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Lim Z, Sebastin SJ, Chung KC. Health Policy Implications of Digital Replantation. Clin Plast Surg 2024; 51:553-558. [PMID: 39216941 DOI: 10.1016/j.cps.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.
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Affiliation(s)
- Zhixue Lim
- Department of Hand & Reconstructive Microsurgery, National University Hospital, Level 11, National University Health System Tower Block, 1E Kent Ridge Road, 119228, Singapore
| | - Sandeep Jacob Sebastin
- Department of Hand & Reconstructive Microsurgery, National University Hospital, Level 11, National University Health System Tower Block, 1E Kent Ridge Road, 119228, Singapore.
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Hospital, 1500 E Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48109, USA
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2
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Kobayashi K, Shinoura S, Nishimura K, Masuyama N. Success Rates of Finger Revascularization and Replantation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5638. [PMID: 38440366 PMCID: PMC10911518 DOI: 10.1097/gox.0000000000005638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/17/2024] [Indexed: 03/06/2024]
Abstract
Background Revascularization surgery has been reported to have a higher success rate than replantation due to sufficient venous return. However, in complex cases, success depends on a wide range of indications. This study aimed to investigate success rates in cohorts that included severe cases. Methods This single-center, noninterventional, retrospective cohort study included 292 patients (349 digits) who underwent revascularization or replantation at our institution between January 2000 and December 2022. Sex, age, smoking history, comorbidities, affected digit, amputation level, complete or incomplete amputation, type of fracture and mechanism, artery diameter, needle, vein anastomosis in the revascularization subgroup, vein grafting, warm ischemic time, and outcomes were investigated and compared between the revascularization and replantation subgroups of the distal and proximal amputation groups. Results In the distal amputation group, the arterial diameter in the revascularization subgroup was larger than that in the replantation subgroup (P < 0.05). In the proximal amputation group, the revascularization subgroup had a lower frequency of multiple amputations than the replantation subgroup (P < 0.05). Vein grafts were more frequently used in both revascularization subgroups than in the replantation subgroups (P < 0.05). However, the other injury severity indices were similar, and the success rates were not significantly different between the subgroups. Conclusions The revascularization success rate was similar to that of replantation. Vein anastomosis or vein grafting to the veins should be advocated for revascularization in severe cases where skin bridges may not have sufficient venous return.
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Affiliation(s)
- Koichi Kobayashi
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki-shi, Kanagawa-ken, Japan
| | - Susumu Shinoura
- Department of Gastroenterology, International University of Health and Welfare, Narita-shi, Chiba-ken, Japan
| | - Ken Nishimura
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki-shi, Kanagawa-ken, Japan
| | - Naoko Masuyama
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki-shi, Kanagawa-ken, Japan
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3
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Pugliese P, De Francesco F, Pangrazi PP, De Francesco M, Santanelli di Pompeo F, Riccio M. Tamai zone -I and -II replantation versus reconstruction with local flaps: retrospective analysis for functional and cosmetic results. Case Reports Plast Surg Hand Surg 2024; 11:2320882. [PMID: 38415206 PMCID: PMC10898269 DOI: 10.1080/23320885.2024.2320882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
A retrospective study were presented to compare functional and cosmetic outcomes in relation to local flap reconstruction or fingertip replantation in cases of zones I and II amputation. Outcomes were evaluated using Semmens Weinstein monofilament, Weber DiskCriminator, total active motion (TAM) assessment and Michigan Hand Questionnaire after a 1-year follow-up.
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Affiliation(s)
- Pierfrancesco Pugliese
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
- Department of Surgical, Oncological and Oral Sciences, Section of Plastic and Reconstructive Surgery, University of Palermo, Palermo, Italy
| | - Francesco De Francesco
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
| | - Pier Paolo Pangrazi
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
| | | | - Fabio Santanelli di Pompeo
- Plastic Surgery Unit, NESMOS Department, Faculty of Medicine and Psychology, University Sapienza of Rome, Rome, Italy
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
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Ince B, Uyanik O, Ismayilzade M, Yildirim MEC, Dadaci M. The effect of dobutamine treatment on salvage of digital replantation and revascularization. Eur J Trauma Emerg Surg 2023; 49:2113-2120. [PMID: 37367969 DOI: 10.1007/s00068-023-02312-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
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.
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Affiliation(s)
- Bilsev Ince
- Department of Plastic, Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Orkun Uyanik
- Department of Plastic, Reconstructive and Aesthetic Surgery, Basaksehir Cam and Sakura State Hospital, Istanbul, Turkey
| | - Majid Ismayilzade
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Istinye University, Istanbul, Turkey.
| | | | - Mehmet Dadaci
- Department of Plastic, Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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5
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Brown DJ, Lin J, Payne RM, Pet MA. Technical considerations for replantation: from bony fixation to soft tissue coverage. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03724-6. [PMID: 37749419 DOI: 10.1007/s00590-023-03724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/04/2023] [Indexed: 09/27/2023]
Abstract
Digital replantation is a challenging and at-time tedious operation, but if approached thoughtfully and with reasonable expectations can be a reliable and rewarding undertaking. This article summarizes technical considerations for digital replantations involving flexor tendon zone II. The article has been ordered according to the recommended sequence of a structure-by-structure repair in a non-thumb digit. Special considerations are described for thumb, multiple digits, and heterotopic replantation.
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Affiliation(s)
- Danielle J Brown
- Division of Plastic Surgery, Department of Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Mailstop MSC8238-43-1150, St. Louis, MO, 63110, USA
| | - Jason Lin
- Division of Plastic and Reconstructive Surgery, St. Louis University, St. Louis, MO, USA
| | - Rachael M Payne
- Division of Plastic Surgery, Department of Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Mailstop MSC8238-43-1150, St. Louis, MO, 63110, USA
| | - Mitchell A Pet
- Division of Plastic Surgery, Department of Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Mailstop MSC8238-43-1150, St. Louis, MO, 63110, USA.
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BATTISTON B, FACCENDA C, FULCHIGNONI C, ADANI R, ZOCCOLAN A, BRAGHIROLI L, FONZONE CACCESE A, DE VITIS R, CATENA N, TOS P. Indications to upper and lower limb replantations. MINERVA ORTHOPEDICS 2023; 74. [DOI: 10.23736/s2784-8469.23.04310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2024]
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Kobayashi K, Shinoura S, Nishimura K, Sugawara R. Selection Bias in Avoiding Vein Graft in Replantation/Revascularization May Exist in Distal and Proximal Amputations, Respectively. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4992. [PMID: 37235131 PMCID: PMC10208696 DOI: 10.1097/gox.0000000000004992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/20/2023] [Indexed: 05/28/2023]
Abstract
No difference in the success rate has been reported between the vein graft and non-vein graft groups in replantation/revascularization. However, this depends on a wide range of indications in difficult cases. This study aimed to investigate the selection bias in avoiding vein grafts. Methods This is a single-center, noninterventional, retrospective cohort study comprising 229 patients (277 digits) who underwent replantation/revascularization between January 2000 and December 2020 at our institution. Sex, age, smoking history, comorbidities, affected side, level of amputation, complete or incomplete amputation, type of fracture and mechanism, diameter of the artery, needle, warm ischemic time, and results were investigated and compared between the subgroups with and without vein graft. Results were investigated between the subgroups with and without a vein graft in the distal and proximal groups. Results In the distal group, the mean arterial diameter of the vein graft subgroup was larger than that of the non-vein graft subgroup [0.7 (0.1) mm and 0.6 (0.2) mm, respectively, P < 0.05]. In the proximal group, the vein graft subgroup had higher severity than the non-vein graft subgroup (comminuted fracture, 31.1% versus 13.4%; and avulsion or crush amputation, 57.8% versus 37.1%, respectively, P < 0.05). However, the success rate was not significantly different between the aforementioned subgroups. Conclusion There was no significant difference between the vein graft and non-vein graft subgroups owing to the selection bias avoiding small arteries in the distal amputation and the absence of said bias in the proximal amputation.
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Affiliation(s)
- Koichi Kobayashi
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki City, Kanagawa Prefecture, Japan
| | - Susumu Shinoura
- Department of Healthcare Management, School of Psychology and Healthcare Management at Akasaka, International University of Health and Welfare, Tokyo, Japan
| | - Ken Nishimura
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki City, Kanagawa Prefecture, Japan
| | - Runa Sugawara
- From the Department of Orthopedic Surgery, Kanto Rosai Hospital, Kawasaki City, Kanagawa Prefecture, Japan
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Thibedeau M, Ramji M, McKenzie M, Yeung J, Nickerson DA. Single Digit Index Finger Amputation-To Replant or Not? Plast Surg (Oakv) 2023; 31:44-52. [PMID: 36755823 PMCID: PMC9900044 DOI: 10.1177/22925503211024753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.
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Affiliation(s)
| | - Maleka Ramji
- Section of Plastic Surgery, University of Calgary, Alberta,
Canada
| | | | - Justin Yeung
- Section of Plastic Surgery, University of Calgary, Alberta,
Canada
| | - Duncan A. Nickerson
- Section of Plastic Surgery, University of Calgary, Alberta,
Canada,Duncan Alexander Nickerson, Section of
Plastic Surgery, University of Calgary, Suite 200, 2004—14 Street NW, Calgary,
Alberta, Canada T2M 3N3.
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9
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Zhang Z, Credico P, Bristol S, Macadam S. Determinants of Success in Single- and Multi-Digit Replant. Plast Surg (Oakv) 2023; 31:53-60. [PMID: 36755824 PMCID: PMC9900039 DOI: 10.1177/22925503211024767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.
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Affiliation(s)
- Zach Zhang
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Credico
- Faculty of Medicine, University of British Columbia, Vancouver,
British Columbia, Canada
| | - Sean Bristol
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheina Macadam
- Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Li AY, Watt AJ. Approach to Complex Upper Extremity Reconstruction. Semin Plast Surg 2022; 36:221-232. [PMID: 36561426 PMCID: PMC9762996 DOI: 10.1055/s-0042-1758131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of complex upper extremity trauma can be overwhelming in its urgency and complexity. Having a systematic approach that maintains a clear set of priorities focused on hand and upper extremity function, operative efficiency, and long-term planning for future operations allows the reconstructive extremity surgeon to effectively treat these complex injuries. This article addressed these overall clinical considerations and details the approach taken at the Buncke Clinic including replantation and revascularization as well as osseous and soft tissue reconstruction.
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Affiliation(s)
- Alexander Y. Li
- Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, California
| | - Andrew J. Watt
- The Buncke Clinic, San Francisco, California
- Division of Plastic and Reconstructive Surgery, Adjunct Clinical Faculty, Stanford University, Stanford, California
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11
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“Finger Replantation as an Office Hour procedure: Is overnight delay safe?”. J Plast Reconstr Aesthet Surg 2022; 75:1261-1282. [DOI: 10.1016/j.bjps.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/04/2021] [Accepted: 01/09/2022] [Indexed: 11/18/2022]
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12
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Echieh CP, Ozinko M, Omoregbee BI, Okonta KE. Replantation of amputation at the wrist: challenges of management in sub-Saharan Africa. BMJ Case Rep 2021; 14:14/3/e238393. [PMID: 33653835 PMCID: PMC7929889 DOI: 10.1136/bcr-2020-238393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Amputations of the upper limb, in particular, have a major impact on patients' lives, as loss of function can not only cause reduced autonomy in daily life but also hinder social interactions and capacity for work. Replantation at or proximal to the wrist, referred to as wrist-proximal replantation, remains a daunting challenge that presents the hand surgeon with an array of difficulties distinct from digital replantation.We present our experience with a successful replantation of a near-complete amputation at the non-dominant left wrist in a 25-year-old man managed in sub-Saharan Africa. Two years after replantation, the patient had a Disabilities of the Arm, Shoulder and Hand score of 40 and 2-point discrimination of 6 mm. We also discuss the peculiar challenges which have limited the development of replantation in the tropics. Environmental temperatures, manpower, expertise and technology are possible factors that limit this practice in the tropics.
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Affiliation(s)
- Chidiebere Peter Echieh
- Department of Surgery, University of Calabar, Calabar, Cross River, Nigeria .,Department of Surgery, University of Calabar Teaching Hospital, Calabar, Cross River, Nigeria
| | - Mba Ozinko
- Department of Surgery, University of Calabar, Calabar, Cross River, Nigeria
| | - Benjamin Irene Omoregbee
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospital NHS, Kingston-Upon-Hull, UK
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13
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Özkan B, Uysal AÇ, Markal Ertas N. Successful Replantation of Tamai Zone I Amputation with Delayed Vein Repair. HANDCHIR MIKROCHIR P 2021; 53:494-497. [PMID: 33477171 DOI: 10.1055/a-1276-1333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- Burak Özkan
- Baskent University, Department of Plastic Reconstructive and Aesthetic Surgery
| | - Ahmet Çagri Uysal
- Baskent University, Department of Plastic Reconstructive and Aesthetic Surgery
| | - Nilgün Markal Ertas
- Baskent University, Department of Plastic Reconstructive and Aesthetic Surgery
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14
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Milone MT, Klifto CS, Lee ZH, Thanik V, Hacquebord JH. Relationships Between Vein Repairs, Postoperative Transfusions, and Survival in Single Digit Replantation. Hand (N Y) 2020; 15:488-494. [PMID: 30762426 PMCID: PMC7370399 DOI: 10.1177/1558944719828002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The general teaching is that increased number of vein repairs in digit replantation leads to improved venous outflow, resulting in lower need for iatrogenic bleeding, lower postoperative transfusion requirements, and better survival rates. The purpose of this study was to determine whether the traditional teaching that emphasizes the repair of multiple veins per arterial anastomosis results in superior survival rates. Methods: A retrospective review of a single urban replant center's single-digit replants distal to the mid-metacarpal level in adult patients from 2007 to 2017 was performed. Data on patient demographics, mechanism and level of injury, veins repaired, iatrogenic bleeding, postoperative transfusions, and replant survival were obtained. Results: There were a total of 54 single-digit replants. The most common mechanism was lacerations (N = 38), and the most common injury level was at the proximal phalanx (N = 21). All digits were replanted with a single arterial anastomosis-44% via grafting. In all, 0 to 3 veins were repaired per digit (mean = 1.5 veins). The mean transfusion requirement was 1.7 units. The survival rate was 50%. Digits with 1 or 2 veins repaired had lower transfusion requirements (1.1-1.3 units) and higher survival rates (56%-61%) compared with those replanted with 0 or 3 veins repaired (2.9-3.5 transfused units, 25%-29% survival). There were no differences between those digits replanted with either 1 or 2 veins repaired for transfusion requirements or survival. Conclusions: More veins repaired do not necessarily improve survival or possibly venous outflow, calling into question the traditional teaching that 2 veins should be repaired for every arterial anastomosis.
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Affiliation(s)
- Michael T. Milone
- New York University Langone Orthopedic Hospital, New York City, USA,Michael T. Milone, NYU Langone Orthopedic Hospital, 14th Floor, 301 East 17th Street, New York, NY 10003, USA.
| | | | - Z-Hye Lee
- New York University Langone Medical Center, New York City, USA
| | - Vishal Thanik
- New York University Langone Medical Center, New York City, USA
| | - Jacques H. Hacquebord
- New York University Langone Orthopedic Hospital, New York City, USA,New York University Langone Medical Center, New York City, USA
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15
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Woo SH. Practical Tips to Improve Efficiency and Success in Upper Limb Replantation. Plast Reconstr Surg 2020; 144:878e-911e. [PMID: 31688770 DOI: 10.1097/prs.0000000000006134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Sang Hyun Woo
- From the W Institute for Hand and Reconstructive Microsurgery and the Department of Plastic and Reconstructive Surgery, W General Hospital
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16
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Nikkhah D, Berner JE, Pickford M. Use of cannulated compression screws for skeletal stabilisation during digital re-vascularisation. J Plast Reconstr Aesthet Surg 2020; 73:1174-1205. [PMID: 32008942 DOI: 10.1016/j.bjps.2020.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/10/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Dariush Nikkhah
- Consultant Plastic Surgeon FRCS Plast, Royal Free Hospital NHS Foundation Trust, Pond St, Hampstead, London, NW3 2QG, United Kingdom.
| | - Juan Enrique Berner
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Mark Pickford
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
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17
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Barbato B, Salsac AV. Finger and thumb replantation: From biomechanics to practical surgical applications. HAND SURGERY & REHABILITATION 2019; 39:77-91. [PMID: 31837487 DOI: 10.1016/j.hansur.2019.10.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/23/2019] [Accepted: 10/31/2019] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- B Barbato
- Urgences Main Val de Seine, Centre hospitalier privé du Montgardé, 32, rue de Montgardé, 78410 Aubergenville, France.
| | - A-V Salsac
- Laboratoire de Biomécanique et Bioingénierie (UMR 7338), CNRS-université de Technologie de Compiègne, Alliance Sorbonne université, rue du Docteur Schweitzer, CS 60319, 60203 Compiègne cedex, France.
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Boesch CE, Fuchsberger T, Beutler K, Bender D, Daigeler A, Medved F. Value of the Two-Point Discrimination Test: Evaluation of 238 Isolated Finger Nerve Injuries. J Hand Surg Asian Pac Vol 2019; 24:477-482. [PMID: 31690192 DOI: 10.1142/s2424835519500620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: It may be difficult to diagnose a nerve injury on a finger or a hand under emergency settings. The goal of this study was to elaborate whether the clinical testing of two-point discrimination was a safe and reliable method in the diagnosis of acute finger nerve injuries. Methods: Through a retrospective assessment, patients' records were analyzed whether the result of the two-point discrimination test corresponded with the intraoperative findings of a damaged nerve. Patients with a prolonged or missing two-point discrimination, who had undergone surgery at our institution between the years 2008 and 2017, were included in the study. The control groups were identified in the same manner and as an additional group, patients with Dupuytren's contracture were included to serve as a healthy cohort regarding finger nerves. Results: A total of 249 patients with nerve lesion were enrolled in the study; apart from this, 25 patients with Dupuytren's contracture were included. The sensitivity of the two-point discrimination test was 99%, with a positive predictive value of 0.93 and with high inter-observer reliability. Conclusions: The two-point discrimination is a valid test to use in the routine examination of suspected nerve injuries on the hands and fingers; it is very reliable and safe for indicating surgical interventions.
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Affiliation(s)
- Cedric Emanuel Boesch
- Department for Plastic, Reconstructive and Aesthetic Surgery, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Fuchsberger
- Clinic of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Traunstein, Germany
| | - Kevin Beutler
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Dominik Bender
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Adrien Daigeler
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Fabian Medved
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
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Abstract
Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.
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Affiliation(s)
- Adnan Prsic
- Plastic and Reconstructive Surgery, Yale School of Medicine, PO Box 208041, New Haven, CT 06520-8041, USA.
| | - Jeffrey B Friedrich
- Orthopaedics, Division of Plastic Surgery, University of Washington, Harborview Medical Center, Seattle Children's Hospital, 325 9th Avenue, Box 359796, Seattle, WA 98104, USA
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Abstract
Digital replantation and revascularization have evolved significantly since the first published reports in the 1960s. Advances in techniques and instruments have made these once formidable procedures a routine part of hand surgery training. Despite this, the frequency of successful outcomes for replantation may be on the decline in the United States. This review summarizes key mechanisms and innovations used to maximize efficiency when presented with a digital replantation, from the moment the patient arrives in the emergency department until the time of discharge.
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Lee DC, Kim JS, Roh SY, Lee KJ, Kim YW. Flap Coverage of Dysvascular Digits Including Venous Flow-Through Flaps. Hand Clin 2019; 35:185-197. [PMID: 30928050 DOI: 10.1016/j.hcl.2019.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A dysvascular digit is defined as a threatened circulatory condition of a digit caused owing to multiple reasons, such as medical illness or trauma. A dysvascular digit always needs surgical manipulation of the vessel in trauma cases. The revascularization of the digit is a priority in such conditions, after which reconstruction of the defect is performed. In this article, the authors present and discuss the venous free flap, thenar free flap, toe plantar free flap, free style perforator flap, hypothenar free flap, and anconeus muscle free flap.
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Affiliation(s)
- Dong Chul Lee
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea.
| | - Jin Soo Kim
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Si Young Roh
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Kyung Jin Lee
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Yong Woo Kim
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
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Survival after Digit Replantation and Revascularization Is Not Affected by the Use of Interpositional Grafts during Arterial Repair. Plast Reconstr Surg 2019; 143:551e-557e. [DOI: 10.1097/prs.0000000000005343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Effect of Increasing Age on Outcomes of Digital Revascularization or Replantation. Plast Reconstr Surg 2018; 143:495-502. [PMID: 30531624 DOI: 10.1097/prs.0000000000005195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of increasing age on rates of digital failure. METHOD A retrospective cohort study of digital replantation or revascularization patients was undertaken from 2005 to 2016. Data collected consisted of patient demographics, smoking status, injury mechanisms, procedure types, and postoperative morbidity and mortality. Descriptive statistics and logistic regression were performed to assess outcomes. All comparisons were made between patients older than and younger than 60 years. RESULTS Two hundred eighty-three patients underwent replantation or revascularization; 11 percent were older than 60 years. The majority of patients had multiple devascularized digits (70 percent), most commonly inflicted by a blade mechanism (77 percent). Approximately half of the patients underwent revascularization alone (54.4 percent). American Society of Anesthesiologists score and number of comorbidities were significantly greater in the older adult group. Overall, 88 patients (31 percent) experienced digital replantation or revascularization failure, with 12 failures in patients aged 60 years or older. Multivariate logistic regression demonstrated that age did not have an impact on failure rate. Older patients did not experience more major complications, but had significantly higher rates of minor complications (p = 0.0485). CONCLUSIONS Older patients presented with significantly higher American Society of Anesthesiologists physical status and number of comorbidities, but did not experience higher rates of digital failure, major perioperative complications, or 30-day mortality. Adults aged 60 years or older should be offered digital replantation or revascularization if medically or surgically indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Hatchell AC, Sandre AR, McRae M, Farrokhyar F, Avram R. The success of salvage procedures for failing digital replants: A retrospective cohort study. Microsurgery 2018; 39:200-206. [PMID: 30496615 DOI: 10.1002/micr.30379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 08/07/2018] [Accepted: 08/28/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.
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Affiliation(s)
- Alexandra C Hatchell
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anthony R Sandre
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matthew McRae
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Departments of Surgery & Health, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ronen Avram
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Spiers E. Managing vascular compromise of hand and digit replantation following traumatic amputation. ACTA ACUST UNITED AC 2018; 27:S50-S56. [PMID: 30418845 DOI: 10.12968/bjon.2018.27.sup20.s50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hands are anatomically complex and have great social, physical and emotional importance. Hand or digit replantation following traumatic partial or complete amputation is a complex injury for nursing staff to understand and manage. The absence of clear guidance, combined with a lack of consensus in the literature gives rise to ambiguity and insufficient understanding of appropriate and effective management. This article aims to outline nursing care of the patient in the first few days following hand or digit reattachment, particularly focusing on the recognition and management of arterial and venous compromise. Complications must be recognised and acted on quickly to give the best chance of survival so it is essential for nurses to have an accurate understanding of the signs, symptoms and management options of vascular compromise. Leech therapy, also discussed, has long been used as a nonsurgical option in the management of venous congestion and is a simple and minimally invasive method of managing congestion.
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Affiliation(s)
- Emma Spiers
- Military Burns and Plastics Nurse, The Queen Elizabeth Hospital, Birmingham
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Cavadas PC, Rubí C, Thione A, Pérez-Espadero A. Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes. J Hand Surg Am 2018; 43:625-630. [PMID: 29751978 DOI: 10.1016/j.jhsa.2018.03.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 02/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Ischemia time has been traditionally considered a critical factor in replantation survival rate. The objective of this study was to compare the survival rate between immediate and overnight-delayed digital replantation. METHODS We performed a retrospective cohort study of all digital replantations performed at our clinic between 2005 and 2016. The survival rate was compared between the immediate digital replantation group (immediate replantation group) and those that were replanted the morning after they were admitted to the hospital (overnight-delayed replantation group). The decision to delay the replant was made in cases admitted in the evening with less than 12 hours of previous ischemia time and without farm-related contamination. RESULTS Five hundred ninety-seven digital replantations (456 patients) were analyzed. One hundred eighty-five (31%) digital replantations were performed the following day (delayed replantation group) and 412 (69%) digital replantations were performed the same day that they were admitted to the hospital (immediate replantation group). The overall survival rate was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2% (376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185). There were no statistically significant differences between the immediate and the delayed replantation groups with respect to age, zone of amputation, or presence of multiple amputations. CONCLUSIONS Our study suggests that overnight delay is a safe approach for digital replantation when performed by experienced microsurgeons. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Pedro C Cavadas
- Reconstructive Surgery Unit, Clínica Cavadas, Valencia, Spain
| | - Carlos Rubí
- Private Practice at Hospital IMED Valencia, Valencia, Spain
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Shaterian A, Rajaii R, Kanack M, Evans GRD, Leis A. Predictors of Digit Survival following Replantation: Quantitative Review and Meta-Analysis. J Hand Microsurg 2018; 10:66-73. [PMID: 30154618 DOI: 10.1055/s-0038-1626689] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/02/2017] [Indexed: 10/17/2022] Open
Abstract
Introduction Microsurgical replantation following digital amputation has variable success rates. Sociodemographic factors and surgery-related variables have been shown to influence survival rates; however, few studies have evaluated these data systematically across a combined dataset. Therefore, the objective of this study was to analyze the current literature to identify the predictors of replant survival. Materials and Methods A literature review was performed using the PubMed/Medline database focused on complete digit amputation/replantation studies. Studies were evaluated for patient and surgery-related variables and their respective effects on survival. Statistical analysis was conducted to identify predictors of survival and derive pooled estimates from the combined dataset. Results Thirty-two studies representing more than 6,000 digit amputation/replantation cases met inclusion/exclusion criteria. Statistical analysis revealed the number of venous anastomosis (0 vs. 1 vs. 2), the number of arterial anastomosis (0 vs. 1 vs. 2), and the mechanism of injury (sharp cut versus blunt cut versus avulsion versus crush) to influence replant survival ( p < 0.05). The authors failed to find a significant association between survival and the following variables: age, sex, zone of injury, digit number, tobacco use, ischemia time, method of preservation, and use of vein graft. Conclusion Patient- and surgery-related variables affect digit survival following replantation. The etiology of injury can help risk-stratify patients and assist in an informed decision making process, whereas surgery-related factors can guide surgeon practice to improve clinical outcomes following replantation.
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Affiliation(s)
- Ashkaun Shaterian
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Ramin Rajaii
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Melissa Kanack
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Gregory R D Evans
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Amber Leis
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
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Sindhu K, DeFroda SF, Harris AP, Gil JA. Management of partial fingertip amputation in adults: Operative and non operative treatment. Injury 2017; 48:2643-2649. [PMID: 29100662 DOI: 10.1016/j.injury.2017.10.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider. METHODS Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years. RESULTS In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing. CONCLUSION In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed.
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Affiliation(s)
- Kunal Sindhu
- Department of Medicine, Mount Sinai Beth Israel, New York, NY 10003, United States
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States.
| | - Andrew P Harris
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
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Deutsch CJ, Nikkhah D. An efficient method of soft tissue preparation of amputated digits for replantation. Ann R Coll Surg Engl 2017; 99:584-585. [PMID: 28853587 DOI: 10.1308/rcsann.2017.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Lamb J, Monkhouse R. Positioning tips for distal fibula ankle fracture fixation. Ann R Coll Surg Engl 2017; 99:585. [PMID: 28853586 DOI: 10.1308/rcsann.2017.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- J Lamb
- Leeds Teaching Hospitals NHS Trust , UK
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Nolte MT, Shauver MJ, Chung KC, Giladi AM. Effect of Policy Change on the Use of Long-Distance Transport and Follow-Up Care for Patients With Traumatic Finger Amputations. J Hand Surg Am 2017; 42:610-617.e2. [PMID: 28499510 PMCID: PMC5545056 DOI: 10.1016/j.jhsa.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE In January 2006, the American College of Emergency Physicians released updated guidelines for air transfer. Digit amputation and near-amputation were no longer an indication for this costly service. We analyzed the effect of this update on the use of air transport and associated care outcomes for finger amputation patients and examined factors involved in providing follow-up care for these patients. METHODS A retrospective chart review identified all patients treated for traumatic finger amputation between 1995 and 2012 at a major hand trauma referral center. Analysis of available outcome measures was conducted using multiple logistic and linear regression models. Analysis of factors affecting frequency of return visits was performed via negative binomial regression. RESULTS We identified 724 patients with isolated traumatic finger amputations. A total of 267 patients (37%) were transferred from an outside hospital. Patients injured after 2006 were less likely to be transferred via air, with a decrease from 29.5% pre-2006 to 14.9% post-2006. There was no difference in likelihood of replantation success, length of hospital stay, or number of return visits pre- versus post-2006. Patients transferred via helicopter after 2006 were more likely to be younger than 20 years of age and injured in a winter month. Following successful replantation, work-relatedness was associated with a higher number of return visits, whereas increasing age and transfer from farther than 100 miles away were associated with fewer. CONCLUSIONS After the American College of Emergency Physicians policy update, decreased use of emergency air transport to a hand trauma referral center for patients with traumatic finger amputations did not adversely affect care delivery and outcomes. These changes may be successfully implemented on a center-by-center basis to reduce costs without detriment to patient care; however, coordination of follow-up care for long-distance transport patients may require special focus when designing policy around referral centers. TYPE PF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Melissa J. Shauver
- Clinical Research Coordinator, Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Aviram M. Giladi
- Resident, Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Analysis of Bone Fixation Methods in Digital Replantation. Arch Plast Surg 2017; 44:53-58. [PMID: 28194348 PMCID: PMC5300925 DOI: 10.5999/aps.2017.44.1.53] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/26/2016] [Accepted: 11/02/2016] [Indexed: 11/08/2022] Open
Abstract
Background Adequate fixation of replanted digits is essential not only for short-term healing but for long-term function. Various bony fixation methods using Kirschner (K-) and intraosseous wire are available in replantation. We examined clinical and radiographic outcomes of fixation methods on bone union after digital replantation. Methods A single institutional retrospective review identified 992 patients who had undergone 1,247 successful replantations between July 2009 and September 2015. Exclusion criteria included amputations of the distal phalanx, comminuted fractures, and intra-articular fractures. Patients were classified according to 5 categories of fixation methods: single K-wire, double longitudinal K-wires, cross K-wires, wire with, and wire without K-wire support. Bone union was evaluated by 5-month postoperative X-ray and fixation outcomes were compared across the 5 groups. Results The exclusion criteria were applied, and 88 patients with 103 replanted digits remained for analysis. Single K-wire fixation was used in 40 digits, double longitudinal K-wires in 30, and cross fixation in 14. Wire with and without K-wire support was required in 15 and 4 digits. Nonunion was observed in 32 digits (31.1%), of which 13 required additional operations such as bone graft or corrective osteotomy. The highest percent of nonunion was observed after cross fixation (35.7%) and the lowest after wire alone (25.0%). Conclusions In this study, contrary to general knowledge, we found that single K-wire fixation was not associated with poorer outcomes. Successful bone union outcomes may be achieved by careful selection of bone fixation methods. This study provides useful information for planning bone fixation in digital replantation.
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Abstract
With the available microsurgical techniques, salvage of the limb can almost always provide a useful upper limb, even in the most complex combined injuries. Having a low threshold for revascularization of doubtfully viable extremities and making full use of the current armamentarium of soft tissue cover techniques, including flow through free flaps, will salvage many limbs. Secondary procedures, including free functioning muscle transfers and toe transfers, further increase the possible functional outcome. Even in the most complex combined injuries, intelligent reconstruction will obtain better outcomes than the best available prosthesis, making the efforts of salvage worthwhile.
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Racial Variation in Treatment of Traumatic Finger/Thumb Amputation: A National Comparative Study of Replantation and Revision Amputation. Plast Reconstr Surg 2016; 137:576e-585e. [PMID: 26910702 DOI: 10.1097/01.prs.0000479969.14557.9d] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic finger/thumb amputations are some of the most prevalent traumatic injuries affecting Americans each year. Rates of replantation after traumatic finger/thumb amputation, however, have been declining steadily across U.S. hospitals, which may make these procedures less accessible to minorities and vulnerable populations. The specific aim of this study was to examine racial variation in finger replantation after traumatic finger/thumb amputation. METHODS Using a two-level hierarchical model, the authors retrospectively compared replantation rates for African American patients with those of whites, adjusting for patient and hospital characteristics. Patients younger than 65 years with traumatic finger/thumb amputation injuries who sought care at a U.S. trauma center between 2007 and 2012 were included in the study sample. RESULTS The authors analyzed 13,129 patients younger than 65 years with traumatic finger/thumb amputation. Replantation rates declined over time from 19 percent to 14 percent (p = 0.004). Adjusting for patient and hospital characteristics, African Americans (OR, 0.81; 95 percent CI, 0.66 to 0.99; p = 0.049) were less likely to undergo replantation procedures than whites, and uninsured patients (OR, 0.73; 95 percent CI, 0.62 to 0.84; p < 0.0001) were less likely than those who were privately insured. CONCLUSIONS Despite advancements in microsurgical techniques and the increasing use of reconstructive surgery in other fields, finger/thumb replantation rates are declining in the United States and vulnerable populations are less likely to undergo replantation after amputation injuries. Regionalization of care for these injuries may not only provide a higher quality care but also reduce variations in treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Impact of the number of veins repaired in short-term digital replantation survival rate. J Plast Reconstr Aesthet Surg 2016; 69:640-5. [DOI: 10.1016/j.bjps.2015.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/24/2015] [Accepted: 12/06/2015] [Indexed: 11/23/2022]
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Kabakaş F. Dorsal approach for vascular repairs in distal finger replantations. Microsurgery 2016; 36:628-636. [DOI: 10.1002/micr.30057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 02/09/2016] [Accepted: 03/23/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Fatih Kabakaş
- Hand and Microsurgery Department; Medicalpark Gebze Hospital, Istanbul Bilgi University; Medicalpark Gebze Hospital Kavak Cad. No.3 Gebze-Kocaeli Turkey
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Wilkens SC, Claessen FMAP, Ogink PT, Moradi A, Ring D. Reoperation After Combined Injury of the Index Finger: Repair Versus Immediate Amputation. J Hand Surg Am 2016; 41:436-40.e4. [PMID: 26794123 DOI: 10.1016/j.jhsa.2015.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify factors associated with unplanned reoperation of severely injured index fingers and to address the number of amputations after initial repair. METHODS In this retrospective study, we included all patients older than 18 years of age who had repair or immediate amputation for combined index finger injury at 2 level I trauma centers and 1 community hospital tied to a level I trauma center between January 2004 and February 2014. Twelve patients were excluded because of inadequate follow-up. Bivariate and multivariable analyses sought factors associated with unplanned reoperation after repair and immediate amputation. RESULTS Among 114 patients with combined injury, 75 were treated with repair and 39 with immediate amputation. A total of 41 patients had an unplanned reoperation, 33 after repair (44%) and 8 after immediate amputation (21%). In multivariable analysis, patients who had a reoperation for fingers other than the index finger were at risk for unplanned reoperation after repair. Women were more likely to have an unplanned reoperation than men, and patients who had a ray amputation were at risk for unplanned reoperation after immediate amputation. Six patients (18%) had amputation after initial repair. CONCLUSIONS Surgeons may counsel patients that they are twice as likely to have an unplanned reoperation after a repair for combined injury of the index finger compared with an immediate amputation. Unplanned reoperations were more common among patients with injuries involving multiple fingers. Effective shared decision making is particularly important in this setting given that 1 in 5 repaired index fingers were eventually amputated. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Suzanne C Wilkens
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Femke M A P Claessen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Paul T Ogink
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Ali Moradi
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - David Ring
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA.
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Nikkhah D, Sadr AH, Murugesan L, Konczalik W, Rodrigues J. Cross-clamping of bony stumps in preparation for osteosynthesis in digital replantation. Microsurgery 2016; 37:356-357. [PMID: 26880131 DOI: 10.1002/micr.30035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/02/2016] [Accepted: 01/20/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Dariush Nikkhah
- Royal Free Hospital, Plastic Surgery Registrar, Hampstead, London, United Kingdom
| | - Amir H Sadr
- Royal Free Hospital, Plastic Surgery Registrar, Hampstead, London, United Kingdom
| | - Log Murugesan
- Royal Free Hospital, Plastic Surgery Registrar, Hampstead, London, United Kingdom
| | - Wojciech Konczalik
- Royal Free Hampstead, Plastic Surgery SHO, Hampstead, London, United Kingdom
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Abstract
INTRODUCTION Replantation surgery is an established treatment for amputated digits, and published literature report a high success rate. However, a proportion of replantations do encounter postoperative problems with vascularity, but the incidence is unknown. Although there are studies that look at the factors affecting the success of replantations and the management of postoperative replantations, there is little literature available on this transitional period. We introduce the term "troubled replantation" to describe the replantation that manifests any form of vascular insufficiency after replantation surgery. Our study focuses on reviewing our centre's experience with the management and outcomes of troubled replantations. MATERIALS AND METHODS Data was collected retrospectively from 389 digital replantations performed in our centre over an 11 year period. We included only single level digital replantations. We analysed the perioperative data, and the measures taken postoperatively to promote their survival. RESULTS There were a total of 137 troubled digits (35.2%). 53 digits responded to non-surgical measures such as dressing change and bedside bleeding procedures. 27 digits required re-exploration surgery, of which 16 survived. The majority of troubled replantations were due to arterial causes, and manifested signs within the first 48 h. 69 troubled digits (51%) survived. The remainder did not respond to any form of treatment including re-explorations and ultimately failed. CONCLUSION One third of all replantations are troubled replantations, and half of these eventually fail despite any intervention. As troubled replantations can lead to postoperative failure, it is important to understand this clinical scenario in order to improve immediate postoperative care.
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Affiliation(s)
- Dawn Sinn Yii Chia
- Hand and Microsurgery Section, Department of Orthopaedics, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Bueno RA, Battiston B, Ciclamini D, Titolo P, Panero B, Tos P. Replantation: current concepts and outcomes. Clin Plast Surg 2015; 41:385-95. [PMID: 24996460 DOI: 10.1016/j.cps.2014.03.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Techniques to improve the chance of successful replantation of digits are well established. Indications and contraindications for replantation are generally agreed on, but they continue to evolve as excellent outcomes are achieved at centers with experience and expertise. Form and function can be restored with avulsion injuries and distal amputations, with good results and high patient satisfaction. Increased financial pressure to control the costs of health care and increased accountability for evidence-based outcomes may lead to the regionalization of replantation care and shared decision making in recommending replantation or revision amputation.
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Affiliation(s)
- Reuben A Bueno
- Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA.
| | - Bruno Battiston
- Microsurgery Unit, Trauma Center, CTO Hospital, Via Zuretti 29, Torino 10100, Italy
| | - Davide Ciclamini
- Microsurgery Unit, Trauma Center, CTO Hospital, Via Zuretti 29, Torino 10100, Italy
| | - Paolo Titolo
- Microsurgery Unit, Trauma Center, CTO Hospital, Via Zuretti 29, Torino 10100, Italy
| | - Bernardino Panero
- Microsurgery Unit, Trauma Center, CTO Hospital, Via Zuretti 29, Torino 10100, Italy
| | - Pierluigi Tos
- Microsurgery Unit, Trauma Center, CTO Hospital, Via Zuretti 29, Torino 10100, Italy
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Bourke G. Amputations, replantation and thumb reconstruction. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Engin MS, Aksakal İA. Heterotopic Transarticular Replantation: A Functional Reconstruction Design for a Mutilated Hand with Multiple Digit Involvement. JBJS Case Connect 2015; 5:e25. [PMID: 29252603 DOI: 10.2106/jbjs.cc.n.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE A patient sustained a high-energy trauma that resulted in amputation of the middle and ring fingers, along with injuries to the thumb and the index finger. The amputations were not clean; therefore, heterotopic replantation of the best amputated part of the finger to the most functional stump was undertaken. Transarticular replantation was done at the level of the proximal interphalangeal joint without osseous fixation. Early active motion was initiated the next day. The replanted finger had excellent function. CONCLUSION Whenever possible, designing a heterotopic transarticular replantation can minimize the functional drawbacks resulting from the prolonged immobilization often associated with fracture fixation.
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Affiliation(s)
- Murat Sinan Engin
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey 55270. E mail address for M.S. Engin: .
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Choi Y, Cox C, Lally K, Li Y. The strategy and method in modulating finger regeneration. Regen Med 2015; 9:231-42. [PMID: 24750063 DOI: 10.2217/rme.13.98] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The tip of the human finger can regenerate if the amputation is distal to the nail bed, usually in young children. Studies in regeneration of rodent digits have shown that regeneration occurs if the amputation is distal to the mid-third phalanx for certain ages. The digit contains many different components, such as muscle, tendon, bone, skin, nerves and blood vessels, which must all be regrown in the proper location in order to restore functionality. The mechanism behind the complex healing/regeneration processes is still under investigation; however, improvements in injured finger regeneration have been gradually developing in animal models over the past few years. This review discusses a few strategies and methods to possibly enhance digit regeneration beyond current natural limits, focusing on aspects including scarless wound healing, cell-based treatments, tissue engineering and electrical stimulation.
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Affiliation(s)
- Yohan Choi
- Children's Regenerative Medicine, Department of Pediatric Surgery, University of Texas Medical School at Houston, TX 77030, USA
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Abstract
Traumatic thumb amputations are a common problem with significant associated cost to patients, hospitals, and society.The purpose of this study was to review practice patterns for traumatic thumb amputations using the National Trauma Data Bank. By using a large nationwide database, we hoped to better understand the epidemiology and predictors of attempts and successful replantation.The design was a retrospective review of the National Trauma Data Bank between the years 2007 and 2010, investigating patients with traumatic thumb amputations. Analyses of these patients based on replantation attempt, mechanism of injury, and demographics were performed. Comparisons were made between hospitals based on teaching status and on patient volume for replant attempt and success rates.There were 3341 traumatic thumb amputations with 550 (16.5%) attempts at replantation and an overall success rate of 84.9%. Nonteaching hospitals treated 1238 (37.1%) patients, and attempted 123 (9.9%) replantations with a success rate of 80.5%. Teaching hospitals treated 2103 (63.0%) patients, and attempted 427 (20.3%) replantations with a success rate of 86.2%. Being in a teaching hospital increased the odds of attempted replantation by a factor of 3.1 (P < 0.001) when compared to a nonteaching hospital. Treatment at a high-volume center increased the rate of attempted replantation by a factor of 3.4 (P < 0.001), as compared to low-volume hospitals.Practice patterns show that teaching and high-volume hospitals attempt to replant a higher percentage of amputated thumbs. Success rates are similar across practice settings.
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Fufa D, Calfee R, Wall L, Zeng W, Goldfarb C. Digit replantation: experience of two U.S. academic level-I trauma centers. J Bone Joint Surg Am 2013; 95:2127-34. [PMID: 24306700 DOI: 10.2106/jbjs.l.01219] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite advances in microsurgery, digit replantation now is performed less frequently in the U.S. compared with fifteen years ago. There has been uncertainty regarding whether previously reported U.S. replantation success rates and results reported from other countries reflect the current experience in the U.S. We hypothesized that the success of digit replantation at two academic level-I referral hospitals in the U.S. would be similar to previously published results. METHODS In this retrospective case series, we examined all cases of digit replantation that were performed from 1997 through 2010 at two institutions. The cumulative rate of viable digit replantations was determined. Binary logistic regression modeling determined the relative impact of patient, injury, and operative factors on replantation survival. RESULTS During the study period, 135 digit replantations were performed in 106 patients. Fourteen cases did not meet our inclusion criteria, yielding a cohort of 121 replantations. The thumb (n = 40) was the most commonly replanted digit, followed by the long finger (n = 31). The mechanism of injury was classified as sharp in eighty-three digits, crush in nineteen digits, and avulsion in eighteen digits. The majority of replantations were performed following Tamai level-III (n = 49) or level-IV (n = 56) amputations. Sixty-nine (57%) of the digit replantation procedures were successful. Logistic regression analysis identified replantation of the radial three digits and no history of tobacco use as significant independent predictors of replantation success. CONCLUSIONS The rate of success of digit replantation (57%) at two academic level-I trauma hospitals was lower than previously published rates. Radial-digit involvement and no prior tobacco use were associated with replantation success. This modest success rate reflects a need for additional evaluation of our current benchmarks and clinical settings for replantation surgery. These data help to better inform patients, families, and physicians who are considering digit replantation.
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Affiliation(s)
- Duretti Fufa
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63108. E-mail address for D. Fufa:
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Abstract
BACKGROUND The purpose of this study was to analyze factors associated with the decision to replant or revascularize rather than amputate an injured digit as well as factors associated with successful replantation or revascularization. METHODS We reviewed 315 complete and subtotal amputations at or proximal to the distal interphalangeal joint in 199 adult patients treated over 10 years. Ninety-three digits were replanted (30 %), 51 were revascularized (16 %), and 171 were amputated (54 %), including 5 attempted replantations. Bivariate and multivariable analyses sought factors associated with replantation vs. amputation, revascularization vs. amputation, and success of replantation or revascularization. RESULTS Factors associated with replantation rather than amputation were injury to the left hand, thumb, middle digit, and ring digit, more than one digit affected, and surgeon. Factors associated with revascularization are surgeon and shorter ischemia time. Forty-five replantations (48 %) and 41 revascularizations (80 %) were successful. Successful replantation was associated with the side of injury (left side more likely to survive), zone of injury (distal interphalangeal and interphalangeal joint more likely to survive and proximal phalanx less likely to survive), and shorter ischemia time. Success of revascularization was associated with the mechanism of injury (saw and not crush injury), multiple digits involved, and the surgeon. CONCLUSIONS The decision to replant, revascularize, or amputate a nonviable digit and the success of replantation and revascularization are related to both injury factors, such as mechanism of injury, affected digit, and zone of injury, and the surgeon.
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Casal D, Gomez MM, Antunes P, Candeias H, Almeida MA. Defying standard criteria for digital replantation: A case series. Int J Surg Case Rep 2013; 4:597-602. [PMID: 23702366 DOI: 10.1016/j.ijscr.2013.03.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 02/27/2013] [Accepted: 03/29/2013] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION There is much controversy regarding the current indications and contraindications for digital replantation. PRESENTATION OF CASE Three patients with absolute contraindications for digital replantation according to classical criteria are presented (Case 1: multilevel amputation of the hand and fingers; Case 3: avulsion of the thumb; Case 4: index amputation proximal to the insertion of the flexor digitorum superficialis). In addition a patient with a very distal digital amputation (Case 2), whose indication for replantation is controversial is also presented. In all cases, the patients were replanted and showed good functional and aesthetical results. DISCUSSION Most authors advocate that the classical indications for replantation have been validated by experience, are predicated on the potential for long-term function, and should be followed in most if not all cases. However, some surgeons have been adopting a more liberal attitude with good results. CONCLUSION The clinical cases presented in this paper suggest that the standard criteria for digital replantation should not be followed rigidly but instead should be regarded as a general guide.
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Affiliation(s)
- Diogo Casal
- Department of Plastic and Reconstructive Surgery and Burn Unit, São José Hospital, Lisbon, Portugal; Lisbon Medical Sciences Faculty, Portugal.
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49
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Abstract
Since the first successful salvage of an amputated finger using microsurgical anastomoses in 1965, replantation has been widely used in these decades and is now firmly established as a viable treatment option in traumatic limb amputation. The current concepts of replantation surgery for upper limb amputation are discussed in this review article in terms of history of replantation, present indications for the procedure, pre-theater care, technical refinements, postoperative management and functional outcome. In this article, we demonstrated that the advent of microsurgery has led to replantation of almost every amputated part of the upper limb possible. Replantation of digits and the hand can restore not only circulation but also function and cosmetic appearance. However, major amputations remain a challenge and the functional outcome is often disappointing, albeit the success rate of replantation exceeds 80%. Proper patient selection, adequate pre-theater preservation, good operative skill and postoperative care, as well as tight cooperation among the patient, the surgeon, and the rehabilitation therapist will help to achieve a better final functional outcome.
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Affiliation(s)
- Pao-Yuan Lin
- Division of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taiwan
| | - Seng-Feng Jeng
- Department of Plastic Surgery, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Tsan-Shiun Lin
- Division of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taiwan
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Taiwan
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Abstract
Digital replantation has become a well-established technique among reconstructive hand surgeons. Numerous replantation centers around the world have published series with impressive survival rates. The ultimate goal of replantation is the restoration of normal hand or digital function; thus, replantation success is not solely related to the outcome of the microvascular anastomosis, but also to the adequacy of bone, tendon, skin, and nerve repairs. In this manuscript, we review the literature on upper extremity and digital replantation from its historical background to current surgical outcomes, outlining surgical indications and contraindications, and the preoperative, operative, and postoperative management of these patients.
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