Revision Amputation Research Articles

Trends in the Management of Traumatic Upper Extremity Amputations

Treatment for upper extremity amputations includes revision amputation or attempted replantation. The rate of digital replantation has been declining in the United States. Prior studies discovered the presence of socioeconomic disparities associated with these injuries. The goals of this study were to investigate yearly trends of traumatic upper extremity amputations and evaluate the presence of disparities with access to care in these injuries. The 2008 to 2014 New York Statewide Planning and Research Cooperative System (SPARCS) inpatient and outpatient databases were utilized to identify patients who had traumatic upper extremity amputations. We queried the database for patient characteristics, resource utilization characteristics, insurance status, major in-hospital complications, and mortality. Patientsat low-, medium-, and high-volume institutions were compared. We performed multivariable logistic regressions for the binary variable replantation (yes/no) controlling for age, sex, race, insurance status, amputation level, admission hour, and comorbidities. A total of 2,492 patients met our inclusion criteria: 92.1% sustained digital amputations and 7.9% sustained arm amputations. The annual rate of inpatient finger amputations decreased significantly (1.9 per 100,000 people in 2008 vs 1.4 per 100,000 people in 2014) during the study period while that of outpatient finger amputations increased significantly (12.0 per 100,000 people in 2008 vs 15.5 per 100,000 people in 2014). Multivariable analysis demonstrated incrementally lower odds for replantation with increasing age and increased odds for replantation in patients with private insurance (odds ratio, 1.64; 95% confidence interval, 1.08-2.50). The number of replantation surgeries at medium-volume institutions decreased by 45% while remaining steady in low- and high-volume institutions. Our findings corroborate the findings of other studies that underscore the existence of disparities with respect to insurance status in these injuries. Replantations occur more frequently at high-volume hospitals and are more common in younger patients with private insurance. This finding suggests that patients with traumatic amputations may benefit from treatment at high-volume institutions. Further research to help improve access to such institutions is warranted. Prognostic II.

Prevention of symptomatic neuroma in traumatic digital amputation: A RAND/UCLA appropriateness method consensus study

IntroductionThe appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol. MethodsA literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol. ResultsNine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain. DiscussionIn order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped. ConlusionsThe prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury.

Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection.

Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. IV, Case Series.

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

Optimal treatment for traumatic finger amputation is unknown to date. To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. Treatment with revision amputation or replantation. Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.

The Preferred Management of a Single-Digit Distal Phalanx Amputation.

Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of this study was to analyze international microsurgeons' clinical decisions when faced with this common scenario. A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences. Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively p < 0.001). Having completed a microsurgery fellowship increased the attempt rate of replantation by 15.3% (p = 0.004). Clinical experience and the surgeons' specialties did not show statistical significance in clinical decision making. From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.

Spotlight in Plastic Surgery: January 2020

Spotlight in Plastic Surgery: January 2020

Clinical profile and surgical management of Fingertip injuries -Three-year experience at a Tertiary Care Hospital in North India.

Background: Fingertip injuries are very common due to workplace accidents with a wide spectrum ranging from a small laceration and nail bed injuries to traumatic amputation and severe crush. It is best to retain as much native tissue as possible when viable. Out of the various available reconstructive options, one needs to select an option which preserves the length of the digit and achieves a painless fingertip with durable and sensate skin cover. Materials and Methods: This is a prospective study of 63 cases with fingertip injuries over a period of 3 years from Aug 2016- Jul 2019. Various reconstructive options were considered for the fingertip injuries depending upon the size, shape, site, status of surrounding skin and structures exposed. The total duration of treatment varied from two to six weeks and follow-up ranged from two months to one year. Results: Eighty out of 90 (88.88%) fingertip injuries in 63 patients required healing by tertiary intention either in the form of skin graft in 24/90(26.66%) or a flap cover in 50/90(55.55%) to ensure preservation of finger length/ contour and retention of sensation, while revision amputation was done in 6/90 (6.67%). Four out of 90(4.44%) healed by secondary intention. Eight out of 63(12.69%) developed wound infections while wound dehiscence and marginal necrosis in flaps were found in 2/50(4%) and 4/50(8%) in a total of 50 fingertip injured treated with flaps. Only 4 patients (9.5%) had persistent cold intolerance. Conclusions:Majority of the fingertip injuries are machine related. Public awareness and ensuring strict adherence to workplace safety regulations may prevent these to a great extent.The treatment needs to be individualized and tailored to geometry of the defect and needs of the patients.All possible techniques of reconstruction must be known to the operating surgeon to achieve optimal recovery.

Reliability and Validity of Upper Extremity Patient-Reported Outcome Measures in Assessing Traumatic Finger Amputation Management

This study investigates the psychometric properties of patient-reported outcome instruments for assessing outcomes in postsurgical traumatic digit amputation patients. The authors hypothesize that the Michigan Hand Outcomes Questionnaire (MHQ) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are the most valid and reliable instruments. The authors studied traumatic digit amputation patients as part of the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE) study initiated by The Plastic Surgery Foundation. The MHQ, DASH questionnaire, Patient-Reported Outcomes Measurement Information System (PROMIS), and 36-Item Short-Form Health Survey were used to assess patients at least 1 year postoperatively. Internal consistency was measured by Cronbach's alpha and criterion validity with Pearson correlation coefficient (r). Construct validity was tested with four predefined hypotheses. Discriminant validity was analyzed by receiver operating characteristic curves. One hundred sixty-eight replantation and 74 revision amputation patients met the inclusion criteria. All instruments demonstrated fair to good internal consistency in both cohorts (0.7 < α < 0.9). The MHQ and DASH questionnaire scores correlated strongly (r > 0.60) in both cohorts. The 36-Item Short-Form Health Survey had moderate to weak correlation with the remaining instruments, and its mental component had poor discriminant validity (area under the curve, 0.64 to 0.67). The MHQ, DASH questionnaire, and PROMIS demonstrated good construct validity confirming 75 to 100 percent of predefined hypotheses, whereas the 36-Item Short-Form Health Survey confirmed only 25 percent. The authors recommend using the Michigan Hand Outcomes Questionnaire or the Disabilities of the Arm, Shoulder and Hand questionnaire when assessing patient-reported outcomes in digit amputation patients based on good internal consistency and validity. The Patient-Reported Outcomes Measurement Information System has fair validity and reliability but should be an adjunct instrument. The 36-Item Short-Form Health Survey should not be used as a primary assessment tool, but as an adjunct to assess overall quality of life.

Major upper limb replantation: a review of clinical pearls

Replantation of major segments of the extremities can be a formidable task. Adequate debridement of crushed tissues is a prerequisite for successful major limb replantation. This article serves to elucidate the important situational and patient factors a surgeon must consider when choosing between replantation or revision amputation for upper limb salvage.

Cost-effectiveness of Finger Replantation Compared With Revision Amputation

Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown. To assess the cost-effectiveness of finger replantation compared with revision amputation. This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis. Revision amputation or replantation of traumatic finger amputations. Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness. Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns. With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.

Should Chopart Amputation be Performed in Diabetic Foot Ulcer Patients?

Category:Diabetes, Midfoot/ForefootIntroduction/Purpose:Diabetic foot ulcers (DFU) with deep infections and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation is challenging, and is a complex decision based on the patient’s function at baseline, extent of infection, vascular patency and comorbidities. Although Chopart amputation preserves greater limb length than Syme amputation, additional procedures, such as Achilles tenectomy and tendon transfers are necessary to optimize residual foot function. Challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes including patient reported outcomes of Chopart and Syme amputations.Methods:A query utilizing current procedural terminology (CPT) codes was performed to identify patients who had undergone Syme or Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Twenty-two patients with average age of 59.8 (range, 28-79) years, comprising 18 Chopart amputations and 4 Syme amputations were identified. Demographic characteristics, body mass index, hemoglobin A1c, medical comorbidities, major and minor post-operative complications, unplanned admission or return to OR, revision surgeries, and time to receiving a brace or prosthesis information were compiled. After informed consent was obtained, subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments (Pain Interference (PI), Physical Function (PF), and Depression), and the SF-36. Unpaired student t-tests and Fisher’s exact test were utilized to compare patient cohorts. Statistical analysis was performed using Stata®.Results:The majority (17/18) of Chopart and half (2/4) of Syme patients developed complications including wound dehiscence and recurrent/persistent infection. Readmission and unexpected return to the OR for irrigation and debridement or revision occurred in 11/18 (61%) of Chopart and 2/4 (50%) of Syme patients. Revision amputations occurred in 10/18 (56%) Chopart patients (2 Syme, 8 BKA), and 1/4 (25%) Syme patients (BKA). Half of Chopart patients never received a prosthesis due to delayed wound healing and revision amputation. All Syme amputation patients received a prosthesis and resumed ambulation. The average time to prosthesis was 4.5 and 6.5 months for Syme and Chopart patients, respectively.There was no significant difference between Syme and Chopart patients in all PROMIS domains, or the SF-36 (p-values > 0.05) (Table 1).Conclusion:We found a high rate of complications and revision procedures in Chopart amputation patients. In our patient cohort, there was a high likelihood that a patient who underwent a Chopart amputation ultimately received a below knee amputation. Even after wound healing, patients with Chopart amputations may struggle with obtaining a prosthesis suitable for ambulation. Syme amputation patients were less likely to require revision amputation, and received a prosthesis more rapidly relative to Chopart amputation patients. The complication and revision rates of Chopart amputations indicate that surgeons should exercise judicious patient selection prior to performing these procedures.

Clinical Outcome Differences Between Single and Multi-stage Transtibial Amputations

Category:Diabetes, Trauma, AmputationIntroduction/Purpose:Transtibial amputations are often necessary when patients experience irreversible tissue damage in their lower extremities. Current amputation methods incorporate either a single-stage amputation with primary wound closure or a two-stage amputation. A two-stage amputation consists of an initial amputation, typically performed at a more distal site, followed by a second more proximal amputation with stump formalization. The reported advantages of two-staged amputations include decreased muscle retraction and the reduced spread of infection/necrosis. This has been reported to allow for reduced failure rates and lower rates of stump revision. Since two-stage amputations are associated with increased monetary costs, time spent in the hospital, and clinical resources used over single-stage amputations, establishing the differences between the clinical outcomes of both types of amputations can provide benefit-cost insight.Methods:This study was a retrospective study, so we began by pulling a query for all patients that underwent a below-the-knee amputation at our institution from January 1, 2015 through January 1, 2018. We excluded revision amputation patients and patients that suffered a traumatic amputation. We will then perform a chart review while recording demographic data, comorbidities, indication for amputation, labs and culture data if present. We will also record the final outcome of the surgery including any revision surgeries. We will collect data on total length of stay and total cost of care from the date of index surgery to the date of prosthetic fitting. For the cost analysis, a Markov model will be used, which can be incorporated with decision tree modeling to estimate the usage of healthcare resources by determining costs through the different phases of healthcare.Results:Our query returned 152 total patients, of which we estimate approximately 25% to 33% underwent a two staged amputation based on the surgeon’s typical amputation preferences. A power analysis was performed which suggested we needed 144 total patients to show a 20% anticipated absolute reduction in complication rates in two-stage amputations compared to single-stage amputations, based on a previous study. We just received the data this week and have not yet performed the full chart review. We hypothesize that two-stage amputations will be considerably more costly than single-stage but that the more involved two-stage strategy may be beneficial in certain subgroups of patients.Conclusion:While we do not yet have the chart review completed for this project, we are excited to elucidate the differences between single-stage and two-stage amputations. We anticipate having all data extracted within the next two months and a complete manuscript by the beginning of the summer. This project has the strong potential to change clinical practice of how trans-tibial amputations are performed depending on the outcome, revision rates, wound complication rates and total healthcare costs.

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost.

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

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.

Incisional Negative Pressure Wound Therapy: An Effective Tool for Major Limb Amputation and Amputation Revision Site Closure

Objective: To evaluate our institutional experience of incisional negative pressure wound therapy (iNPWT) applied immediately after major limb amputation closure or amputation revision closure. Approach: A retrospective review was performed on 25 patients who underwent major limb amputation or amputation revision and had iNPWT placed intraoperatively upon incision closure. Results: Twenty-one patients underwent lower extremity amputation and four underwent upper extremity amputation. Seventeen were primary amputations and eight were amputation revisions. No patients developed dehiscence, seroma, or hematoma. One patient developed a surgical site infection (4%) that was treated with oral antibiotics. The average time to eligibility for prosthetic fitting for lower extremity amputations was 6.3 weeks. Innovation: Amputee patients have increased wound healing demands that can impact prosthetic wear and ambulation status. Stump incisions are located at the distal end of their extremities and often are in areas that have had prior surgical procedures performed. Thus, blood supply to the incision site may not be optimal. iNPWT is an effective incision management technique to promote healing and decrease postoperative complications in this patient population, which can lead to increased mortality. Conclusion: iNPWT is an effective technique of minimizing wound complications in the amputee and should be considered in this high-risk patient population.

Replantation of a Completely Amputated Thumb with Assistance of High-Speed Video Recording.

Generally, surgeons assess the quality of vascular anastomosis in digit replantation on the basis of their experience. The steps for replantation of a completely amputated thumb, with assistance of high-speed video recording, consist of (1) debridement, (2) fixation, (3) tendon suture, (4) anastomosis, and (5) wound closure1,2. Revision amputation or flap coverage. With the assistance of high-speed video recording, the refilling velocity ratio (RVR) is an objective index for the quality assessment of the vascular anastomosis.

The fate of delayed revascularization for neglected vascular injury of incompletely amputated digits and hands.

We report the fate of neglected vascular injury in cases of incomplete amputation of the digits and hand after delayed revascularization. Twelve patients underwent primary bone fixation, tendon or skin repair for hand injuries without vessel repair despite ischaemic findings. There was discoloration or necrosis of the fingertips during follow-up examination and the patients were referred to us for treatment. The mean warm ischaemic time was 53 hours (range 17-120). Delayed revascularization was performed with end-to-end anastomosis of the digital arteries in eight and vein graft in four cases. Digital nerves were repaired in four cases and flexor tendons in two cases. Of the 12 cases, eight cases showed complete survival. However, in four patients, complete necrosis of the fingers occurred, with one finger surviving partially. Revision amputation was performed in the four cases where necrosis occurred. We conclude that neglected vascular injury associated with incomplete amputation of digits and hands can be overcome in some patients by delayed revascularization even after prolonged warm ischaemic time. Level of evidence: IV.

Fast and slow myosin as markers of muscle regeneration in mangled extremities: a pilot study.

Mangled extremities were classically managed by amputation. But over the past few decades, with the advancement in surgical techniques, an increased number of limb salvages have been possible. As muscles usually get damaged in such grievous injuries, a thorough understanding of muscle regeneration may give a better insight into muscle healing in these injuries. Muscles are composed of slow and fast fibers which can be represented by slow and fast myosin, respectively. There are some animal studies which reported differential regeneration of slow and fast muscle fibers during muscle healing. We conducted this pilot study to find out whether the same holds true for muscle healing in mangled extremities also. This pilot study is designed in 15 patients with lower limb mangled extremities presenting to trauma center of PGIMER, Chandigarh, who were operated within 24h of injury to see whether muscle healing in mangled extremities follows the same pattern. Biopsies were taken during initial surgery conducted within 24h of injury and on the 7th day of injury when patient was posted again for secondary wound closure procedure or revision amputation. The biopsy samples were subjected to histopathological and immunohistochemistry examination using antibodies against fast and slow myosin. We found that the regenerating muscle fibers in the biopsy sample taken on the 7th day of injury showed only slow muscle fibers with the absence of fast muscle fibers when compared with the initial biopsy results showing differential regeneration of slow muscle fibers.

The Impact of Surgical Amputation and Valproic Acid on Pain and Functional Trajectory: Results from the Veterans Integrated Pain Evaluation Research (VIPER) Randomized, Double-Blinded Placebo-Controlled Trial.

To determine if the perioperative administration of valproic acid reduces the incidence of chronic pain three months after amputation or revision surgery. Multicenter, randomized, double-blind, placebo-controlled trial. Academic, military, and veteran medical centers. One hundred twenty-eight patients undergoing amputation or amputation revision surgery at Duke University Hospital, Walter Reed National Military Medical Center, or the Durham Veterans Affairs Medical Center for either medical disease or trauma. Patients were randomized to placebo or valproic acid for the duration of hospitalization and treated with multimodal analgesic care, including regional anesthetic blockade. Primary outcome was the proportion of patients with chronic pain at three months (average numeric pain score intensity of 3/10 or greater). Secondary outcomes included functional trajectories (assessed with the Brief Pain Inventory short form and the Defense and Veterans Pain Rating Scale). The overall rate of chronic pain was 68.2% in the 107 patients who completed the end point assessment. There was no significant effect of perioperative valproic acid administration, with a rate of 65.45% (N = 36) in the treatment group and a rate of 71.15% (N = 37) in the placebo group. Overall, pain scores decreased from baseline to follow-up (median = -2 on the numeric pain scale). Patients additionally experienced improvements in self-perceived function. The rate of chronic pain after amputation surgery is not significantly improved with the perioperative administration of valproic acid. In this cohort treated with multimodal perioperative analgesia and regional anesthetic blockade, we observed improvements in both pain severity and function.

Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations

Optimal treatment for traumatic digit amputation is unknown. To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. Revision amputation or replantation of traumatic digit amputations. The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (-4.29; 95% CI, -8.45 to -0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03). When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.