Outcomes Following Replantation/Revascularization in the Hand

Is Replantation Associated With Better Hand Function After Traumatic Hand Amputation Than After Revision Amputation?

BACKGROUND

Replantation is an established treatment for traumatic upper extremity amputation. Only a few studies, however, have assessed the patient-reported outcomes of replantation, and the findings of these studies have been conflicting.

QUESTIONS/PURPOSES

(1) Is replantation associated with better hand function than revision amputation? (2) Is replantation associated with better health-related quality of life, less painful cold intolerance, and more pleasing hand esthetics than revision amputation after a traumatic hand amputation?

METHODS

In this retrospective, comparative study, we collected the details of all patients who sustained a traumatic upper extremity amputation and were treated at the study hospital. Between 2009 and 2019, we treated 2250 patients, and we considered all patients who sustained a traumatic amputation of two or more digital rays or a thumb as potentially eligible. Based on that, 15% (334 of 2250) were eligible; a further 2% (8 of 334) were excluded because of a subsequent new traumatic amputation or bilateral amputation, and another 22% (72 of 334) refused participation, leaving 76% (254 of 334) for analysis here. The primary outcome was the DASH score. Secondary outcomes included health-related quality of life (EuroQOL-5D [EQ-5D-5L] Index), painful cold intolerance (the Cold Intolerance Symptom Severity score), and hand esthetics (the Michigan Hand Questionnaire aesthetic domain score). The minimum follow-up time for inclusion was 18 months. Patients were classified into two treatment groups: replantation (67% [171 of 254], including successful replantation in 84% [144 of 171] and partially successful replantation in 16% [27 of 171], in which some but not all of the replanted tissue survived), and revision (complete) amputation (33% [83 of 254], including primary revision amputation in 70% [58 of 83] and unsuccessful replantation followed by secondary amputation in 30% [25 of 83]). In this cohort, replantation was performed if possible, and the reason for choosing primary revision amputation over replantation was usually an amputated part that was too severely damaged (15% [39 of 254]) or was unattainable (2% [4 of 254]). Some patients (3% [8 of 254]) refused to undergo replantation, or their health status did not allow replantation surgery and postoperative rehabilitation (3% [7 of 254]). Gender, age (mean 48 ± 17 years in the replantation group versus 50 ± 23 years in the revision amputation group; p = 0.41), follow-up time (8 ± 4 years in the replantation group versus 7 ± 4 years in the revision amputation group; p = 0.18), amputation of the dominant hand, smoking, extent of tissue loss, or presence of arterial hypertension did not differ between the groups. Patients in the replantation group less frequently had diabetes mellitus (5% [8 of 171] versus 12% [10 of 83]; p = 0.03) and dyslipidemia (4% [7 of 171] versus 11% [9 of 83]; p = 0.04) than those in the revision group and more often had cut-type injuries (75% [129 of 171] versus 60% [50 of 83]; p = 0.02).

RESULTS

After controlling for potential confounding variables such as age, injury type, extent of tissue loss before treatment, and accident of the dominant hand, replantation was not associated with better DASH scores than revision amputation (OR 0.82 [95% confidence interval (CI) 0.50 to 1.33]; p = 0.42). After controlling for potential cofounding variables, replantation was not associated with better EQ-5D-5L Index scores (OR 0.93 [95% CI 0.56 to 1.55]; p = 0.55), differences in Cold Intolerance Symptom Severity scores (OR 0.85 [95% CI 0.51 to 1.44]; p = 0.79), or superior Michigan Hand Questionnaire esthetic domain scores (OR 0.73 [95% CI 0.43 to 1.26]; p = 0.26) compared with revision amputation.

CONCLUSION

Replantation surgery was conducted, if feasible, in a homogenous cohort of patients who underwent amputation. If the amputated tissue was too severely damaged or replantation surgery was unsuccessful, the treatment resulted in revision (complete) amputation, which was not associated with worse patient-reported outcomes than successful replantation. These results contradict the assumed benefits of replantation surgery and indicate the need for credible evidence to better guide the care of these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Knowledge, attitudes and practice towards postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses in Beijing: a cross-sectional survey

OBJECTIVE

To explore the knowledge, attitudes and practice (KAP) towards the postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses.

DESIGN

Cross-sectional survey.

SETTING

Two tertiary medical centres in Beijing, China.

PARTICIPANTS

New nurses with working experience within 2 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The demographic characteristics of the nurses and their KAP towards the postoperative nursing of patients with digit replantation and skin flap transplantation were collected using a self-administered questionnaire. The primary outcome was the KAP scores towards the postoperative nursing of patients with digit replantation and skin flap transplantation. The secondary outcomes were the factors associated with the KAP scores and how the KAP dimensions interacted among them.

RESULTS

A total of 206 valid questionnaires were collected. The mean KAP scores were 7.72±3.28 (total score 13; 59.3%), 37.95±6.05 (total score 50; 75.9%) and 38.23±6.12 (total score 45; 84.9%), indicating poor knowledge, moderately favourable attitudes and active practice. The structural equation model analysis showed that knowledge directly influences attitudes (β=0.82, 95%CI 0.60 to 1.05, p<0.001) and that attitudes directly influence practices (β=0.72, 95%CI 0.62 to 0.83, p<0.001). Knowledge had no direct influence on practices (β=0.10, 95%CI -0.09 to 0.29, p=0.313), but the indirect influence was significant (β=0.60, 95%CI 0.41 to 0.78, p<0.001).

CONCLUSION

The lack of sufficient knowledge towards the postoperative nursing of patients with digit replantation and skin flap transplantation among nurses with <2 years of experience and the correlation among the KAP dimensions suggested the importance of proper training.

Characteristics of Rodeo Injuries and Suggestions for Injury Prevention: A Systematic Review

Background

Rodeo is a globally popular sport, with its athletes prone to various types of injuries. There is no systematic review discussing rodeo injuries across all age groups.

Purpose

To (1) review the published literature on incidence, types of injuries, and factors leading to injuries in rodeo athletes; (2) provide prevention recommendations for health care providers; and (3) identify gaps in the research.

Study Design

Systematic review; Level of evidence, 4.

Methods

A comprehensive search of available literature was electronically performed through MEDLINE, Embase, and SPORTDiscus databases using the key terms "rodeo" and "injury" or "trauma" between 1995 and 2021. A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which identified 116 eligible studies. Outcome data included frequency of injuries, risk factors for injury, and types of injury.

Results

A total of 23 studies met the inclusion criteria (N = 2105 athletes), of which 13 were retrospective studies. In the included studies, the injury rate per competition exposure (CE) ranged from 4.2 to 19.1 injuries per 1000 CE. Sprains and strains accounted for the highest percentage of injury types, ranging from 15% to 34%. The knee was the most common location of injury, making up 11.1% to 17% of injuries. Concussions occurred in up to 15.3% of injuries for all events and up to 77% of injuries in roughstock events. Of all rodeo events reported, bull riding caused the highest percentage of injuries, making up 19.4% to 58.4% of injuries, and bareback had the second highest at 15.3% to 28.8% of injuries.

Conclusion

There was a high prevalence of various injury types and mechanisms in rodeo. Improved injury surveillance and the introduction of a comprehensive standardized injury reporting system would be helpful in the future prevention, diagnosis, and treatment of rodeo injuries.

Success Rates of Finger Revascularization and Replantation

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Outcomes following replantation surgery

The ability to perform surgical replantation of individual digits and limbs can provide substantial functional improvement for patients who sustain devastating upper extremity injuries. Defining success in replantation surgery extends beyond the acute period and the binary metrics of survival or loss of the replanted part to include the long-term overall functional outcomes. Functional outcomes include both objective clinical evaluation and patient-reported outcomes. There has been significant variation in the way outcomes following replantation are measured, which inherently leads to heterogeneity in the reported outcome data. Given the variability among outcome measures, we aim to explore the outcomes of replantation surgery, particularly clinical evaluation and patient-reported functional outcomes following replantation.

Selection Bias in Avoiding Vein Graft in Replantation/Revascularization May Exist in Distal and Proximal Amputations, Respectively

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.

Predictors of Success following Microvascular Replantation Surgery of the Upper Extremity in Adult Patients

The purpose of this study is to ascertain which factors are associated with successful replantation in the upper extremity. Secondarily, the purpose was to determine patient factors that differentiate those patients who undergo initial replantation versus initial amputation.

Methods

Data gathered for this retrospective study were obtained from a custom subset of the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. Data were sorted using Current Procedural Terminology codes and International Classification of Disease, Ninth and Tenth Revision, diagnosis codes.

Results

Increasing age was significantly associated with undergoing initial amputation compared with replantation (P < 0.001; 95% CI, 47.146-50.654). Among comorbid conditions, patients with diabetes mellitus type II (2.4% versus 24.3%; P < 0.001), hypertension (11.9% versus 28.0%; P = 0.03), end-stage renal disease (0% versus 10.5%; P = 0.03), and hypertensive chronic kidney disease (0% versus 8.7%; P = 0.04) more commonly underwent an initial amputation procedure. When evaluating the need for secondary procedure after replantation, there was no statistical significance between groups when comparing age, gender, insurance type, general comorbidities, connective tissue disorders, mental health disorders, or geographic location.

Conclusions

In conclusion, this study demonstrates that age and the presence of comorbidities are important factors in the differentiation of which patients undergo initial reimplantation versus initial amputation. Additionally, no specific factors were identified that were associated with secondary procedures after replantation.

Multilevel Dysvascular Injury of the Hand: Replantation versus Revision Amputation

BACKGROUND

Multilevel dysvascular injury of the hand can be treated with replantation or revision amputation. The authors compared both modalities regarding functional outcomes, patient-reported outcomes, and required resources, as relevant studies are scarce.

METHODS

In this retrospective review of consecutive case series (replantation, n = 8; revision amputation, n = 11), clinical results and functional outcomes (including grip strength, range of motion, sensory recovery, and grip or pinch ability) were assessed. Patient-reported outcomes, required hospital resources, and treatment cost until 1 year after surgery were compared between both groups.

RESULTS

Six patients used passive prostheses, two used body-powered prostheses, and three did not use a prosthesis in the revision amputation group. All patients in the replantation group could grip objects and had restored hands, with protective sensory recovery and substantial wrist motion, whereas six patients in the revision amputation group were unable to grip or pinch objects. Replantation was associated with superior patient-reported outcomes, but required more hospital resources and treatment costs.

CONCLUSIONS

This study suggests that in the treatment of multilevel dysvascular injury of the hand, the surgical method should be chosen on a case-by-case basis. For better functional and patient-reported outcomes, replantation is preferred. Revision amputation can be performed in the absence of sufficient hospital resources and to reduce treatment cost. These findings can aid in the preoperative counseling of patients with multilevel dysvascular injury of the hand.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reporting Outcomes and Outcome Measures in Digital Replantation: A Systematic Review

Introduction  There is a lack of consensus on what the critical outcomes in replantation are and how best to measure them. This review aims to identify all reported outcomes and respective outcome measures used in digital replantation. Materials and Methods  Randomized controlled trials, cohort studies, and single-arm observational studies of adults undergoing replantation with at least one well-described outcome or outcome measure were identified. Primary outcomes were classified into six domains, and outcome measures were classified into eight domains. The clinimetric properties were identified and reported. A total of 56 observational studies met the inclusion criteria. Results  In total, 29 continuous and 29 categorical outcomes were identified, and 87 scales and instruments were identified. The most frequently used outcomes were survival of replanted digit, sensation, and time in hospital. Outcomes and measures were most variable in domains of viability, quality of life, and motor function. Only eight measures used across these domains were validated and proven reliable. Conclusion  Lack of consensus creates an obstacle to reporting, understanding, and comparing the effectiveness of various replantation strategies.