Digital Replantation Research Articles

The Role of Intravenous Heparin Following Digital Replantation: A Retrospective Cohort Study on 1,155 Digits

The purpose of this study was to determine if the use of postoperative therapeutic dose intravenous heparin (POTDIVH) was indicated in digital replantation and revascularization by assessing digit survival and complications associated with heparin. All patients with amputation distal to the carpal tunnel treated at our center from 2004 to 2020 were included for chart review. Digit survival and complication rates were compared between patients who received POTDIVH (group A) and those who did not (group B). Logistic regression analysis and subgroup analysis were conducted. A total of 795 patients (1,155 digits) were included in this study (248 patients/374 digits in group A and 547 patients/781 digits in group B). The overall revascularization and replantation success rate was 79.9% in the POTDIVH group and 92.8% in the non-POTDIVH group. In our retrospective regression and subgroup analyses, group A demonstrated increased odds of failure compared with group B and was associated with increased bleeding-related complications. Subgroup analyses stratified by the mechanism of injury and vein grafting also showed a significantly decreased survival in the POTDIVH group. Our retrospective data seem to indicate that heparin in digit replantation and revascularization appears to have no benefit on digit survival across all subgroups, including crush and avulsion injuries, and is associated with a significantly increased rate of complications. Therapeutic IV.

First clinical applications for the NIR-II imaging with ICG in microsurgery.

In microsurgery, it is always difficult to accurately identify the blood supply with ease, such as vascular anastomosis, digit replantation, skin avulsion reconstruction and flap transplantation. Near-infrared window I (NIR-I, 700-900nm) imaging has many clinical applications, whereas near-infrared window II (NIR-II, 1,000-1700nm) imaging has emerged as a highly promising novel optical imaging modality and used in a few clinical fields recently, especially its penetration distance and noninvasive characteristics coincide with the needs of microsurgery. Therefore, a portable NIR-II imaging instrument and the Food and Drug Administration (FDA) approved indocyanine green (ICG) were used to improve the operation efficiency in microsurgery of 39 patients in this study. The anastomotic vessels and the salvaged distal limbs were clearly visualized after intravenous injection of ICG. The technique enabled identification of perforator vessels and estimation of perforator areas prior to the flap obtention and made it easier to monitor the prognosis. Overall, this study highlights the use of the portable NIR- II imaging with ICG as an operative evaluation tool can enhance the safety and accuracy of microsurgery.

Association Between Daytime vs Overnight Digit Replantation and Surgical Outcomes

Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown. To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation. This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein. Daytime or overnight digit replantation. Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery. A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (β, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (β, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time. In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.

Comparison of the hepatotoxicity of low-molecular-weight versus unfractionated heparin for anticoagulation therapy after digital replantation

Purpose: Unfractionated heparin (UFH) is more commonly used as an anticoagulant after digital replantation than low-molecular-weight heparin (LMWH). We compared the success and complication rates of these two anticoagulants, since only a few studies have made this comparison directly. Methods: Forty-four patients who underwent digital replantation for complete or incomplete digital amputation in the past 7 years at a single institution were included. The patients were divided into LMWH and UFH groups according to the anticoagulant administered. The success rates for each group were obtained, and the postoperative serum aspartate aminotransferase (AST) and alanine transaminase (ALT) levels were analyzed to compare the complication rates.Results: All patients, except one, had successful recovery of circulation after replantation, and the success rate did not show a statistically significant difference between the two groups. The statistical analysis showed that the proportion of patients with abnormal serum AST or ALT levels in the LMWH group was significantly lower than that in the UFH group.Conclusion: Although there was no significant difference in the success rate between the two groups, the risk of hepatotoxicity was significantly lower in the LMWH group than in the UFH group. Considering the advantages of LMWH, its extensive use is highly recommended for anticoagulation therapy in patients after digital replantation.

Postoperative Interventions in Pediatric Digital Replantation: A Tertiary Referral Center Case Review

Although a few case series have been published describing the excellent outcomes of replantation and revascularization operations in children, there has been limited study of the hospital course that these patients experience and the number of potentially harmful interventions and treatments that occur. The purpose of this study was to detail the results of various postoperative interventions, including anticoagulation, transfusion, leeching, sedation, and additional anesthetic exposures. Twenty-nine patients aged less than 18 years had 34 digital revascularizations or replantations performed between January 2000 and May 2020. The details of each patient's presentation, surgery, and postoperative care were analyzed. Nine of 29 children underwent repeat anesthetics, including 6 revision amputations. No demographic, surgical, or postoperative variables consistently preceded revision amputation or additional anesthetic procedures. Only 5 patients had >1 hemoglobin (Hb) measurement. Two patients received blood transfusions; the average drop in Hb was 3.5 g/dL from before surgery to the lowest after surgery. Four patients underwent leech therapy. Only patients receiving leech therapy required postoperative transfusions. Anticoagulation regimens were prescribed on the basis of demographic and surgical factors, although no medication or regimen seemed to affect outcomes. Although the experience of digital replantation is essentially the same in pediatric patients as adults, there may be different ramifications for children. Specifically, postoperative management of pediatric digital replantation or revascularization can involve multiple interventions that carry their risks. Parents should be counseled about the risks of anticoagulants, transfusions, and repeat anesthetics, and clinicians should monitor Hb closely when using leech therapy. Therapeutic IV.

Functional outcome after digit replantation versus amputation

BackgroundThe success of digit replantation is mainly based on survival rates. The functional outcome as well as the recovery of sensibility are essential parameters for judging the outcome after digit replantation but have been poorly assessed in previous studies.Patients and methodsForty-eight patients with 56 complete traumatic digit amputations occurring between 2008 and 2013 returned for a follow-up examination, the earliest being 6 months postoperatively. Each patient’s range of motion, fingertip-to-table distance, fingertip-to-palm distance, grip and pinch strengths, static two-point discrimination (2-PD), and Semmes–Weinstein monofilament (SWM) test level were assessed in order to compare functional outcome and recovery of sensibility between successful replantation (n = 19) and primary or secondary amputation (n = 37). Subjective assessments of the pain level and function of the upper extremity were performed using the numerical rating scale and the DASH score, respectively.ResultsReplanted digits achieved 58% of the median total range of motion of the corresponding uninjured digits. Grip and pinch strength were not significantly different after thumb or finger replantation or amputation. Recovery of sensibility was excellent after replantation, with a median static 2-PD of 5 mm and a reduction of pressure sensibility of two levels of the SWM test compared to the contralateral side. After amputation, the median static 2-PD was also very good, with a median value of 6 mm and a reduction of pressure sensibility of only one level according to the SWM test. There was significantly less pain after replantation at rest (p = 0.012) and under strain (p = 0.012) compared to patients after amputation. No significant differences were observed in the DASH score between the two groups.ConclusionComparable functional results and sensory recovery but significantly less pain at rest and under strain can be expected after digit replantation when compared to digit amputation.Level of evidenceIV.

Venous system mapping of the digits and the hand: An anatomical study and potential surgical applications

BackgroundVenous anatomy of the digits and the hand is poorly reported in the literature compared to arterial anatomy. While knowledge of the venous anatomy is crucial to ensure safe skin incisions, skin flap design, or blood return restoration for digital replantations, data in anatomical and clinical textbooks are rather limited. The purpose of this anatomical study was to describe the venous anatomy of the digits and the hand.MethodOur series reports descriptive results from 10 non-embalmed hand dissections from 5 different corpses. Hands were previously co-injected by arteries followed by veins with a different colored latex before being dissected under optical magnification (x4). Each anatomical specimen was photographed before being analyzed.ResultsEach injection revealed both arterial and venous vascular systems. Latex injections were a useful technique to show the dorsal, volar superficial, and deep venous system. There was a constant and reliable topographic vascular anatomy of the superficial venous system of the digits and hand. However, we could not observe a high density of dorsal superficial venous valves as previously reported.ConclusionThe knowledge of the arrangement of the venous system of the digits and the hand should help the surgeon when performing surgical procedures in the hand. The surgeon should take into consideration this venous anatomy when performing skin incisions, skin flaps, or replantation procedures which would preserve the normal venous physiology as much as possible.

The clinical effectiveness and safety of intravenous unfractionated heparin following digital replantation and revascularization: A narrative systematic review.

Digital replants and revascularization (DRV) have been performed since the 1960s but there are no recognized standard peri-operative anticoagulation practices. A narrative systematic review of the clinical effectiveness and safety of therapeutic peri-operative unfractionated heparin following DRV was undertaken. A review of the literature from 1985 to March 2022 was conducted using Medline, Embase, CINAHL and EBM reviews. Unfractionated heparin (UFH) use following DRV was compared to low-molecular weight heparin, other anticoagulants or no anticoagulation. Randomized trials, observational studies as well as guidelines were selected and independently screened. The Revised Cochrane risk-of-bias (RoB 2) tool and ROBINS-I were used to appraise risk of bias. While the search strategy identified 1490 references, only six studies met the inclusion criteria. Significant heterogeneity and the low methodological quality of the evidence precluded a meta-analysis. Among the four studies that documented the surgical success rate associated with the use of a therapeutic dose of UFH post DRV, only two reported improved clinical outcomes. Evidence of a higher complication rate related to UFH use was found in four studies. Low quality evidence suggests that a therapeutic dose of unfractionated heparin leads to a higher risk of complications when compared with heparin given as an intermittent bolus of unfractionated heparin or subcutaneous heparin, or prostaglandin E1 or no heparin. Current evidence suggests that IV UFH use following DRV has no significant impact on the success of the intervention. Heparin use may not be innocuous as some studies showed increased bleeding complications.

Management of Artery-Only Digit Replantation: A Systematic Review of the Literature.

Artery-only replantation may be necessary in circumstances when venous repair cannot be performed due to their size or vessel injury. Venous congestion of the replanted part is inevitable. A systematic review was performed to identify techniques for mitigating congestion and analyze the outcomes of those techniques. A comprehensive literature search was performed to identify relevant articles related to artery-only replantation. An initial query identified 1286 unique articles. A total of 55 articles were included in the final review. Included studies were categorized by decongestive technique. Data from each article included the number of patients treated, level of amputation, graft use, anticoagulation or antiplatelet therapy, replant viability, and follow-up duration. Weighted averages were determined from studies that reported five or more digits. A total of 1498 individual digital replantations were described. Very rarely did studies report artery-only replantation proximal to the distal interphalangeal joint. An overall survival rate of 78.5 percent was found irrespective of technique but was variable based on each particular study. Studies utilizing medicinal leech therapy were more likely to report use of intravenous anticoagulation, whereas surface bleeding techniques were more likely to report use of topical or local anticoagulant. Lack of a vein for anastomosis should not be regarded as a contraindication to replantation. These digits instead require a method to establish reliable drainage sufficient to allow for low resistance inflow and maintain a physiologic pressure gradient across capillary beds. The surgeon should select a decongestive technique that best suits the patient and their specific injury.

Investigation of Predictors of Successful Replantation of Distal Digits at the Nail Bed Level: The Contribution of Digital Nerve Repair to Survival Rate.

Replantation of amputated digits at the nail bed level is surgically challenging and differs from replantation at a more proximal amputation level. This study aimed to determine the predictors influencing the success rate of fingertip replantation. Overall, 239 digits of 226 patients who underwent replantation surgery from August of 2009 to March of 2020 were considered. A total of 15 independent variables (i.e., sex; age; injured hand; digit; history of smoking; history of hypertension or diabetes; injury mechanism; amputation level; ischemia duration; surgeon's expertise; numbers of repaired arteries, veins, and nerves; and the need for a vein graft) were investigated for their effects on the survival of the replanted digits. Of all 239 digits, 190 (79.5 percent) survived. Univariate analysis indicated that non-crush-avulsion injury, expertise and experience of the surgeon, vein repair, and nerve repair contributed to increasing the survival rate. Binary logistic regression analysis demonstrated that injury mechanism, vein repair, and nerve repair were significant predictive factors. In addition, in non-vein-repaired, blunt cut, or Ishikawa subzone II cases, digital nerve repair contributed significantly to promote the success rate relative to vein-repaired, crush-avulsion-type injury, and subzone I cases. Vein repair, nerve repair, non-crush-avulsion injury, and surgeon's expertise and experience were the predictors for successful replantation. Intraoperative vein and nerve repair are recommended to improve the survival rate of fingertip replantation at the nail bed level. Risk, III.

Discussion: Investigation of Predictors of Successful Replantation of Distal Digits at the Nail Bed Level: The Contribution of Digital Nerve Repair to Survival Rate.

Austin, Texas From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin. Received for publication April 1, 2021; accepted July 16, 2021. Disclosure:The author has no financial interest to declare in the content of this Discussion. Steven L. Henry, M.D., Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, 1601 Trinity Street, Suite 704D, Austin, Texas 78712, [email protected]

Breaking the technical barrier of microvascular anastomosis with high-speed videography: A prospective cohort study

BackgroundMicrosurgical anastomosis is technically difficult especially for less-experienced surgeons. Traditionally, surgeons in training could only accomplish these surgeries under intensive guiding and supervision from senior surgeons. This study presents and characterises a new method for microsurgical trainees to objectively evaluating the quality of vascular anastomosis intraoperatively. Materials and methodsWe conducted a prospective study to determine the utility of patency test of vascular anastomosis with assistance of high-speed video recording (PTHVR) to evaluate the quality of vascular anastomosis during microsurgery. To determine whether the use of PTHVR outperformed traditional supervision from senior surgeons (historical control), we compared the outcomes of microsurgeries including free flap transfer and replantation between the two groups. ResultsA total of 211 patients were enrolled, of which 98 underwent surgery under traditional supervision and 113 underwent surgery with PTHVR. Of the 211 patients, 102 underwent digit replantation (48%), 22 underwent limb replantation (10%), and 87 underwent free flap transfer (42%). There was no statistical difference between the two groups in age, gender, BMI, pre-existing comorbidities, smoking status, alcohol consumption, and duration of surgery. Use of PTHVR as an intraoperative guide significantly decreased the rate of re-exploration surgeries (PTHVR, 8.0% [9/113]; control, 23.5% [23/98]; P = 0.002) and replantation/free flap failures (PTHVR, 8.8% [10/113]; control, 19.4% [19/98]; P = 0.029) compared with historical control under traditional supervision. ConclusionsPTHVR is a useful tool for improving the success rate of microsurgery for less-experienced surgeons when compared with traditional supervision mode.

Preoperative Deficiency Anemia in Digital Replantation: A Marker of Disparities, Increased Length of Stay, and Hospital Cost

Introduction The effects of preoperative anemia have been shown to be an independent risk factor associated with poor outcomes in both cardiac and noncardiac surgery. Socioeconomic status and race have also been linked to poor outcomes in a variety of conditions. This study was designed to study iron deficiency anemia as a marker of health disparities, length of stay and hospital cost in digital replantation.Materials and Methods Digit replantations performed between 2008 and 2014 were reviewed from the National Inpatient Sample (NIS) database using the ICD-9-CM procedure codes 84.21 and 84.22. Patients with more than one code or with an upper arm (83.24) or hand replantation (84.23) code were excluded. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Digit replantations were separated into patients with and without deficiency anemia. Demographics, comorbidities, and access to care were compared between cohorts by chi-squared and t-tests. Multivariate regressions were utilized to assess the effects of anemia on total cost and length of stay. The regression controlled for demographics, region, income, insurance, hospital type, and comorbidities. Beta coefficient was calculated for length of stay and hospital cost. The regression controlled for significant age, race, region, and comorbidities in addition to the above variables.Results In the studied patient population of those without anemia, 59.5% were Caucasian, and in patients with anemia, 46.7% were Caucasian (p < 0.001). Whereas in the in the studied patient population of those without anemia, 6.7% were Black, and in patients with anemia, 15.7% were Black (p < 0.001). Median household income, payer information, length of stay and total cost of hospitalization had statistically significant differences. Using regression and β-coefficient, the effect of anemia on length of stay and cost was also significant (p < 0.001). Regression controlled for age, race, region and comorbidities, with the β-coefficient for effect on cost 37327.18 and on length of stay 3.96.Conclusion These data show that deficiency anemias are associated with a significant increase in length and total cost of stay in patients undergoing digital replantation. Additionally, a larger percentage of patients undergoing digital replantations and who have deficiency anemia belong to the lowest income quartile. Our findings present an important finding for public health prevention and resource allocation. Future studies could focus on clinical intervention with iron supplementation at the time of digital replantation.

A Nomogram for Predicting Survival Rate of Digit Replantation after Traumatic Amputations: Development and Validation Based on a Prospective Multicenter Cohort

A Nomogram for Predicting Survival Rate of Digit Replantation after Traumatic Amputations: Development and Validation Based on a Prospective Multicenter Cohort

Negative-Pressure Wound Therapy Application in Fingertip Replantations and a Systematic Review

Fingertip replantation is technically challenging. Venous congestion is one of the most common causes of replantation failure. Therefore, various venous drainage procedures and salvage techniques have been used in venous congestion. Negative-pressure wound therapy has proven beneficial in limb injuries, yet limited studies of fingertip replantation exist. This study aims to analyze risk factors in fingertip replantation and to evaluate the feasibility and clinical benefits of negative-pressure wound therapy compared with other salvage techniques. From January of 2015 to December of 2019, 27 patients (27 digits) who experienced fingertip amputation over Tamai zone I or II underwent replantation. Salvage negative-pressure wound therapy was applied for venous congestion postoperatively. Replantation data were collected for further analysis. The overall survival rate of digit replantation with salvage negative-pressure wound therapy was 92.6 percent (25 of 27). The blood transfusion rate was 11.1 percent (three of 27). The average hospitalization time was 8.04 ± 1.43 days and the median duration of negative-pressure wound therapy was 6 days (range, 4 to 8 days; interquartile range, 2 days). There is no significant difference between the survival and failure groups for all risk factors evaluated. Negative-pressure wound therapy is a simple and effective salvage option to relieve venous congestion in fingertip replantation with a satisfactory survival rate, low blood transfusion rate, and short inpatient stay. Therapeutic, IV.

Survival Statistics of Digital Replantation in the UK.

BackgroundDigital replantation is associated with a substantial risk of failure. There is considerable variation in survival rates globally, and the current data are limited by poor statistical methods and bias of selection, which limits its translation to Europe and the USA. We aimed to establish a more representative survival rate of digit replantation for western populations and evaluate espoused prognostic variables using robust statistical methodology.Materials and MethodsRetrospective data were collected from 58 consecutive patients who underwent digital replantation following traumatic amputation in three tertiary care hand centres in the UK over seven years. The unit of analysis was the digit. Generalized linear modelling was used to estimate the odds ratio (OR) of digit survival.ResultsForty-six of 68 replanted digits survived (68%). The typical replant candidate was a 40-year-old male manual worker. Digit survival was more likely with guillotine injuries (adjusted OR 25.5 [95% CI 5.60, 115]) and when intraoperative skeletal shortening was performed (adjusted OR 15.3 [95% CI 2.62, 89.5]). The age of the patient, seniority of the operating surgeon, and use of vein grafts was not associated with digit survival.ConclusionWe provide robust data to show that guillotine amputations have more favourable survival rates, which can be further improved by skeletal shortening at the time of replantation. We suggest that research networks worldwide set up digit amputation registries to capture individual patient data on this uncommon injury.

Digit Replantation under Wide-Awake Local Anesthesia.

Digit replantation under wide-awake local anesthesia is a challenging method, and there are only a few works of literature on this procedure. This article describes the authors' clinical experience in finger replantation under wide-awake local anesthesia compared to general anesthesia. Fifty-one patients who received single finger replantation after initial sharp amputation were included in the study, of whom 16 received wide-awake local anesthesia and 35 general anesthesia treatment. The indications for wide-awake local anesthesia were sharp amputation injury, estimated operation time less than 3 hours, and cooperative patients. The wide-awake local anesthesia was performed with 1% or 2% lidocaine infiltrated at the volar midpoint of the metacarpophalangeal joint of the affected digit without sedation medications. Demographic data included surgical outcome, waiting time, operation time, and hospital stay. A total of 51 consecutive patients were included in this study. There were significantly shorter waiting times and operation times in the wide-awake local anesthesia group. The other parameters showed no significant differences. The overall success rate was 76.47 percent, with a mean overall operation time of 207 minutes. In selected patients, finger replantation can be successfully performed under wide-awake local anesthesia, which has lower anesthesia risk and fewer medical expenses than general anesthesia. The method is feasible for single-digit replantation. Therefore, the finger replantation under wide-awake local anesthesia is a practicable alternative to general anesthesia. Therapeutic, III.

Variation in Surgeon Proficiency Scores and Association With Digit Replantation Outcomes

Risk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes. To assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes. This case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure. Digit replantation and revascularization. Digit survival at 1-month follow up (case success) and number of complications. A total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93. Operative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.

Discussion: A 17-Year Experience in Hand and Digit Replantation at an Academic Center.

Discussion: A 17-Year Experience in Hand and Digit Replantation at an Academic Center.

Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation

Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation. Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted. Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission. In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States. Economic/Decision Analysis III.