Replantation of a multiple digit and circular palm amputation: a case report

Multilevel Dysvascular Injury of the Hand: Replantation versus Revision Amputation

BACKGROUND

Multilevel dysvascular injury of the hand can be treated with replantation or revision amputation. The authors compared both modalities regarding functional outcomes, patient-reported outcomes, and required resources, as relevant studies are scarce.

METHODS

In this retrospective review of consecutive case series (replantation, n = 8; revision amputation, n = 11), clinical results and functional outcomes (including grip strength, range of motion, sensory recovery, and grip or pinch ability) were assessed. Patient-reported outcomes, required hospital resources, and treatment cost until 1 year after surgery were compared between both groups.

RESULTS

Six patients used passive prostheses, two used body-powered prostheses, and three did not use a prosthesis in the revision amputation group. All patients in the replantation group could grip objects and had restored hands, with protective sensory recovery and substantial wrist motion, whereas six patients in the revision amputation group were unable to grip or pinch objects. Replantation was associated with superior patient-reported outcomes, but required more hospital resources and treatment costs.

CONCLUSIONS

This study suggests that in the treatment of multilevel dysvascular injury of the hand, the surgical method should be chosen on a case-by-case basis. For better functional and patient-reported outcomes, replantation is preferred. Revision amputation can be performed in the absence of sufficient hospital resources and to reduce treatment cost. These findings can aid in the preoperative counseling of patients with multilevel dysvascular injury of the hand.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Multiple-level Replantation in Elderly Patients: Risk Versus Benefit

Multiple-level amputations of the upper extremity represent a surgical challenge generally only attempted in young patients. This case demonstrates a successful replantation in an elderly woman. The postoperative course was complicated by disseminated intravascular coagulopathy most likely due to inadequate resuscitation. Hand trauma is often underestimated in its general severity. Upper extremity amputations need to be handled similar to polytraumatized patients.

Challenges in replantation of complex amputations

Surgical ingenuity has resulted in continuing microsurgical innovation in replantation. In this article, the authors define complex amputations as those that stretch the boundaries or fall outside traditionally defined indications for replantation. They discuss management of difficult situations involving multiple digit amputations, multiple-level amputations, prolonged ischemia, and multiple trauma. The role of transpositional and ectopic replantation, as well as the requirement for secondary procedures in replantation is also discussed. Although technically challenging, microsurgical management of complex amputations ultimately results in far superior outcomes.

Vein grafting with telescoping anastomoses for repair of a double-cut artery

The rat femoral artery was cut in two places, and the telescoping anastomosis technique was used for all vascular repairs in combination with vein grafting, to determine whether the telescoping technique could safely be used more than three times for repair of an artery that has been injured at two places. One cut was repaired with vein grafting, and the other with either a telescoping anastomosis (the triple group) or with a second vein grafting (the quadruple group). The patency rate 3 weeks postoperatively was 86.4% for the triple group, and 90.5% for the quadruple group. Although tension of the repaired vessel was kept low by vein grafting, and deformities of the inserted vessel were carefully minimized, the patency rate was not 100%. It appears that a telescoping anastomosis should not be used more than three times on the same artery in combination with vein grafting.