomplished using any number of "exsanguination techniques" designed to facilitate egress through ongoing passive blood loss. Although reportedly effective, these measures are imprecise and carry a substantial risk of infection, scarring, and/or uncontrolled hemorrhage. Herein, we describe a preemptive alternative for provisional venous drainage, whereby direct catheterization of a distal arterial branch is used to enhance the precision of outflow management following artery-only digital replantation. The establishment of intravascular access, using the technique described, permits remote manipulation of the microcirculatory environment through timed administration of heparinized saline and regulated removal of controlled volumes of blood.

Reverse Distal Transverse Palmar Arch in Distal Digital Replantation.

Refinements in microsurgery have made distal finger replantation an established technique with high success rates and good functional and aesthetic outcomes. However, it still represents a technically demanding procedure due to the small vessel caliber and frequent lack of vessel length, requiring the use of interpositional venous grafts in some instances. We describe a new technique for anastomosis in fingertip replantation, whereby the need for venous grafts is eliminated. Applying the reverse distal transverse palmar arch technique, 11 cases of distal digital replantation were performed between January 2011 and July 2016. The described procedure was used for arterial anastomosis in 10 cases and arteriovenous shunting for venous drainage in 1 case. A retrospective case review was conducted. The technical description and clinical outcome evaluations are presented. Ten of the 11 replanted digits survived, corresponding to an overall success rate of 91%. One replant failed due to venous insufficiency. Blood transfusions were not required for any of the patients. Follow-up (range, 1.5-5 months) revealed near-normal range of motion and good aesthetic results. All of the replanted digits developed protective sensation. The average length of hospital admission was 5 days. All patients were satisfied with the results and were able to return to their previous work. The use of the reverse distal transverse palmar arch is a novel and reliable technique in distal digital replantation when an increase in vessel length is required, allowing for a tension-free arterial repair without the need for vein grafts.

Antithrombotic Therapies in Digit Replantation with Papaverine Administration: A Prospective, Observational Study.

The primary objective of this study was to investigate whether the application of antithrombotic therapies affects the success rate of digit replantation. A total 477 digits of 319 patients who received dextran with low-molecular-weight heparin, dextran with prostaglandin E1, or no antithrombotic therapy after replantation of complete amputated digits from January 1, 2012, to January 1, 2016, were included in this study. Papaverine was given by intramuscular injection to all patients at a dosage of 90 mg/day postoperatively. There was no significant difference in any of the potential risk factors, including age, smoking, Tamai level of amputation, causes of injury, and warm ischemia time among groups. The survival rates of digits from patients who received dextran with low-molecular-weight heparin, dextran with prostaglandin E1, or no antithrombotic therapy were not significantly different. Antithrombotic therapies showed no significant benefit for digit replantation in patients receiving papaverine. Therapeutic, II.

Survival Rate of Revascularization and Replantation of Digits with Vein Graft Versus Direct Arterial Anastomosis

There is no financial information to disclose. The use of vein graft in revascularization and replantation of dysvascular digit yields survival rates similar to direct arterial anastomosis. A retrospective review of all patients > 18 years old at a public urban teaching hospital from 2007 to 2017 that required revascularization and/or replantation of one or more digits due to traumatic full or partial amputation was performed. Demographic data, mechanism of injury, level of injury, and digits requiring revascularization and/or replantation were collected. In addition, length of vein graft used, donor site, and use of graft (for artery or vein) were collected. Digit survival was the primary outcome measure. 135 patients (129 male, 6 female) were identified with 186 affected digits, 127 of which required revascularization and 59 replantation. The data set included 39 thumb, 36 index, 54 middle, 38 ring, and 19 small digits. The average length of stay was 9.2 days. The average peri-operative transfusion requirement was 1.1 units (range 0-13). Vein graft for arterial anastomosis was utilized in 45.7% of all digits (53% of replanted and 40% of revascularized digits). The average vein graft length was 4.4 cm (range 0.15-12 cm). The overall digit survival rate was 80%. The 81% survival rate of digits requiring a vein graft was not different (P = 0.74) than the 79% survival rate of those that underwent direct arterial anastomosis. Similarly, the survival rate of revascularized digits was not different for digits treated with or without a vein graft (93% survival for both vein grafted digits and for those treated with direct arterial anastamosis, P = 0.86). Finally, digits replanted with a vein graft survived 53% of the time compared to the 52% survival rate of those replanted without the use of a vein graft, which was also not statistically different (P = 0.94). •Vein grafts were utilized for arterial repairs in nearly half of all dysvascular digits that underwent revascularization or replantation.•There was no statistical difference in the survival rate of dysvascular digits treated with a vein graft versus those that underwent direct arterial anastomosis.•The need for a vein graft for a large zone of injury should not be considered a relative contraindication to perform revascularization or replantation of dysvascular digits.•If the zone of injury is large, surgeons should have a low threshold to use vein grafts for the revascularization or replantation of digits.

Institutional Outcomes of Leech Therapy for Venous Congestion in 87 Patients.

Background We aimed to report the outcomes associated with leech therapy and to identify risk factors associated with reconstructive failure. Methods We retrospectively reviewed cases of flap reconstruction or replanted appendages that required leech therapy over an 8-year period at the Duke University Medical Center. Using logistic regression, we assessed the association of risk factors with reconstructive failure. Results The study cohort included 87 patients which correspond to 2.1% of 4,115 cases done during the study period. The most common flap recipient site was the lower extremity (n = 33, 37.9%) followed by the upper extremity (n = 30, 34.5%), head and neck (n = 13, 14.9%), and trunk (n = 11, 12.6%). Flap types were pedicled in 44 (50.5%) cases and free in 24 (27.5%) cases. Fifteen (17.2%) were digital replantation, and four (4.5%) were replanted appendages. The average duration of therapy was 4.6 days (range: 1–11). The overall leech therapy success rate was 60.9% (53/87) and accounted for cases without flap loss (n = 45, 51.7%) and with partial flap loss in which the original reconstructive goal was achieved without further reconstructive procedures (n = 8, 9.2%). Postoperative blood transfusion was administered in 32 (36.7%) cases, and infectious complications occurred in 7 cases in spite of the administration of prophylactic antibiotics (8%). Conclusions This study represents the largest single-institution series evaluating the outcomes after leech therapy. Our data support the use of leeches as an adjunct for the management of venous congestion after reconstructive surgery. However, the morbidity associated with it should be considered, particularly the need for a blood transfusion.

Skin Perfusion Changes within 12 h after Axillary Plexus Block

Background/Purpose: An improvement of the blood flow would be beneficial in microvascular upper-extremity reconstruction and in digit replantation. In the present work, skin perfusion changes and their duration due to axillary plexus block were quantified. Methods: The peripheral blood flow of the upper extremities in 20 patients undergoing trapeziectomy under axillary plexus block was analyzed. Results: Laser Doppler spectrophotometry was used to measure perfusion factors over a 12-h period, with the contralateral hand acting as the control. Axillary plexus block produced a significant increase of peripheral oxygen saturation (117 ± 35% vs. control 93 ± 22%, p = 0.019), peripheral blood flow (220 ± 166% vs. 130 ± 77%, p = 0.037), and velocity (164 ± 58% vs. 117 ± 45%, p = 0.011). Conclusion: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremities over the first 6 h after the inception of anesthesia. This suggests a potential benefit especially for critically perfused tissues.

Results After Distal Digital Replantation - Is It Worth The Effort?

There are only relative indications for distal digital replantation in zones 1 and 2 according to Tamai. In contrast to primary closure for fingertip amputations, replantation is a complex procedure that requires skills in supermicrosurgical techniques, as vessels with diameters between 0.3-0.8 mm are connected. In addition the time spent in hospital and the time off from work are longer. Distal digital replantation is thus only indicated, if the expected functional and aesthetic benefits surmount those of primary closure. We retrospectively analysed all fingertip amputations in zone 1 and 2 according to Tamai between 9/2009 and 7/2014 where we attempted distal digital replantation. The success of replantation, wound healing and functional results were evaluated according to Yamano. We performed 11 distal digital replantations in the study period. There were 6 total amputations, 4 subtotal amputations and 1 avulsion of the digital pulp. Revascularisation with long-term reattachment of the amputated tissues was possible in 8 cases (73%). In 3 cases (27%) secondary amputation closure was necessary. The mean operating time was 3 h 56 min. 6 patients, which had a successful replantation, were available for follow-up examinations after a mean period of 19 months. 5 patients were satisfied with the result and would again prefer replantation over primary amputation closure. 4 patients reported a good function of the replanted digits and did not complain about any limitations in their use. 2 patients complained about restricted function. All patients could return to their previous places of employment and were free of pain. Of the 12 affected digital nerves 11 nerves had a 2-point discrimination (2-PD) of ≤15 mm, 3 of them had a 2-PD between 7 and 10 mm and 4 of them of <6 mm. Soft tissue atrophy was obvious in 3 replanted digits and nail deformities in 2 patients. Distal digital replantation is complex and technically challenging. It leads to high patient satisfaction with only minimal functional limitations, if successful. Due to the good results that can be obtained by these procedures, fingertip replantation should be attempted, if operative risks are minimal and if requested by the patient.

Annual Hospital Volume and Success of Digital Replantation.

Digital replantation attempt and success rates have been declining in the United States. Regionalization of digit replantation has been proposed as a solution to improve both attempt and success rates of these procedures. There is limited information about which criteria could establish a hospital as a center specialized for digit replantation. The authors analyzed hospital replantation volume and patient factors associated with successful thumb/finger replantation. A retrospective study using data from the 2008 to 2012 State Inpatient Databases of the Health Care Cost and Utilization Project from five states (New York, California, North Carolina, Utah, and Florida) was performed. The generalized estimating equation method was used to examine the association between patient characteristics and hospital volume and success of thumb/finger replantation. A receiver operating characteristic curve and Youden's J statistic were used to determine annual hospital replantation volume cutoff levels for success rates. There were 3417 digit amputation injuries, with 631 replantation attempts (18 percent) and with an overall thumb/finger replantation success rate of 70 percent. The hospital annual replantation volume increased the odds of success (OR, 1.06; 95 percent CI, 1.02 to 1.10). The annual hospital volume of three replantations was needed to achieve a success rate of 70 percent. Practice patterns demonstrate that hospitals with higher annual volume have greater success. Identifying high-volume centers and regionalization of digit replantation should be considered a priority. Therapeutic, III.

Pre-operative predictive factors for the survival of replanted digits.

The primary objective of this study was to evaluate factors that influence the survival rate after digit replantation. A total of 291 digits of 200 patients who received digital replantation after complete amputation from 1 January 2014 to 31 December 2015 were included in this study. Univariate and multivariate analysis were performed to evaluate the correlation between potential risk factors and the failure rate. Age, gender, smoking status, Tamai level of amputation, causes of injury and ischemia time were recorded before replantation. Age, smoking, causes of injury and ischemia time were pre-operative predictors for survival. On the contrary, gender and Tamai level did not alter the survival rate significantly. We divided patients into four groups according their smoking status: none, mild (<10 cigarettes per day), moderate (10-20 cigarettes per day) and heavy (>20 cigarettes per day). Our data demonstrated that the risks of failure only increased in heavy group. Mild and moderate cigarette consumption (<20 cigarettes per day) did not increase the risk for replant failure of digits. Heavy (>20 cigarettes per day) cigarette consumption, increased age (>45years), non-cut injury and prolonged ischemia time (>12 hours) were risk factors for replant failure.

Abstract P29. Early Experience Using Anastomotic Couplers in Digital Replantation and Revascularization

Abstract P29. Early Experience Using Anastomotic Couplers in Digital Replantation and Revascularization

The Effect of Patient Age on the Success Rate of Digital Replantation.

The purpose of this study was to evaluate outcomes and risk factors for failure after digital replantation in elderly patients, with a special focus on the effect of patient age on replantation success. Replantation patients older than 60 years were analyzed thoroughly to characterize outcomes and risk factors for failure in older patients. Survival rates of all age groups older than 20 years were then analyzed to determine the specific effect of patient age on replantation success. The clinical and functional outcomes and risk factors for failure were evaluated at a minimum 1-year follow-up. Among 161 patients older than 60 years, 189 of 208 replanted digits survived completely (91 percent survival). The only factors predictive of failure were mechanism of injury and age. Excellent or good results (Chen criteria) were obtained in 58 percent of patients, and 94 percent of patients were completely or fairly satisfied. Analysis of all age groups older than 20 (1648 patients) demonstrated a significant increase in failure rate in those aged 70 years and older. The authors demonstrated a high rate of digit replantation success in elderly patients. However, 70 years and older was identified as an important factor predicting replantation failure. Risk, III.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation. Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only. For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation. Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States. Therapeutic, III.

Effects of Postoperative Methycobal Administration on Digital Replantation Based on Stellate Ganglion Stimulation

To study the impact of stellate ganglion block (SGB) on digital replantation and analyze its mechanism. Digital arterial diameter was enlarged after SGB, and the difference in the survival rate of severed finger after replantation was not statistically significant between the two groups (P>0.05). Through the treatment with Methycobal, the recovery of 2-point discrimination (2-pd) of the experimental groups (A, B) was significantly better than that of the negative control group, between which the difference was statistically significant (P<0.01 between Groups A and C, P<0.05 between Groups B and C), indicating that the methyl vitamin B 12 can significantly promote the regeneration of peripheral nerves. Methycobal is of great significance to the postoperative treatment of digital replantation, which is worthy of being widely applied in clinic practice.

Analysis of Bone Fixation Methods in Digital Replantation.

BackgroundAdequate fixation of replanted digits is essential not only for short-term healing but for long-term function. Various bony fixation methods using Kirschner (K-) and intraosseous wire are available in replantation. We examined clinical and radiographic outcomes of fixation methods on bone union after digital replantation.MethodsA single institutional retrospective review identified 992 patients who had undergone 1,247 successful replantations between July 2009 and September 2015. Exclusion criteria included amputations of the distal phalanx, comminuted fractures, and intra-articular fractures. Patients were classified according to 5 categories of fixation methods: single K-wire, double longitudinal K-wires, cross K-wires, wire with, and wire without K-wire support. Bone union was evaluated by 5-month postoperative X-ray and fixation outcomes were compared across the 5 groups.ResultsThe exclusion criteria were applied, and 88 patients with 103 replanted digits remained for analysis. Single K-wire fixation was used in 40 digits, double longitudinal K-wires in 30, and cross fixation in 14. Wire with and without K-wire support was required in 15 and 4 digits. Nonunion was observed in 32 digits (31.1%), of which 13 required additional operations such as bone graft or corrective osteotomy. The highest percent of nonunion was observed after cross fixation (35.7%) and the lowest after wire alone (25.0%).ConclusionsIn this study, contrary to general knowledge, we found that single K-wire fixation was not associated with poorer outcomes. Successful bone union outcomes may be achieved by careful selection of bone fixation methods. This study provides useful information for planning bone fixation in digital replantation.

Effect of Hospital Volume on Success of Thumb Replantation

Hospital volume-outcome association has been examined for many high-risk surgical procedures. Little is known about this association for thumb replantation, a complex but essential surgical procedure to restore hand function. We aimed to determine patient and hospital characteristics that are associated with increased probability of replanted thumb survival and to examine volume-outcome association among hospitals that performed thumb replantation. We used data from 2008 to 2012 from the National Trauma Data Bank. Our sample included 773 patients who underwent thumb replantation procedures in 1 of 180 hospitals during the study period. We used patient-level logistic models to examine the association between a hospital's annual thumb replantation volume and the probability of survival for the replanted thumb. Patients with drug/alcohol abuse record, and higher numbers of comorbid conditions had lower odds of replant success. Treatment in teaching hospitals and hospitals with a higher volume of thumb replantation increased the odds of replant survival. The risk-adjusted replantation success rate in high-volume hospitals was 12% higher than in low-volume hospitals. Regionalization of digit replantation procedures to high-volume centers can achieve the highest rate of successful revascularization. Economic/Decision Analysis II.