Dorsal approach for vascular repairs in distal finger replantations

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

INTRODUCTION

Tamai zone 1 replantation poses a challenge due to the very small size of the vascular structures; often there is no vein for anastomosis. Replantation may have to be done with only an arterial anastomosis. In our study, we aimed to evaluate the success of replantation by combining external bleeding and hyperbaric oxygen treatment (HBOT) in Tamai zone 1 replantation.

METHODS

Between January 2017 and October 2021, 17 finger replantation patients who underwent artery-only anastomosis due to Tamai zone 1 amputation received 20 sessions of HBOT with external bleeding after the 24th postoperative hour. Finger viability was assessed at the end of treatment. A retrospective review of outcomes was performed.

RESULTS

Seventeen clean-cut finger amputation patients were operated on under digital block anaesthesia with a finger tourniquet. No blood transfusion was required. In one patient, complete necrosis developed and stump closure was performed. Partial necrosis was observed in three patients and healed secondarily. Replantation in the remaining patients was successful.

CONCLUSIONS

Vein anastomosis is not always possible in fingertip replantation. In Tamai zone 1 replantation with arteryonly anastomosis, post-operative HBOT with induced external bleeding appeared to shortened the hospital stay and was associated with a high proportion of successful outcomes.

The Roles of Injury Type, Injury Level and Amputation Type in the Need for Revision Surgery after Replantation: Retrospective Clinical Outcome with 296 Finger Replantation

BACKGROUND

With the development of microsurgical techniques, the replantation survival rate has increased, but in some cases, revision surgery is required. Although there are many studies on replantation survival rate, studies on revision surgery are limited. In this study, we evaluated replantation patients requiring revision surgery in terms of amputation level, injury type, and amputation type (single-multiple).

METHODS

This is a retrospective study.Two hundred fifty-six patients (296 fingers) who were operated on for total finger amputation in our hospital between 2013 and 2018 were included in the study. In the postoperative period, revision surgery was required for 24 fingers due to vascular insufficiency. Patients were evaluated in terms of amputation level, injury type, and amputation type.

RESULTS

Two hundred sixty-four fingers were saved after primary surgery. Eight fingers failed before they could undergo revision surgery. Revision surgery was performed for 24 fingers. After revision surgery, 19 fingers were saved, and five fingers were failed. There was no significant effect of gender and age in terms of revision (p > 0.05).There was no statistically significant difference in injury level and injury type, but there was a statistically significant difference in terms of amputation type (p < 0.05).

CONCLUSION

Despite advanced microsurgery and experience, vascular insufficiency can be observed after replantation. Surgical re-exploration is necessary for salvage.

Successful Replantation of Tamai Zone I Amputation with Delayed Vein Repair

Digital vein repair is one of the most challenging phases of distal phalanx replantation. Digital veins at very distal levels have a small vessel caliber and collapsed lumens, which makes them hard to identify and handle. Digital veins may not be visible immediately after arterial anastomosis. In this scenario, the patient can be taken to the operative room several hours after revascularization to visualize dilated and expanded veins for late digital vein repair. Late digital vein repair is a reliable and alternative method to artery only replantation. In this report, a successful replantation with late digital vein repair in Tamai Zone I is presented.

Etiology and Survival of Secondary Revascularizations after Hand and Digit Replantations

Introduction  Hand and digit replantations can be complicated by vascular insufficiency necessitating revision of the original replantation. To date, few studies have evaluated outcomes in secondary revascularizations following replantation. Therefore, the objective of this study was to evaluate the incidence, etiology, and survival rates following secondary revascularization after hand and digit replantations. Materials and Methods  A literature search was performed on NCBI for studies documenting secondary revascularization procedures following hand and digit replant. Studies were evaluated for the etiology of vascular failure, frequency of secondary revascularization, and survival rates following intervention. Statistical analysis was conducted across the pooled dataset. Results  A total of 16 studies including 1,192 amputations were analyzed. We found that 16.9% (201/1,192) of replants were complicated by vascular compromise. The frequency of vascular compromise was not statistically different between arterial and venous etiologies. The survival rate following secondary revascularization was 55.6%, with no significant difference between the arterial and venous groups. Secondary arterial revascularization was often treated with arterial revision (nine of nine studies) and/or with vein grafting (two of nine studies). Secondary revascularization for venous insufficiency resulted in different survival rates for nonsurgical modalities (58%) versus vein revision (37.5%) versus vein grafting (100%). Conclusion  Survival rates following secondary revascularization are lower; however, they may be improved using vein grafts following venous insufficiency. These data can be used to better understand the etiology of replant failure and guide decision-making.

Survival and Comparison of External Bleeding Methods in Artery-Only Distal Finger Replantations

PURPOSE

If there are no veins available in a distal amputation, an artery-only replantation is performed, and an external bleeding method is commonly used. We conducted a survival analysis in a large series of artery-only replantations and compared 2 different external bleeding methods in artery-only distal replantations: nail matrix or hyponychial area bleeding and pulp skin area bleeding, which we have called the crater method.

METHODS

Two hundred twenty-eight artery-only distal finger replantations in 199 patients were included in the study. The replanted digits were divided into 2 groups according to the external bleeding methods. One group (n = 94; 41.2%) included the patients in whom the external bleeding was performed using a traditional nail bed incision and the second group (n = 134; 58.8%) included the patients in whom external bleeding was performed using the crater method. The finger survival rates and postoperative circulatory problems were examined. The impact of the injury mechanism, injury level, and external bleeding method on survival were evaluated.

RESULTS

Clinical findings indicating venous insufficiency were observed in 198 (86.8%) replanted fingers. One hundred eighty-two (79.8%) survived, and complete necrosis developed in 46 (20.2%). Viability was maintained in 84% of patients treated with the nail bed bleeding method and 76.9% of patients treated using the crater method. Clean-cut cases had the best results and subzone 3 cases had the worst results.

CONCLUSIONS

The artery-only replantation was associated with a 79.8% survival rate. The method of achieving venous outflow did not appear to have an impact on survival.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.