Fingertip Replantation Research Articles

Single- versus double-artery repair without vein anastomosis in Tamai I fingertip replantations: a retrospective cohort study.

III.

Current trends in digital replantation-a narrative review.

Digital replantation for traumatic amputation has become the standard of care with advances in microsurgical techniques and technology. While digital replantation has progressed significantly, there are still gaps in knowledge in many aspects. Some of the controversial topics in digital replantation include the indications and contraindications, anesthesia, number of vessel anastomoses, mechanism of injury, role of vein graft, distal fingertip replantation, and postoperative management. This article is a narrative review that discusses these controversies and current issues pertaining to digital replantation. PubMed, Web of Science, and Google scholar were searched using keywords relating to "digit replantation", "amputation", and "digital replant" with the following terms: "indications", "contraindications", "anaesthesia", "survival", "vessels", "mechanism of injury", "vein graft", "outcome", and "thrombophylaxis". Relevant articles pertaining to digital replantation and deemed by the authors as current or controversial were included. The reported survival rates of digital replantation are high. With the advancement of microsurgical techniques and technology, the boundaries of digital replantation continue to be pushed. Various methods have been described recently to improve the success rates of difficult replants, such as strategies for venous outflow and vein grafting. However, there are still aspects of digital replantation that remain unanswered, such as the number of veins to anastomose and the thromboprophylaxis regime. The review delves into controversial aspects of digital replantation, including contraindications, anesthesia, and postoperative management. Indications and contraindications will continue to evolve alongside advancements in microsurgical techniques and anesthesia. It highlights key factors influencing survival rates, such as the number of repaired vessels and the mechanism of injury. Finally, the review consolidates strategies for managing challenging digital replantations.

External Bleeding after Fingertip Replantation: Combination of a De-epithelialization Technique and Subcutaneous Heparin Injection

External Bleeding after Fingertip Replantation: Combination of a De-epithelialization Technique and Subcutaneous Heparin Injection

Distal fingertip replantation: indications, strategy and postoperative management.

Distal fingertip replantation is associated with being a technically demanding procedure and dubious outcomes, although it is now performed more frequently across the world. However, the technique and outcomes remain controversial with disagreement among replantation surgeons due to lack of consensus about the indications, intraoperative strategy and postoperative regimes. In this article, we asked six experienced hand surgeons several pertinent questions that every replantation surgeon performing distal fingertip replantation would face in their clinical practice. The article summarizes their responses, which might provide valuable insight to every replantation surgeon in different parts of their career while managing these injuries.

Limiting Levels of Fingertip Replantation Without Venous Anastomosis

This study aimed to compare the success rates of fingertip replantation with and without venous anastomosis. This retrospective study included 132 patients with 148 fingertip injuries who had undergone fingertip replantation (Ishikawa's classification I‒IV) between 2003 and 2020 at our hospital. Among them, 117 and 15 were men and women respectively, and their mean age was 43 years. There were 53, 44, and 51 fingertips with Ishikawa subzone II, III, and IV amputations respectively, and no cases were classified as Ishikawa subzone I. Venous anastomosis was performed on 64 fingertips (group A). This was not possible in the remaining 84 fingertips; thus, an external bleeding method was used (group B). Our external bleeding protocol consisted of 4-hourly skin pricks of the distal pulp with a 23-gauge needle for the first 5 days. The analyses included survival rates, hemoglobin levels (Hb), and blood transfusions administered. The overall survival rate was 90.5% (134 of 148). In group A, survival was achieved in 92.3%, 100%, and 94.3% of those with subzones II, III, and IV amputations, respectively. In group B, survival was achieved in 100%, 82.1%, and 62.5% of those with subzones II, III, and IV, respectively. Subzone IV in group B showed a significantly lower rate of replantation success. In groups A and B, the preoperative and 7-day postoperative Hb levels were 14.5 g/dL and 14.6 g/dL, and 11.3 g/dL, and 11.6 g/dL, respectively. In addition, blood transfusion was required for five patients (7.9%) in group A and six patients (7.9%) in group B. Thus, the Hb levels and blood transfusion administered were similar between the two groups. Subzone IV is an important threshold for artery-only replantation. Furthermore, our external bleeding protocol is a safe and effective method. Therapeutic IV.

Fingertip Replantation: Surgical Technique, Tips, and Tricks.

Replantation of fingertip amputations restores the original tissue and is the ideal treatment to provide the best aesthetic and functional outcome. However, successful fingertip replantation is considered challenging because it requires supermicrosurgery techniques. This article provides a detailed surgical technique for fingertip replantation and the authors' preferences and recommendations. In the authors' experience, the most important factors for successful fingertip replantation are meticulous vascular dissection, reliable arterial repair, and venous anastomosis to avoid postoperative venous congestion. Proximal arterial dissection until pulsatile bleeding is encountered avoids the zone of vascular injury, and is particularly important in crush or avulsion amputations. Distal arterial dissection is performed until undamaged intima is identified. The authors believe anastomosis to the central artery is reliable even in a Tamai zone II amputation. When an arterial defect is present, the authors recommend using a vein graft to anastomose to the central artery. In addition, the authors highly recommend at least one venous anastomosis to avoid postoperative venous congestion. In Tamai zone I, available veins can be found on the palmar side of the pulp. It is important to search directly below the dermis and remove adipose tissue around the vessels to secure space for anastomosis. The authors consider nerve suture in Tamai zone I and II replantations inessential, because spontaneous sensory recovery can be expected. Postoperative management of venous congestion, spasm in artery, and arterial thrombosis are as important as surgery.

Effects of external bleeding and hyperbaric oxygen treatment on Tamai zone 1 replantation.

Tamai zone 1 replantation poses a challenge due to the very small size of the vascular structures; often there is no vein for anastomosis. Replantation may have to be done with only an arterial anastomosis. In our study, we aimed to evaluate the success of replantation by combining external bleeding and hyperbaric oxygen treatment (HBOT) in Tamai zone 1 replantation. Between January 2017 and October 2021, 17 finger replantation patients who underwent artery-only anastomosis due to Tamai zone 1 amputation received 20 sessions of HBOT with external bleeding after the 24th postoperative hour. Finger viability was assessed at the end of treatment. A retrospective review of outcomes was performed. Seventeen clean-cut finger amputation patients were operated on under digital block anaesthesia with a finger tourniquet. No blood transfusion was required. In one patient, complete necrosis developed and stump closure was performed. Partial necrosis was observed in three patients and healed secondarily. Replantation in the remaining patients was successful. Vein anastomosis is not always possible in fingertip replantation. In Tamai zone 1 replantation with arteryonly anastomosis, post-operative HBOT with induced external bleeding appeared to shortened the hospital stay and was associated with a high proportion of successful outcomes.

The Efficacy of Subdermal Pocket Procedure in Fingertip Replantation With Composite Graft.

Microsurgical replantation of fingertip amputation is sometimes difficult because of a lack of available vessels. Composite grafting is an alternative method for nonvascularized replantation, but it has a limited success rate. The subdermal pocket (SDP) procedure is proposed to increase the survival of composite graft. We aimed to compare the success rate of the composite graft used in fingertip replantation with or without application of the SDP procedure. From 2000 to 2020, 29 fingertip amputations (28 complete amputations, 1 near-complete amputation) from 28 patients were included. Five of the fingertip amputations were classified as Ishikawa zone Ib and 24 as Ishikawa zone II. Seventeen fingers underwent replantation with composite graft plus SDP procedure, whereas the remaining 12 fingers received replantation with composite graft only. The overall success rate was 70.59% (12 of 17) in the SDP group and 41.67% (5 of 12) in the composite graft-only group ( P = 0.119; odds ratio, 3.36). In the subgroup of Ishikawa zone II fingertip amputations, the success rate was 66.67% (10 of 15) in the SDP group and 22.22% (2 of 9) in the composite graft-only group ( P = 0.035; odds ratio, 7.0). The SDP procedure could increase the success rate of fingertip replantation with composite graft, especially for Ishikawa zone II amputations.

Two clinical cases of the reconstruction of distal phalanges of hand in children by combination of the regional flap and scrap bone and nailbed graft

BACKGROUND: The hand and its distal phalanges, especially in children, are among areas mostly exposed to trauma while contacting the environment. Injuries causing loss of soft tissue and bone component are both challenging and interesting. This report presents the treatment results of children with soft tissue and bone defects of distal phalanges, in which reconstructions including combination of regional flaps, bone, and nailbed grafts were performed.
 CLINICAL CASE: This report presents clinical cases of the surgical treatment of 4- and 6-year-old children with fingertip injuries who underwent reconstructions including the combination of regional flaps, bone, and nailbed grafts. A combination of the scrap graft was performed in the first case with antegrade homodigital island flap and in the second case with thenar flap. The results were assessed 6 and 7 months after surgery.
 DISCUSSION: The primary aim of the surgical treatment of children with distal phalangeal defects is coverage of those defects. The restoration of the bone component of the defect is recommended to prevent postoperative deformations of the distal phalanges. Fingertip replantation or microsurgical transplantation of vascularized tissue complexes are technically difficult and require thorough care and monitoring of the childs condition in the postoperative period as all these measures may fail.
 CONCLUSIONS: The possibility to combine the scrap bone and nailbed graft with existing reliable surgical methods open new prospects for the successful treatment of fingertip injuries.

Identifying Predictors of Radiographic Distal Phalangeal Nonunion After Fingertip Replantation

This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation. This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation. At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68). The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible. Prognostic IV.

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.

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.

Replantation fingertip without venous anastomoses in children

Objective. Traumatic complete and partial finger amputations are rare in comparison with adults. There are significant differences between mechanism of trauma, principles of treatment children with this type of injury in comparison with adults.Clinical case. A 15-years old child suffered from injury by axe, which caused the traumatic fingertip amputation of III and IV digits of his right hand. Replantation of both amputated parts was performed. Arteries and nerves were repaired with no veins anastomosed. As a result - survival of replanted parts.Discussion. A submillimeter diameter of vessels and potential venous congestion are basic problems that a surgeon deal with when perform the replantation of fingertips. Respectively, a difficulty in post-operative care of patient appears.Conclusion. Replantation of amputated part of finger is a golden standard of treatment of children with a described type of injury. The correct deliverance of amputated parts, the shortest time of ischemia as possible, a qualitive operation and post-operative care play an important role in successful survival of the replanted segments.

Artery-Only Fingertip Replantation Distal to the Lunula: A Retrospective Analysis of Clinical Results.

Background: Both arterial and venous repair are crucial for optimal results in digital replantation. However, anastomosis of veins becomes challenging in very distal fingertip amputation. This study aimed to report the clinical results of an artery-only replantation without vein repair for a distal fingertip amputation and to analyze the survival rate and clinical outcomes based on the amputation level. Methods: We performed a retrospective review of 47 digits in 38 patients who had undergone fingertip replantation with a mean follow-up period of 12 months. All patients had complete fingertip amputation distal to the lunula. Only one central artery repair distal to the arch was performed. All patients received the postoperative protocol including external bleeding and anticoagulation therapy. Results: By Ishilawa's classification, 12 digits in subzone I, and 35 digits in subzone II. 31 of the 47 fingertip replantations (66%) were successful, and a significantly higher survival rate was observed in subzone I than in subzone II. The mean total active motion of surviving digits was 86% of normal side. The mean grip strength was 82% of normal side. The sensory recovery according to modified Highet and Saunders' classification was S4, S3+, S3, and S2 in fingers 19, 2, 5 and 3, respectively. Conclusions: 66% of survival rate was achieved in fingertip replantation distal to lunula which including large number of crushing/avulsion injury. The result of comparison for the survival rate based on amputation level, a significantly higher survival rate was observed in subzone I compared to subzone II. Therefore, the artery-only fingertip replantation had a better indication for distal amputation, and an aggressive attempt for venous anastomosis or drainage, including a secondary surgery for proximal amputation could be attributed to a higher success rate.

Reply to Letter to the Editor “Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method”

Reply to Letter to the Editor “Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method”

Letter to the Editor "Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method".

Letter to the Editor "Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method".

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution.

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes-Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3months) as compared with adult patients (4.1months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable.Level of evidence: IV.

Assessment of sensory outcomes after successful fingertip replantation with or without nerve repair according to amputation level.

Good sensory outcome in fingertip replantation is a major part of the success of reconstruction and using the finger. Although some sensorial outcomes have been reported in various series in the literature, there is no controlled study, which demonstrates the anatomical levels where nerve repair should or should not be performed. We aimed to assess sensorial outcomes of fingertip amputations with or without nerve coaptation according to amputation level. Between January 2013 and July 2018, patients with Tamai Zone 1 and Zone 2 amputations underwent replantation. The patients were divided two main groups. Patients underwent nerve coaptation were grouped as Group 1, and those coaptation not performed as Group 2. In addition, subgroups were designed according to level of the amputation. Tamai zone 1 amputations were grouped as groups 1a and 2a. Tamai zone 2 amputations were grouped as groups 1b and 2b. The mean age was 30.8 ± 30.8 years in Group 1a, 33.2 ± 12.6 years in Group 1b, 34.1 ± 13.6 years in Group 2a, 34.3 ± 11.1 years in Group 2b. Type of injury were evaluated as clean cut (with knife, saw etc.), moderately crushed, and severely crushed and/or avulsion. In Group 1a, one prominent branch of the nerve was repaired, and in Group 1b, the nerve in both side was repaired. The mean duration of replantation in Group 1a was 1 h and 40 min (1 h and 15 min-2 h), whereas this time was 1 h and 15 min (1 h - 1 h and 35 min) in Group 2a. Then, 2 h 15 min (1 h and 55 min-2 h and 50 min) in Group 1b, and 2 h (1 h and 45-2 h 25 min) in Group 2b. Mean age, type of injury and length of follow-up were statistically compared. Sensorial outcome was evaluated by 2-point discrimination test and the Semmes-Weinstein test. According to the Semmes-Weinstein test, 33% of the fingers tested were normal, 58% had diminished light touch, 8% had diminished protective sensation, and 0% had loss of protective sensation in Group 1a; In Group 1b, these values were 35% (7/20), 55% (11/20), 10% (2/20), 0%; in Group 2a, 38% (6/16), 56% (9/16), 6% (1/16), 0%; in Group 2b, 25% (4/16), 44% (7/16), %25 (4/16), 6% (1/16), respectively Mean static two-point discriminations in Groups 1a, 1b, 2a, and 2b were 4.17 ± 0.58, 4.55 ± 0.69, 4.25 ± 0.68, and 5.9 ± 1.26 mm, respectively. The mean follow-up duration was 24 months in Group 1a, 24 months in Group 1b, 26 months in Group 2a, 21 months in Group 2b. Then, 17 (3 in Group 1a, 6 in Group 1b, 4 in Group 2a, 4 in Group 2b) of the 64 fingers were clean cut amputation, 45 (9 in Group 1a, 14 in Group 1b, 11 in Group 2a, 11 in Group 2b) were moderately crushed amputation, and 2 (1 in Group 2a, 1 in Group 2b) were severely crushed and/or avulsion injury. There was no statistically significant difference between groups 1a and 2a (p = .71). On the other hand, there was a statistically significant increase in sensory outcomes of patients in Group 1b compared to Group 2b (p = .009). There was no statistically significant between the groups in terms of mean age, type of injury and length of follow-up. We think that nerve repair does not have a positive effect on sensorial recovery in Tamai Zone 1 amputations, but nerve coaptation should be performed in Tamai Zone 2 replantations if possible for better sensorial result.

Fingertip Replantation Using Artery-Only Anastomosis With a Pulp Tissue Reduction Method: A Combination of Pulp Tissue Reduction, Bone Fixation Without Gaps, and Pinprick Testing Twice a Day.

In fingertip replantation with arterial anastomosis alone, many external bleeding techniques have been described to satisfy venous outflow, and some patients require blood transfusions. We used a pulp tissue reduction method to avoid the need for external bleeding techniques and blood transfusions. We examined 18 fingers in cases of Ishikawa's subzone II, III, and IV amputation that were replanted with artery-only anastomosis and pulp tissue reduction from April 2003 to March 2018. The method consisted of pulp tissue reduction to the level of the fingerprint core, bone fixation without gaps to promote venous drainage through bone marrow, and pinprick testing twice a day. Prostaglandin E1 and/or urokinase were administered intravenously, but no other anticoagulants were used systemically or locally. Postoperatively, only the pinprick test was performed twice a day for 5 days. The patients ranged in age from 26 to 74 years (mean, 47 years). There were 13 men and 5 women. The total success rate was 89% (16/18). Of the 2 salvage failures, one was due to venous congestion and the other was due to arterial insufficiency. The survival rates of Ishikawa's subzone II, III, and IV amputation were 100% (4/4), 71% (5/7), and 100% (7/7), respectively. No blood transfusions were required in any of the cases. The Semmes-Weinstein test was performed for 14 of 18 fingers: the result was blue in 11 fingers and purple in 3 fingers. The pulp tissue reduction method resulted in a high success rate without the need for external bleeding or blood transfusions. Fingertip replantation with artery-only anastomosis, a pulp tissue reduction method, is effective for replant survival when subcutaneous venous repair is impossible because a reduced pulp volume may facilitate replant survival under conditions of irregular venous drainage, such as bone marrow drainage.

Reconstruction of reflux in fingertip replantation by anastomosis of nailfold vein

Objective To explore the clinical efficacy of anastomosis of nailfold vein in reconstruction of reflux of fingertip replantation. Methods From November 2016 to December 2017, 18 patients with 23 fingers of fingertip amputation in IshikawaⅡ area (from middle nail to nail root plane) were replanted. The parathyroidal longitudinal incision was used to explore and anastomose the nailfold vein to reconstruct the severed finger reflux, and the clinical efficacy was followed up. Results The follow-up period ranged from 8 to 15 months, with an average of 11.1 months. Twenty-one of the 23 fingers survived and two were necrotic. The survival rate was 91.3%. The protective sensation was restored in all surviving fingertips. The two-point discrimination was (8.8±2.4) mm. The active range of motion of distal interphalangeal joint was (49.8±12.3)°, which was 63.4% of the healthy side. The average blood perfusion volume of finger pulp was 89.3% of the healthy side. The complications included cicatricial contracture (5/23), nail deformity (7/23), nonunion (1/23), distal interphalangeal joint dysfunction (4/23), and cold intolerance (4/23). Conclusion The nailfold vein can provide reliable venous reflux in fingertip replantation and restore the good appearance and function of replanted fingertips. Key words: Finger injuries; Replantation; Vein; Microsurgery