Fingertip replantation with an efferent A-V anastomosis for venous drainage: clinical reports

Distal fingertip replantation: indications, strategy and postoperative management

Distal fingertip replantation is associated with being a technically demanding procedure and dubious outcomes, although it is now performed more frequently across the world. However, the technique and outcomes remain controversial with disagreement among replantation surgeons due to lack of consensus about the indications, intraoperative strategy and postoperative regimes. In this article, we asked six experienced hand surgeons several pertinent questions that every replantation surgeon performing distal fingertip replantation would face in their clinical practice. The article summarizes their responses, which might provide valuable insight to every replantation surgeon in different parts of their career while managing these injuries.

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

Finger and thumb replantation: From biomechanics to practical surgical applications

Finger and thumb amputations, which are always dramatic injuries with major functional and psychological repercussions, remain a surgical challenge. This review on digit replantation develops the underlying biomechanical and surgical aspects as well as practical indications. The different stages from trauma to postoperative monitoring are described. We describe the steps to follow from theory to practice in order to optimize the surgical acts that must as effective possible in terms of management and decision-making efficiency. Indications recognized as standards such as thumb amputation, multi-digit amputations and distal amputations are detailed, as well as the more controversial ring finger replantations. The challenge of successful finger and thumb replantation lies in searching for the best functional and cosmetic outcome and not performing irrelevant microsurgical manipulations.

Recent Topics on Fingertip Replantations Under Digital Block

The authors describe 3 cases with successful fingertip replantations using supermicrosurgical arteriole (terminal branch of digital artery) anastomoses, arteriole graft obtained from the same fingertip defect, reverse arteriole flow to subdermal venule, and delayed venular drainage for venous congestion. Among these 16 consecutive distal phalangeal replantations, 7 fingers showed postoperative venous congestion (43.8% of the total fingers) and 5 were reoperated on with delayed venous drainage under digital block. All the reoperated fingers were successfully drained by additional single or double venous drainage with a vein graft (100% success rate). As a result, 13 fingers survived (81.3% success rate).

External bleeding versus dermal pocketing for distal digital replantation without venous anastomosis

Venous congestion in distal digital replantations is a common problem as suitable veins are not always available. We compared two methods of venous decongestion, external bleeding ( n = 15) and dermal pocketing ( n = 28) carried out when venous anastomosis was not possible. The findings of this small study suggest that neither method of venous decongestion is clearly better than the other. Level of evidence: IV.

Replantation of the upper extremity: current concepts

Replantation is the process of reattaching amputated parts. Relative indications for replantation in the upper extremity include amputation of the thumb or multiple digits as well as amputations proximal to zone II and pediatric finger amputations at any level. Preoperatively, the part should be sealed in a bag and placed on ice; maximum ischemia times are approximately 12 hours of warm and 24 hours of cold time for digits, with shorter times tolerated for amputations at more proximal levels. With multiple digit involvement, an assembly line approach is used in the operating room. Postoperatively, close attention must be paid to detect thrombosis because secondary ischemia times are shorter. Success rates vary; survival is predicted in part by the mechanism of injury, with sharp cut injuries having better outcomes. There is no consensus on appropriate postoperative anticoagulation, the number of vessels that must be anastomosed, or whether replantations should be centralized or performed in every hospital.

Replantation of amputated finger composite tissues with microvascular anastomosis

Replantation of the partial amputated finger or the composite tissue in finger would achieve better functional and esthetic results than any reconstructive procedure. In this article, we report the results of microsurgical partial finger or composite tissue replantation at different anatomic sites of 24 fingers in 21 patients. Microvascular anastomosis was performed in all cases of replantation. For the digital palmar and lateral composite tissue defects, the proper palmar digital artery and volar or dorsal subcutaneous veins were repaired by end-to-end anastomoses. For the digital dorsal defects, the blood supply was reestablished by arterialization of a dorsal central vein in the replanted part with one of the proper palmar digital arteries. The average follow-up period was 12.3 months. Twenty-two of 24 fingers survived completely with good functional and esthetic results. Two replantations failed because of vascular complications. In conclusion, if the vascular vessels in amputations of partial finger and composite tissue of finger are suitable for anastomosis, a successful replantation of these parts with excellent functional and esthetic recovery can be achieved.

Distal phalanx replantation using the delayed venous method: A high success rate in 21 cases without specialised technique

BACKGROUND

The purpose of the study was to show that the delayed venous method provides a high success rate in distal phalanx replantation, and does not require the use of specialised techniques. Vein anastomosis is the most important factor determining the 'take rate' in treatment of distal phalanx amputation. However, blood flow in the distal phalanx subdermal vein is lost immediately after an accident, making it difficult to find the collapsed vein and to perform vein anastomosis in the initial surgery. Therefore, we have chosen to perform a two-stage surgical procedure, and we have obtained excellent results with this method.

METHODS

The two-stage delayed venous method for vein anastomosis was first reported in 2005. This surgical procedure includes initial arterial anastomosis, delayed expansion of the vein, and subsequent vein anastomosis in a second surgery.

RESULTS

The delayed venous method was used in 21 cases. Expansion of veins of up to 1mm or more resulted in a high success rate (85.7%) in procedures performed by a junior microsurgeon. In contrast, the success rate for distal phalanx replantation is extremely low in other techniques because of difficulty with vein anastomosis.

CONCLUSIONS

The delayed venous method allows relatively easy anastomosis of the subdermal vein of the distal phalanx. Furthermore, the procedure was performed by a junior microsurgeon with less than 2 years experience, showing that the method does not require special training. Therefore, it is a useful operative technique for treatment of amputated fingers by a non-specialised plastic surgeon.

Mini replants: fingertip replant distal to the IP or DIP joint

Amputations through the distal interphalangeal joint or distal to this joint are frequent and they represent probably one of the best indications for replantation. Details on the vascular anatomy of the fingertip have to be perfectly known by the surgeon who will have to deal with these replantations. Factors such as age, mechanism of amputation and type of anastomosis will influence the overall success rate of the procedure. Return of a true static two points discrimination can be observed in children even in the absence of any neural repair.

Solutions to Challenging Digital Replantations

Replantation of amputated digits remains one of the most challenging areas in plastic and reconstructive surgery. Complicated cases of digital amputation, such as fingertip amputations, multidigital amputations, and so forth, pose an even greater challenge, requiring extraordinary solutions for successful replantation. The authors present their experience with complicated digital replantations at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Cases presented include fingertip replantation, replantation of a finger with impairment of arterial inflow, and two cases of multidigital amputations. In one case of multidigital amputation, heterodigital replantation was performed, and in the other case, a minute skin neurovascular free flap from a nonreplantable finger was used for the reconstruction of another injured finger. Presented cases demonstrate various tools that can be successfully used in the performance of challenging digital replantations.

Distal replantation, nail bed, and nail problems in musicians

Nails enhance pulp sensibility, increase pulp stability and are necessary for fine prehension. A finger without a nail will compromise a musician's career if the finger involved is necessary to play a note (strings, keyboards) or hold a position (winds). Salvage of the nail is then a very important part of any surgical procedure in musicians with distal finger trauma. Surgical techniques will depend on the level and type of nail injury. Replantation is by far the best technique in distal finger amputation but, when not feasible, reposition-flap repair may be used. In isolated nail lesions, sutures, split-thickness nail bed graft, or nail matrix flaps are used according to the level and severity of the lesion.

Pediatric mutilating hand injuries

Mutilating hand injuries in children are a devastating problem. With aggressive efforts at replantation and revascularization, methodic debridement, timely soft tissue coverage, and early mobilization, however, the results in these unfortunate children can be quite rewarding. The child often does well with the functional aspect of recovery and rehabilitation but will probably hide his or her deformed hand from friends and family. These children generally become more shy and reserved. The parents are the key to rehabilitation. A good relationship between the parent, the physician, and the hand therapist is essential for the best result. Interestingly, the parents who are the most demanding on the staff during the initial emergency period are often the most appreciative parents and their children often achieve the best result. Conscientious parents are the best advocates for their children. Obviously, the prevention of these devastating injuries is much preferable to extraordinary heroic reconstruction. Unfortunately, some injuries are inevitable. It is nearly impossible to create an absolutely hazard-free environment for children. Potential injuries can be avoided, however, simply by keeping hazardous machines and equipment out of the reach of the child and by keeping children out of the potentially dangerous workplace.

Evaluation of new improved solution containing trehalose in free skin flap storage

BACKGROUND DATA

In this study, we evaluated a new intracellular type (IT-K) solution containing trehalose in a rabbit free skin flap storage model. Trehalose is a nonreducing disaccharide that can stabilise cell membranes under various stressful conditions.

MATERIAL AND METHOD

Seventy-two free skin flaps of the ear of rabbits were preserved in Euro-Collins (EC) solution or in IT-K solution for 24, 48, and 72 h at 4 degrees C. After completion of preservation, these flaps were replanted to the other ear by microsurgical techniques. Viability study and photo documentation were performed daily for 7 days. Tissue specimens were taken 24 h after vascular anastomosis, fixed in 10% formaldehyde and stained with haematoxylin and eosin (HE). Survival rates were analysed by Fisher's exact test for comparison of the two experimental groups. Values of P < 0.05 were considered to be statistically significant.

RESULTS

After 7 days, a survival rate of 100% of flaps were observed in both solutions after 24 h of preservation. After preservation for 48 h in IT-K solution the survival rate was 100%. However, in EC solution survival decreased to 75% (9 of 12 preserved flaps survived). This difference increased to 33.3% (4 of 12 flaps) in EC solution and 91.6% (11 of 12 flaps) (P < 0.01) in IT-K solution when the flaps were stored for 72 h. Light microscopic examination also showed less damage in flaps preserved in IT-K solution than in these preserved in EC solution.

CONCLUSION

IT-K solution was superior to EC solution in the preservation of free skin flaps on rabbit ears when stored for 48 and 72 h.

Very distal finger amputations: replantation or "reposition-flap" repair?

Management of very distal finger amputations is still controversial. Successful replantation results in an almost normal finger but is not without problems, such as technical difficulty, risk of failure and cost. "Reposition-flap" repair is a simpler procedure: it consists of distal bone and nail bed "graft-reposition" and pulp reconstruction by a flap. We compare ten successful replantations and six reposition-flap reconstructions. Replantation has several advantages over reposition-flap repair in terms of less finger shortening, longitudinal nail curvature, absence of PIP flexion contracture and shorter time off work. The results of reposition-flap repair are less satisfactory, but it is nevertheless a useful alternative when replantation is impossible or has failed.