The success of salvage procedures for failing digital replants: A retrospective cohort study

Microsurgical Digits Replantation in Resource-Limited Setting: A Retrospective Study

Background

This article aims to share our experiences with microsurgical finger replantation in a resource-limited setting.

Methods

This multi-institutional, retrospective study included 21 cases of finger amputation that underwent microsurgical replantation, within 7 years period. Patient demographics, preoperative assessments, surgical approaches, and outcomes were documented and analyzed. A univariate analysis was performed to obtain factors associated with digit reimplantation failure.

Results

Out of 21 cases included, 8 (38.1%) had complete amputations and 13 (61.9%) had incomplete amputations. Crush injuries accounted for the majority (71.4%). On average, 2.2 ± 1.1 digits were affected, with the ring finger being the most commonly injured (71.4%). The mean operative time was 121.5 ± 26.8 minutes. The success rate of digit replantation was 76.2%. During a mean follow-up of 14.3 ± 3.7 months, 85.7% of successfully replanted digits considered their replantation results satisfactory. The majority of replanted digits demonstrated active and effective holding and grasping abilities without pain or instability (76.2%). Replantation failure was associated with a higher number of affected digits (p < 0.001), longer operative time (p = 0.004), complete avulsion (p = 0.003), current smoking (p = 0.025), diabetes (p = 0.006), hypertension (p = 0.047), procedure difficulty score (p= 0.004), and occurrence of complications (p < 0.001).

Conclusion

Microsurgical finger replantation can yield favorable outcomes and acceptable survival rates, even within resource-limited settings. However, this procedure requires specialized equipment and personnel that may not be available at all institutions. Influential factors in digit replantation failure, include an increased number of damaged digits, extended operative duration, complete avulsion, current smoking, diabetes, hypertension, procedure difficulty score, and postoperative complications occurrence.

Principles of microvascular surgery in the upper extremity

Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period.

The effect of dobutamine treatment on salvage of digital replantation and revascularization

PURPOSE

One of the most common causes of a failure after replantation and revascularization surgeries is 'no reflow' from proximal artery that occurs, especially following crush and avulsion injuries. In this study, we aimed to evaluate the effect of dobutamine treatment on salvage of replanted and revascularized digits.

METHODS

The patients with no reflow phenomenon detected in the salvage operations of replanted/revascularized digits between the years 2017 and 2020 were included in the study. Dobutamine treatment was infused at a rate of 4 µg·kg-1·min-1 intraoperatively and of 2 µg·kg-1 min-1 postoperatively. Demographic data (age, sex), digit survival rate, ischemia time, and level of injury were retrospectively analysed. Pre-infusion, intraoperative and postoperative values of cardiac index (CI), mean arterial pressure (MAP), and heart rate (HR) were recorded.

RESULTS

The phenomenon of 'no reflow' was encountered in 35 digits of 22 patients who underwent salvage surgery due to vascular compromise. The survival rate in the revascularization group was 75%, while it was 42.1% in the replanted digits. Metaphysis level of proximal phalanx was the most common localization for 'no reflow' phenomenon. The least values of CI, MAP and HR to obtain sufficient perfusion in salvaged digits were as follows: 4.2 l.min-1.m-2, 76 mm Hg, and 83 beat·min-1, respectively.

CONCLUSIONS

It was demonstrated that dobutamine infusion at a rate of 4 µg·kg-1·min-1 intraoperatively and at 2 µg·kg-1·min-1 postoperatively has favorable effects on the vascular compromise derived from no reflow of proximal artery.

Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure.Level of evidence: IV.

Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation

PURPOSE

Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation.

METHODS

Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted.

RESULTS

Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission.

CONCLUSIONS

In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

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.

Spare Parts Surgery with a Free Posterior Interosseous Artery Perforator Flap for Thumb Tip

Replantation is an ideal method for treating fingertip amputation. However, in some cases, replantation is known to be a challenging issue. This report described a successful thumb tip reconstruction performed with bone and nail bed salvaged as spare parts, and a free posterior interosseous artery perforator (PIAP) flap. A 75-year-old man accidentally amputated his left thumb with an electric saw, and emergency replantation was started under brachial plexus block. However, the distal stump of digital artery was unable to be identified, forcing the initial plan to change to flap reconstruction. After vascular anastomosis, complex tissue containing nail bed and side nail fold was grafted on the adipofascial tissue of PIAP flap. Both PIAP flap and the complex tissue survived completely. At 12 months after surgery, only a slight deformity in the nail plate was observed. Spare parts surgery is a surgical procedure effectively salvaging and utilizing tissue that is going to be discarded in severe limb trauma. This idea can be applied to treatment for the finger amputation. In this case, replantation would be difficult in the thumb tip amputation, so spare parts surgery was performed with a PIAP flap. The innervated PIAP flap is reported, including the posterior antebrachial cutaneous nerve. In this case, the cutaneous nerve was able to be identified, neurorrhaphy was performed, and sufficient sensory recovery was obtained. Surgical procedure with PIAP flaps was found to be a useful method for immediate reconstruction with salvaged spare parts after fingertip replantation was considered to be difficult intraoperatively.

Identifying Factors Affecting Outcomes in Scalp Replantation: A Systematic Review of the Literature

INTRODUCTION

 Replantation is the ideal treatment in traumatic scalp defects to provide immediate coverage with restoration of hair-bearing skin. However, data are limited to case reports and small case series. Comprehensive analysis of techniques and outcomes is not available. Our aim was to systematically analyze the available literature to better understand management and postoperative outcomes of patients undergoing scalp replantation.

METHODS

 A systematic review of the PubMed, Cochrane, and EBSCO databases was performed in October 2019. Search terms included "replantation," "replant," "revascularized," "revascularization," "avulsion," and "scalp." Only papers reporting microvascular replantation of completely avulsed scalps, including case reports, were included. Review articles, non-English language articles, articles discussing nonreplant coverage, incomplete scalp avulsions, and articles discussing delayed scalp replantation were excluded. Data extracted included demographics, percent of scalp affected, mechanism, operative technique, and postoperative outcomes. Statistical analysis was performed using Mann-Whitney U tests, Kruskal-Wallis, and chi-squared tests.

RESULTS

 From a total of 704 initial results, 61 studies were included for analysis comprising 149 scalps. Complete survival was achieved in 54.7%, partial survival in 38.9%, and failure in 6.7%. Total ischemia time greater than 12 hours was associated with complete replant failure. Arterial anastomoses appeared to protect against complete loss. The number of venous repairs, proportion of venous-to-arterial repairs, use of vein grafts, thromboprophylaxis, or intraoperative complications did not affect outcomes. Patients required significant volumes of blood products, which was associated with partial success. Salvage rate after unplanned return to the operating room was 60.0%. Normal hair growth was achieved in all surviving native scalp tissue.

CONCLUSION

 Scalp replantations, while technically challenging, are the ideal treatment for scalp avulsions. Fortunately, these have high rates of success. And as a focal point of a patient's appearance, this is invaluable in restoration of a sense of normalcy.

Clinical outcomes of salvage revision surgery following finger replantation with vascular insufficiency: A retrospective study

OBJECTIVE

The aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations.

METHODS

In this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1-76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6-144) hours. While the average elapsed time for artery procedures was 35.3 (range=8-110) hours, the average elapsed time for vein procedures was 47.1 (range=6-144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately.

RESULTS

After the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level.

CONCLUSION

The results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.