Fingertip replantation: pre-osteosynthesis vein graft technique

Sequential Clinical Recovery after Replantation for Complete Finger Amputation in Tamai Zone 1

Background  The clinical results of replantation for an amputated distal finger are functionally acceptable. However, few reports exist regarding sequential clinical postoperative recovery. The purpose of this study was to examine the clinical recovery at every 3 months up to 1 year postoperatively. Methods  Nineteen patients (16 patients were men), representing 19 fingers with complete amputation at Tamai's zone 1 and replanted successfully, were included in this study. Total active motion (TAM), grip strength (GS), Semmes-Weinstein monofilament (SW) test result, static two-point discrimination (s2PD), and Disability of the Arm, Shoulder, and Hand (DASH) score questionnaire results were obtained postoperatively at 3, 6, 9, and 12 months. Pulp atrophy and nail deformity were assessed at 12 months postoperatively. Results  The postoperative %TAM (compared to the uninjured side, 81.8 ± 18.1 at 3 months vs. 91.5 ± 11.9 at 6 months, p  < 0.01), %GS (compared with the uninjured side, 61.3 ± 25.9 at 3 months vs. 78.3 ± 20.4 at 6 months, p  = 0.02), s2PD (excellent and good/poor; 7/12 at 3 months vs. 18/1 at 6 months, p  < 0.01), and DASH scores (26.1 ± 23.1 at 3 months vs. 12.0 ± 12.9 at 6 months, p  < 0.01) recovered significantly from 3 to 6 months but did not change significantly from 6 months onward. The SW test results showed a significant recovery between 3 and 12 months postoperatively (2.83 and 3.61/4.31, 6.65, and undetectable, 1/18 at 3 months vs. 7/12 at 12 months, p  = 0.04). The DASH score at 12 months postoperatively was significantly associated with %TAM ( r  = -0.64, p  < 0.01) and %GS ( r  = -0.58, p  < 0.01) at 12 months postoperatively and age ( r  = 0.52, p  = 0.02). Five fingers had pulp atrophy and four fingers had nail deformity. Conclusion  This 1-year follow-up study showed the sequential clinical recovery after replantation for complete amputation in Tamai zone 1. Postoperative %TAM, %GS, and the DASH score recovered significantly between 3 and 6 months but significant recovery up to 1 year was not observed.

Long-Term Outcomes of Successful Fingertip Replantation: A Follow-Up of at Least 10 Years

BACKGROUND

The purpose of this study was to evaluate the long-term outcome of successful fingertip replantations with more than 10 years of follow-up after surgery.

METHODS

A total of 34 successfully replanted digits in 31 patients with a mean period to follow-up of 16.5 years were included in this study. The main outcome measures were time to return to work, pain, cold intolerance, sensory recovery, nail deformity, grip strength, range of motion of the thumb interphalangeal or finger distal interphalangeal joint, fingertip atrophy, nonunion, bone shortening, use in activities of daily living, and patient satisfaction.

RESULTS

None of the patients reported chronic pain. No cold intolerance was experienced in 32 digits. Semmes-Weinstein monofilament testing showed recovery of protective sensation in 27 digits. The moving two-point discrimination test showed excellent or good recovery in 91 percent of the patients. Sensory recovery was satisfactory, and there was no significant difference regardless of nerve repair or injury type. Moderate to severe nail deformity was found in six digits. Fingertip atrophy was evaluated by comparing the volume of the replanted fingertip with the contralateral digit. The volume was 82 ± 17 percent of the contralateral normal side. There was no significant difference in the volume comparing the level of amputation, injury type, or incidence of postoperative vascular complication. Ninety-seven percent of the patients were satisfied with the results.

CONCLUSION

Long-term outcome of fingertip replantation more than 10 years after surgery was found to be favorable.

Arterial grafts for proper palmar digital artery reconstruction: An anatomical study

Digital ischemia due to arterial defects need urgent surgical management. The traditional treatment consists of vascular reconstruction using a reversed autologous venous graft as a bypass. Very few studies have described the use of arterial grafts for digital artery reconstruction. This cadaver study characterized the forearm perforator arteries to assess the potential feasibility of using them as donor grafts for digital artery reconstruction. Eleven forearms and twenty hands were dissected from freshly injected cadavers. All clinically significant perforators (>0.5 mm) derived from radial or ulnar arteries and digital arteries were evaluated. The digital palmar arteries were measured at three points: metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (PIP) joint. In the 11 forearms analyzed, 5.5 ± 1.3 perforators from radial or ulnar arteries with a diameter of at least 0.5 mm were found per dissection. The mean diameters were 0.9 ± 0.18 mm proximally and 0.8 ± 0.15 mm distally; the mean length was 35.6 ± 11.35 mm. The mean diameters for the dominant and non-dominant arteries were 1.5 and 1.3 mm at the MCP, 1.3 and 1.0 mm at the PIP, 0.8 and 0.7 mm at the DIP, respectively. The forearms are good donor sites as they have large-diameter arteries of suitable length for arterial grafting. These new arterial grafts may be suitable for vascular reconstruction of digital arteries starting from the PIP joint.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

LEARNING OBJECTIVES

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

SUMMARY

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

Challenges in measuring outcomes following digital replantation

In the early period of replantation surgery, the emphasis was on digit survival. Subsequently, with better microsurgical techniques and instrumentation, the focus has shifted to function and in recent years to consideration of cost-effectiveness. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes of digital replantation has not been performed. This is because of the many confounding variables that influence outcome comparisons. These variables include the mechanism of injury (guillotine, crush, avulsion), the injury itself (total, near total, subtotal, partial amputation), and the surgical procedure (replantation, revascularization). In addition, the traditional outcome measures (two-point discrimination, range of motion, grip strength, or the ability to return to work) are reported inconsistently and vary widely among publications. All these factors make meaningful comparison of outcomes difficult. The recent emphasis on outcome research and cost-effectiveness necessitates a rethinking in the way we report outcomes of digital replantation. In this article, the authors summarize the challenges in assessing outcomes of digital replantation and explain the need to measure outcomes using rigorous clinical research designs that incorporate cost-effectiveness studies in the research protocol.

A systematic review of the outcomes of replantation of distal digital amputation

BACKGROUND

The aim of this study was to conduct a systematic review of the English literature on replantation of distal digital amputations to provide the best evidence of survival rates and functional outcomes.

METHODS

A MEDLINE search using "digit," "finger," "thumb," and "replantation" as keywords and limited to humans and English-language articles identified 1297 studies. Studies were included in the review if they (1) present primary data, (2) report five or more single or multiple distal replantations, and (3) present survival rates. Additional data extracted from the studies meeting the inclusion criteria included demographic information, nature and level of amputation, venous outflow technique, nerve repair, recovery of sensibility, range of motion, return to work, and complications.

RESULTS

Thirty studies representing 2273 distal replantations met the inclusion criteria. The mean survival rate was 86 percent. There was no difference in survival between zone I and zone II replantations (Tamai classification). There was a significant difference in survival between replantation of clean-cut versus the more crushed amputations (crush-cut and crush-avulsion). The repair of a vein improved survival in both zone I and zone II replantation. The mean two-point discrimination was 7 mm (n = 220), and 98 percent returned to work (n = 98). Complications included pulp atrophy in 14 percent of patients (n = 639) and nail deformity in 23 percent (n = 653).

CONCLUSIONS

The common perception that distal replantation is associated with little functional gain is not based on scientific evidence. This systematic review showed a high success rate and good functional outcomes following distal digital replantation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Arterial and venous revascularization with bifurcation of a single central artery: a reliable strategy for Tamai Zone I replantation

BACKGROUND

Replantation of the distal phalanx and pulp can be performed to improve finger function and finger aesthetics; however, establishing adequate venous drainage is a challenge. Slattery et al. reported microsurgical reattachment of a partial distal phalanx with the use of a bifurcated terminal digital artery. The bifurcation was divided into two pedicles, one of which was used for venous drainage. In this article, the authors report their experience with a similar technique and propose a new algorithm for distal finger replantation.

METHODS

From January of 2008 to February of 2009, five replantations were performed using a single central artery. The replanted levels were pulp, avulsed fingertip of the thumb, and distal phalanges. There was no volar vein, dorsal vein, or second artery available in the amputated part for standard venous drainage. Venous drainage in all cases was established by creating an anastomosis from a branch of the solitary terminal artery to a recipient vein.

RESULTS

All digits were replanted successfully without evidence of arterial insufficiency or venous congestion. Partial necrosis was not identified postoperatively in any of the five fingers. There were no cases of wound infection.

CONCLUSIONS

A branch of the central solitary artery may be used successfully to reestablish venous outflow in cases of distal finger tip replantation. This technique allowed for the salvage of all fingers in this study without the use of leeches or other techniques used in cases of venous insufficiency.

Fingertip Replantation Using the Subdermal Pocket Procedure

Restoration of finger length and function are the goals of replantation after fingertip amputation. Methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. To increase the survival rates for composite grafts, the subcutaneous pocket procedure has been used as a salvage procedure. The subdermal pocket procedure, which is a modification of the subcutaneous pocket procedure, was used for replantation of 17 fingertips in 16 consecutive patients. Eight fingertips experienced guillotine injuries and the other nine fingertips experienced crush injuries. Revascularization of one digital artery without available venous outflow was performed for six fingers, and composite graft techniques were used for the other 11 fingers. The success rate was 16 of 17 cases. The difference in success rates for guillotine versus crush injuries was statistically significant. Comparison of patients with arterial anastomoses and patients without arterial anastomoses also indicated a statistically significant difference. Thirteen fingertips survived completely. One finger, demonstrating complete loss and early termination of the pocketing procedure, was amputated on the eighth postoperative day. Two fingers were partially lost because of severe crushing injuries. One finger demonstrated partial loss of more than one quarter of the fingertip, which required secondary revision, because the patient was a heavy smoker. The pocketing period was 8 +/- 1 days (mean +/- SD, n = 6) for the fingers revascularized with one digital arterial anastomosis and 13.3 +/- 1.9 days (n = 10) for the fingers successfully replanted with composite graft techniques. The mean active range of motion of the interphalangeal joint of the three thumbs was 65 +/- 5 degrees, and that of the distal interphalangeal joint of the other 11 fingers was 51 +/- 11 degrees. The static two-point discrimination result was 6.4 +/- 1.0 mm (n = 14) after an average of 11 +/- 5 months of follow-up monitoring. Compared with other methods, the subdermal pocket procedure has the advantages of exact subdermal/subdermal contact, a shorter pocketing period, and more feasible observation. The method can offer an alternative salvage procedure for fingertip amputations with no suitable vessels available for microsurgical replantation.

Replantation of very thumb distal amputations with pre-osteosynthesis interpositional vein graft

Replantation of distal thumb amputations is difficult because of the anatomic orientation of the thumb and the location and size of vessels. A simplified technique is presented, in which interposition vein grafts are anastomosed to a terminal branch of the digital artery and a subcutaneous vein in the amputated thumb tip. This technique is convenient, relatively easy and reliable.

Replantation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the indications and contraindications for extremity replantation. 2. Outline the sequence and technique of replantation. 3. Identify potential complications of replantation and recognize treatment options. 4. Assess the results of replantation in terms of function and costs versus benefits.