Success Rate Of Replantation Research Articles

REPLANTATION OF THE THUMB OR REVISION OF AMPUTATION: AN EPIDEMIOLOGICAL STUDY.

This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

Our Finger Replantation Results in the SARS-COV-2 Pandemic

Purpose: Finger injuries are important causes of emergency department admissions. In order to perform daily activities, the fingers must work fully and flawlessly. Replantation surgery aims to keep the injured finger alive and perform its functions almost completely. Our study aims to evaluate the reasons affecting the success of replantation during the SARS COV-2 pandemic period and to question the functional recovery after replantation. Methods: Finger and hand replantation performed in a single center by the same surgeon were reviewed retrospectively. Preoperative, intraoperative, and postoperative and demographic data of the patients, mechanism of injury, ischemia duration, complications, surgical treatment approaches, and functional evaluation scales after rehabilitation were collected and statistically evaluated. Results: In our study, 88 fingers of 56 patients were replanted. While single finger replantation was performed in 38 patients, multi-finger replantation was performed in 18 patients. The total success rate of replantation was 73.2%. While successful results were obtained in 81.6% of 38 patients with single finger replantation, 55.6% of 50 fingers in 18 patients with multiple finger replantation were successful. We found that 3 patients after surgery and 11 patients in the six months before surgery were positive for SARS COV-2. No finger loss or complications occurred in these 14 patients after replantation. Conclusion: We concluded that SARS COV-2 disease had no significant effect on finger replantation surgery. Our study found that the most important variables affecting surgical success were the mechanism of injury, injury level, age, gender, anesthesia technique applied, number of repaired veins, smoking, and ischemia duration.

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.

Application of Emergency Specialist Nursing Combined with Green Channel Mode in Patients with Limb Amputation.

Background The treatment of limb amputation is always a challenge to emergency medical staff. The success of replantation of severed limbs requires not only emergency professional nursing measures but also rapid transport against time. We that found emergency specialist nursing combined with green channel mode can effectively improve the success rate of amputated limb replantation surgery. Methods From September 2017 to August 2020, the medical records of 80 patients with severed limb replantation treated by the emergency department of our hospital were collected and divided into the control group and the experimental group. 36 patients in the control group were emergency patients treated from September 2017 to May 2019. These patients did not take appropriate emergency specialist nursing measures and opened green channels at that time; the other 44 patients were in the experimental group, for emergency patients treated from June 2019 to August 2020. These patients have received emergency specialist care and opened a green channel. We recorded the gender, age, preoperative examination time, and success rate of amputated limb replantation surgery of the two groups of patients. Results The age of the patients in the control group was 41.17 ± 8.00 years old, and the age of the patients in the experimental group was 41.07 ± 7.31 years old (P > 0.05). The preoperative examination time of the patients in the control group was 46.53 ± 4.11 min, and the preoperative examination time of the patients in the experimental group was 40.34 ± 5.85 min (P < 0.05); the replantation success rate of the control group was 72.2%, and the replantation success rate of the experimental group was 81.8% (P < 0.05). Conclusion Standardized emergency specialist nursing measures combined with green channel mode can effectively shorten the preoperative examination time and help improve the success rate of amputated limb replantation surgery.

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

of replantation surgery following upper extremity traumatic amputation are extensively described in the literature, with success rates varying from 57 to 100 percent. The purpose of this study was to evaluate replantation success rate at a Level I trauma center over a 17-year period and to assess definable factors contributing to these results. A retrospective review of all digit and hand replantations at a Level I trauma center was performed using CPT codes from 2001 through 2018. Descriptive analyses, Mann-Whitney test, Kruskal-Wallis test, and logistic regressions were used. Significance was defined as p ≤ 0.05. Analysis consisted of 76 patients with 101 amputated parts (93 digits and eight hands). Fifty-six single digit amputations (30 percent success rate), 37 multidigit injuries (22 percent digit success rate), and eight hand amputations (50 percent success rate) were attempted. The overall success rate was 25 of 76 patients (33 percent) and 29 of 101 parts (29 percent). The most common mechanism of injury was laceration (n = 56), followed by crush (n = 30), and avulsion (n = 11), with repair of laceration-type injuries having the greatest success rate (36 percent). The authors report a lower success rate of hand and digit replantation than previously described in the literature. Whole hand and thumb replantations resulted in the highest survival rate in our series. Laceration mechanism showed a higher success rate than crush or avulsion-type injuries. The authors' modest results highlight the importance of effective internal auditing of low-volume replantation centers such as their own. Quality improvement measures are proposed for higher future success in replantation surgery at the authors' institution. Therapeutic, IV.

National Population Study of the Effect of Structure and Process on Outcomes of Digit Replantation

Surgeon experience, hospital volume, and teaching hospital status may play a role in the success of digit replantation. This study aims to analyze factors that influence digit replantation success rates. We examined patients with traumatic digit amputations, between 2000 and 2015, from the National Health Insurance Research Database (NHIRD) of Taiwan, which comprises data of more than 99% of its population. We measured the number of traumatic digit amputations and success rate of replantation. Chi-square and ANOVA tests were used for descriptive statistics. Regression models were built to analyze the association among patient, surgeon, and hospital characteristics, and replant success. We identified 13,416 digit replantation patients using the eligibility criteria. The overall replantation failure rate was significantly higher in medium- and high-volume hospitals (low-volume: 11%, medium-volume: 17%, and high-volume: 15%, p < 0.001). Teaching hospitals had significantly higher replantation failure rates [(15.5% vs 7.6%), odds ratio (OR) 2.0; confidence interval (CI) 1.1-3.7]. Lower surgeon case volume resulted in a significantly higher failure rate in the thumb replantation (OR 0.89; CI 0.85-0.94). Teaching hospitals had greater odds of replantation failure, owing to being high volume centers and attempting more replantations. However, the effect of residents performing the replantation during their training should be considered. Teaching units are mandatory for resident training; however, a balance should be established to provide training, but with sufficient supervision to achieve optimal replant success. A national protocol to triage digit amputation cases to high volume centers with experienced microsurgeons will help improve the replantation success rate.

Development and Application of a Quick Cleaning and Portable Storage Device for Dislocated Teeth

Background: The teeth with dental trauma in children are mostly young permanent teeth of school-age children. Once trauma occurs, it will have adverse effects on children's masticatory function, occlusal relationship, beauty, growth and development. Objective: To improve the success rate of replantation of completely dislocated teeth. Methods: Through literature review, we focus on “Tooth Injuries, Complete Dislocation, Replantation” to understand the current rescue measures of dislocated teeth, and conceive a rapid cleaning and portable storage device for dislocated teeth. Results: A device for rapid cleaning and portable preservation of dislocated teeth was successfully designed. Setting the ultraviolet sterilization lamp can play the role of irradiation sterilization and setting the mesh vertical plate can prevent the violent collision of multiple teeth when cleaning. It is possible to divide the storage slot space by setting the baffle, so as to achieve the purpose of classified storage. Conclusion: A rapid cleaning and portable storage device for dropped teeth is described, which solves the problems that the existing rapid cleaning and portable storage device cannot clean teeth uniformly, the cleaning effect is poor, and the cleaned teeth cannot be stored at low temperature.

Low molecular weight heparin for prevention of microvascular occlusion in digital replantation.

Microvascular surgery refers to any surgery involving small sized blood vessels that is performed under the operating microscope, allowing the repair of arteries and veins of the digits. These are typically 1 mm to 2 mm in diameter. Replantation is the reattachment of a completely detached body part, with fingers and thumbs being the most commonly replanted body parts. This is often referred to as digital replantation. In principle, digital replantation involves not only restoring the blood flow through the arteries and veins but also restoring the bony skeleton of the toes, fingers or thumbs, along with repairing the tendons and nerves as indicated. Occlusion of one or more of the repaired vessels due to the formation of a clot (thrombus) within the blood vessel results in failure of the replantation. Anticoagulant medications are used to reduce clotting, and they could potentially prevent such a complication. Anticoagulants such as unfractionated heparin (UFH) have therefore been used to prevent clot formation after digital replantation. It is unclear if low molecular weight heparin (LMWH) has similar benefit. This systematic review identified only two randomised controlled trials comparing UFH with LMWH, with a total of 114 patients. No studies were identified that compared LMWH with placebo, no treatment or other anticoagulants. The limited data from the two trials showed no difference between LMWH and UFH in the success rate for digital replantation but there were less frequent anticoagulation-related adverse events (such as bleeding) with LMWH. The available evidence is insufficient to make a firm conclusion.

Pre-injury level of anxiety is associated with the rate of digit replant failure: A prospective cohort study

Previous studies have demonstrated that age, smoking, Tamai's level of amputation, causes of injury and ischemia time were associated with the success rate of digit replantation. The primary objective of this study is to investigate whether mental status including anxiety and depression is associated with the rate of digit replant failure. This study included 134 digits from 102 patients who received digital replantation after complete amputation from 1 September 2013 to 1 September 2015. The Zung self-rating anxiety scale (SAS) and the Zung self-rating depression scale (SDS) were used to assess the pre-injury level of anxiety and depression for each patient. All participants were followed up for at least 1 month. Failure was defined as necrosis of replanted finger which required revision amputation or flap cover of the skeleton. Multivariate logistic regression analysis showed that increased level of pre-injury anxiety was an independent risk factor correlated with success rate (odds ratios [OR] = 7.69, 95% confidence interval [CI]: 1.93-30.30) in this series. The relative risk of anxiety group was 4.48 (95% CI: 1.38-14.49) compared to normal group. Digits with double arterial anastomosis in anxiety patients showed a higher survival rate while the number of veins repaired showed no significant effect on survival rate. Increased level of pre-injury anxiety was an independent risk factors for digit replantation failure. Double arterial anastomosis increased the success rate of replanted digits in anxiety patients.

Comparison of venous repair results using either arterial or vein grafts in a crush-avulsion injury model

Background/aim Venous insufficiency after replantation or revascularization is one of the most common causes of limb loss in either the short or the long term. The aim of this study was to evaluate the results of a new technique to overcome venous insufficiency.Materials and MethodsA crush-avulsion type of injury was formed in the femoral veins of rats of 3 separate groups. In the control group, primary repair was applied to the damaged veins and the remaining 2 groups were repaired with either an arterial graft or a vein graft. The success rates of anastomosis were then compared.Results In the control group the patency rate was 25% in the 2nd hour, 12.5% on the 2nd day, and 12.5% on the 10th day. The patency rate in the vein group was 87.5% in the 2nd hour, 50% on the 2nd day, and 37.5% on the 10th day, whereas the patency rates in the artery group were 100% in the 2nd hour, 87.5% on the 2nd day, and 75% on the 10th day.ConclusionMicrosurgery requires experience and patience. It can be considered that the use of arterial grafts for venous repair in replantation after crush-avulsion type amputations can increase the success rate of replantation.

Patency Test of Vascular Anastomosis with Assistance of High-Speed Video Recording in Digit Replantation.

Quality assessment of vascular anastomosis primarily depends on the experience of the treating surgeon. This highlights the need for an objective index. The main goal of our study was to establish a method of assessing the quality of vascular anastomosis in digit replantation. A total of 182 digits from 141 patients were included in this study. The patients underwent replantation of completely amputated digits between June 1, 2015, and February 1, 2017. Patency tests of arterial and venous anastomoses were conducted for each replantation and recorded on digital video at 1,000 frames per second. We divided the study into 2 phases. In phase I (103 digits from 80 patients), we investigated whether the refilling velocity ratio (RVR) was associated with replantation failure. In phase II (79 digits from 61 patients), we adopted the RVR as a guiding parameter during surgery and compared the replantation success rate with that of the historical control of phase I. In phase I, ischemia time (>12 hours), arterial RVR (<0.4), and venous RVR sum (<1.0) were significantly associated with the rate of replantation failure in 82 cases with single arterial anastomosis. In phase II, we set the arterial RVR goal to 0.4 and venous RVR sum goal to 1.0. Under the guidance of the RVR test, the survival rate significantly increased compared with that of the historical control of phase I (96% versus 87%; p = 0.037). The patency test, with assistance of high-speed video recording, is a useful tool that can improve the success rate of digit replantation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of two different administration methods of heparin on the survival rate of severed finger replantation

Objective To evaluate the effects of two different administration methods of heparin on the survival rate of severed finger replantation. Methods From March 2010 to January 2015, the operation of single severed finger replantation was performed on 104 patients in emergency department of our hospital. According to the different administration methods of heparin after operation, they were divided into intravenous injection group (group A) and intravenous drip group (group B), with 52 cases in each group. The incidence of vascular crisis, the survival rate of replantation and the adverse reactions were observed postoperatively. The patients were follow-up for 2 months. Results There was no significant difference between two groups in the incidence of vascular crisis and the survival rate of replantation, and the adverse reactions in intravenous injection group were significantly lower than those in intravenous drip group. Conclusion There was no significant difference in the incidence of vascular crisis and the success rate of replantation after operation between intravenous injection of heparin and intravenous drip of heparin. However, intravenous injection can reduce the adverse reactions. Key words: Replantation; Heparin; Administration method; Vascular crisis; Adverse reaction

Replantation and revascularization of amputated upper limb appendages outcome and predicting the factors influencing the success rates of these procedures in a tertiary hospital: An 8-year retrospective, cross-sectional study.

Worldwide advances in microsurgery have made salvaging of amputated hand via replantation and revascularization common procedures. The present study examines the outcome of these procedures in a tertiary hospital in Malaysia. Patients with hand amputation who underwent replantation or revascularization from 2005 to 2012 were identified and reviewed for patient characteristics, amputation characteristics and survival rates. Successfully treated patients were interviewed to assess the functional outcome using Quick Disability of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Statistical analysis was performed to evaluate outcome and elicit predictive factors. Fifty-five patients were enrolled: 37 (67.3%) underwent replantation and 18 (32.7%) underwent revascularization. The overall success rate of 78% ( n = 43) was within the range of previously reported data (61.6% to 96.0%). Ischaemic time <6 h provided significantly better survival rates ( p < 0.05). Functional outcomes were successfully assessed in 34 patients (79%), at a mean follow-up of 40 months (range 11-93 months). The overall Quick-DASH and MHQ scores were 42.82 ± 23.69 and 60.94 ± 12.82, respectively. No previous reports of functional outcome were available for comparison. Both Quick-DASH ( p = 0.001) and MHQ scores ( p < 0.001) were significantly higher for finger injuries, followed by thumb, wrist and palm injuries. Ischaemic time and level of injury are important predictors of success rate of replantation and revascularization of amputated upper limb appendages.

The application of strengthened night nursing to the prevent of vascular crisis in patients after finger replantation

Objective To investigate application effect of strengthened night nursing to the prevent of vascular crisis in patients after finger replantation. Methods A total of 155 patients with finger replantation in Hand surgery from February 2014 to February 2016 were selected as research object, 90 cases from March 2015 to February 2016 with strengthened night nursing were as the observation group, 65 cases from February 2014 to February 2015 with routine nursing were as the control group. The two groups were compared of limb replantation success rate, vascular crisis rate and nursing satisfaction. Results The replantation success rate in the observation group was 90.00%(81/90) higher than 76.92%(50/65) in the control group, the occurrence of vascular crisis rate was 11.11%(10/90) lower than 27.69%(18/65) in the control group, the success rate was 7/10 higher than 10/18 in the control group, and the difference was statistically significant (χ2=4.932, 7.013, 4.216, all P<0.05). The nursing satisfaction in the observation group was (94.32±3.57) points, 93.33%(84/90) higher than (91.22±4.48) points, 83.08%(54/65) in the control group, and the difference was statistically significant (t=4.789, χ2=4.071, P<0.05). Conclusions Strengthened night nursing can effectively prevent vascular crisis in patients after finger replantation, improve nursing satisfaction of patients. Key words: Strengthened; Night nursing; Replantation; Vascular crisis; Prevention

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.

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.

Controlled continuous systemic heparinization increases success rate of artery-only anastomosis replantation in single distal digit amputation: A retrospective cohort study.

Replantation is a prime indication for distal digital amputation, as it helps restore hand aesthetics and functions; however, venous anastomosis is often not feasible. Previous studies used systemic anticoagulation in distal digital artery only anastomosis replantation surgery to improve replantation success rate, however, which yielded limited level of clinical evidence. This study aimed to compare controlled continuous heparinization (CCH) and intermittent bolus heparinization (IBH) for surgical outcome and clinical variables after single distal digital artery only anastomosis replantation surgery.A single-institution, retrospective cohort study was performed. Out of 324 patients who underwent digital replantation surgery, we focused the study for the Zone I and II single distal digital amputation patients excluding confounding factors. Sixty-one patients were included in this study and underwent artery-only anastomosis replantation surgery with postoperative CCH (34 patients) or IBH (27 patients) protocols. The CCH group targeted activated partial thromboplastin time (aPTT) at 51 to 70 seconds, monitoring aPTT levels every eight hours and administering 100 mg of aspirin per day. The IBH group received 300 mg of aspirin per day and underwent IBH (12,500 U). Both groups received intravenous prostaglandin E1 drips (10 μg). To verify the factors affecting the success rate of the heparin protocol, patient factors, clinical factors, and operative factors were extracted from the medical records. Statistical analysis with inverse probability of treatment weights propensity score methods compared treatment outcomes and clinical variables.The CCH group's replantation success rate was higher (91.17% vs 59.25%), and the transfusion rate was increased (P = 0.032). However, the significant decrease in hemoglobin levels (>15%) did not differ between the groups (P = 0.108). Multivariable logistic regression analysis with potent univariate variables (P < .10) revealed that CCH was a statistically significant variable in replantation success rate (P = 0.004). Neither the major bleeding complications nor the significant decrease in patients' platelet levels were observed in both groups.Our study suggests that CCH after artery-only anastomosis replantation surgery in Zone I and II distal digital replantation is a safe method to improve the replantation success rate and may provide a guideline for use of the anticoagulation method following artery-only anastomosis distal digital replantation surgery.

Eight years of clinical experience with digit replantation: Demographic characteristics and outcomes.

Despite surgical and technical advances in microsurgery, it is still difficult to obtain satisfactory results after replantation of finger amputation. The aim of the present study was to discuss some of the many factors that can affect the success rate of replantation. A retrospective analysis of 60 patients with 85 finger replantations was performed. Revascularizations and replantations proximal to the metacarpophalangeal joint were excluded. Demographic characteristics of the patients, place of injury, mechanism of injury, level of amputation, and success rate were examined. A total of 53 male and 7 female patients with mean age of 31 years were included in the study. Index finger (27%) was the most commonly replanted digit. Left side was the more affected, with 62%. Mechanism of injury was crush in 56%, guillotine in 23%, and avulsion in 21% of replanted digits. Success rate was 81%, 53%, and 36% in guillotine, crush, and avulsion injuries, respectively. In conclusion, the injury type and personal variables are very important in the rate of replantation success. Knowledge about the effects of different factors on the results of replantation surgery will provide guidance to hand surgeons in order to inform patients and their relatives properly.

Our Strategy for Fingertip Amputation

From January 2005 to December 2008, we treated 59 patients with a total of 67 complete fingertip amputations. By statistically analyzing these 67 cases, we reported that up to subzone III (Ishikawa’s subzone), replanted fingertips could survive with arterial anastomosis alone, and we established a new treatment strategy. 1. For cases with amputation levels subzones I to III, arterial anastomosis was performed under digital block and venous anastomosis if possible. If the venous anastomosis was not performed, care was taken to relieve postoperative congestion. General anesthesia was used in cases where the patient had difficulty in staying still, such as a child. 2. For cases with amputation levels more proximal than subzone IV, both arterial and venous anastomoses were performed. Venous anastomosis is essential and considering the possibility of a vein graft, operations were performed either under axillary block or general anesthesia. From July 2012 to November 2014, we treated 21 patients with 22 fingertip amputations according to the new treatment plan. Results: Amputation levels were as follows: subzone I, 10 fingers; subzone II, 7 fingers; subzone III, 1 finger; and subzone IV, 4 fingers. Overall replantation success rate was 95% (21 out of 22 fingers). Conclusion: For the past two years, we have established a new treatment strategy for complete fingertip amputations, and obtained favorable outcomes. Depending on the situation of the patients and institutions, this strategy could become one of the treatment options.

Low molecular weight heparin for prevention of microvascular occlusion in digital replantation

The success of digital replantation is highly dependent on the patency of the repaired vessels after microvascular anastomosis. Antithrombotic agents are frequently used for preventing vascular occlusion. Low molecular weight heparin (LMWH) has been reported to be as effective as unfractionated heparin (UFH) in peripheral vascular surgery, but with fewer adverse effects. Its benefit in microvascular surgery such as digital replantation is unclear. To assess whether subcutaneous LMWH treatment improves the salvage rate of the digits in patients with digital replantation after traumatic amputation. The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (October 2012), CENTRAL (2012, Issue 10) and trials databases. In addition, the authors searched PubMed, CNKI (China National Knowledge Infrastructure) and CEPS (Chinese Electronic Periodical Services), and sought additional trials from reference lists of relevant publications. We selected randomised or quasi-randomised controlled trials of LMWH in patients who received digital replantation. Two review authors independently extracted data and assessed the risk of bias of the included trials. Disagreements were resolved by discussion. Two randomised trials involving 114 patients with at least 122 replanted digits met the inclusion criteria and were included. Both trials compared the efficacy and safety of LMWH with UFH. We found no trials comparing LMWH with placebo or other anticoagulants. The data from the two included studies were insufficient for meta-analysis. The overall success rate of replantation did not differ between the LMWH and UFH groups, 92.3% versus 89.2% in one trial (risk ratio (RR) 1.03; 95% confidence interval (CI) 0.87 to 1.22) and 94.3% versus 94.15% in the other trial (RR 1.00; 95% CI 0.89 to 1.13). The incidence of both postoperative arterial and venous insufficiency were reported in one trial and did not significantly differ between the LMWH and UFH groups (RR 1.08; 95% CI 0.16 to 7.10 and RR 0.81; 95% CI 0.20 to 3.27, respectively). Direct and indirect causes of microvascular insufficiency were not reported in the trials. Different methods were used to monitor the adverse effects related to anticoagulation in the two trials. Bleeding tendency was monitored for the LMWH and UFH groups in one trial and was reported by the incidence of wound haemorrhage (11.5% versus 17.9%; RR 0.65; 95% CI 0.17 to 2.44), ecchymoses (3.8% versus 10.7%; RR 0.36; 95% CI 0.04 to 3.24), haematuria (3.8% versus 7.1%; RR 0.54; 95% CI 0.05 to 5.59), nasal bleeding (0% versus 7.1%; RR 0.21; 95% CI 0.01 to 4.28), gingival bleeding (0% versus 10.7%; RR 0.15, 95% CI 0.01 to 2.83) and faecal occult blood (0% versus 3.6%; RR 0.36; 95% CI 0.02 to 8.42). The bleeding tendency was increased in the UFH group but this was not statistically significant. This trial also monitored coagulability changes using parameters such as antithrombin activity, factor Xa activity, bleeding time, clotting time and activated partial thromboplastin time (aPTT). No comparison was made between the LMWH and UFH groups but all data consistently showed that coagulability was reduced more in the UFH group than in the LMWH group. The other trial reported a postoperative decrease in platelet count in the UFH group (preoperative 278.4 ± 18.7 x 10(9)/L, postoperative 194.3 ± 26.5 x 10(9)/L; P < 0.05) but not in the LMWH group (preoperative 260.8 ± 32.5 x 10(9)/L, postoperative 252.4 ± 29.1 x 10(9)/L; P > 0.05). Current limited evidence based on two small-scaled low-to-medium quality randomised trials found no differences in the success rate of replantation between LMWH and UFH, but a lower risk of postoperative bleeding and hypocoagulability after the use of LMWH. Further well-designed and adequately powered clinical trials are warranted.