Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit

Return-to-Work After Attempted Digit Replantation: A Systematic Review of 31 Studies

BACKGROUND

Traumatic digit amputation is a common injury with life-altering consequences for thousands of patients each year. In this study, we aim to update and expand the reported outcomes of return-to-work (RTW) and functional recovery in patients treated with digit replant after traumatic amputation.

METHODS

A PRISMA-guided systematic review was performed to identify all published articles related to digit replantation following amputation. We queried the following 4 databases: Scopus, Embase, Web of Science, and PubMed-MEDLINE. A total of 31 studies were included in the analysis of return-to-work data.

RESULTS

Of the 31 included studies, 26 studies reported that 1976 digits were successfully replanted, while 27 studies reported that 300 replants failed (86.8% success rate). Among 1087 patients in these studies, 82.9% who underwent replantation returned to work. The mean RTW time in 16 studies was 4.7 months (weighted average). Return-to-work time ranged from 0 to 26 months in 12 studies. Of 352 patients who returned to work in 17 studies, 90.9% resumed their previous occupation, while 29 (8.2%) changed occupations. The RTW for finger-only replantations was significantly lower compared to thumb-only, distal digit-only, and any digit replantations (66.0% vs 82.8%; 66.0% vs 87.6%; 66.0% vs 82.9%).

CONCLUSION

Despite a declining prevalence of digit replantation surgery in recent years, this study illustrates that replantation provides beneficial outcomes for patients with a high return-to-work rate.

Partial hand replantation using free microsurgical replantation with staged heterotopic banking of amputated parts: towards improving long term outcomes

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the "Three R's" - Recovery, Rehabilitation, and Revision over the first year of recovery.

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.

Comparison treatment of medium-sized volar fingertips defects with modified triangular neurovascular unilateral advancement flap versus digital artery dorsal perforator flap

PURPOSE

The reconstruction of medium-sized soft tissue defects of the fingertip remains a challenge for hand surgeons. The aim of this study was to compare the outcomes of modified triangular neurovascular unilateral advancement flap and digital artery dorsal perforator flap in the treatment of this injury.

METHODS

From May 2018 to May 2022, 70 patients with medium-sized volar soft tissue defects were enrolled. The patients were divided into two groups based on the flap type: modified triangular neurovascular unilateral advancement flap (Group A) and digital artery dorsal perforator flap (Group B). The debridement times, defect size, operation time, and flap survival rate were recorded. At follow-up, hand function, aesthetics, and complications were evaluated. Function was evaluated using the TAM score. The aesthetics of the reconstructed and donor sites were assessed using the vancouver scar scale (VSS). The static two-point discrimination of the finger pulp served as a measure of tactile agnosia.

RESULTS

A total of 10 patients were lost to follow-up for various reasons, resulting in 30 cases remaining in each group. The general information of the two groups showed no significant differences in age, sex, injury side, cause of injury, time from injury to surgery, and operation time (P > 0.05). Additionally, the debridement times and size of the defect were similar between the groups (P > 0.05). However, the operation time was significantly shorter in Group A compared to Group B (P = 0.001). With regard to complications, there was no significant difference between them. At one-month follow-up, TAM scores indicated that Group B performed significantly better than Group A. However, at the final follow-up period, there was no significant difference in TAM scores between the two groups. When considering the VSS, significant differences were observed between the two groups in both the reconstructed site and donor site.

CONCLUSION

Both flaps can effectively repair medium-sized fingertip defects. Furthermore, the modified triangular neurovascular unilateral advancement flap offers anatomical reconstruction possibilities, ensuring satisfactory sensation and cosmetic contour.

Evidence-based postoperative replantation protocols

Postoperative care is essential to upper extremity replantation success and includes careful and frequent monitoring of the replanted part. During this period, pharmacologic agents such as antithrombotic and anticoagulants may prevent complications such as arterial thrombosis and venous congestion. Dressings and therapy can also impact short- and long-term outcomes following replantation. This article reviews the literature to provide guidance for postoperative protocols following upper extremity replantation.

From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery

Thromboembolism is a feared complication in plastic surgery and is linked to higher rates of morbidity and mortality. Despite extensive research, there is a lack of consistency between recommendations and clinical protocols to be implemented pre and post-surgery to reduce the incidence of thromboembolism. A systematic literature review was conducted using Pubmed and Scopus databases to determine the risk factors, screening methods, and existing treatment models for thromboembolism prevention. Articles in non-English languages were excluded. Analysis indicated that predominant risk factors include age (>35), elevated body mass index, coagulation disorders, smoking, estrogen therapies, genetic predisposition, vascular endothelium damage, stasis, and use of general anesthesia in patients with a history of cancer. Implementation of a proper prophylactic protocol is dependent on understanding the interplay between the aforementioned risk factors and the utilization of well-defined, evidence-based guidelines, such as the 2005 Caprini Risk Assessment Model and ultrasound surveillance. The literature review revealed that mechanical prophylaxis is the primary prevention method, followed by thromboprophylaxis for patients with higher Caprini scores. Plastic surgeons often underestimate the present risk stratification tools available for the prophylactic intervention of thromboembolism due to the fear of bleeding or hematoma complications postoperatively. In summary, this literature review emphasizes the importance of plastic surgeons selecting protocols that is inclusive of the patient's risk profile to yield a reduced risk of thromboembolism.

The Role of Intravenous Heparin Following Digital Replantation: A Retrospective Cohort Study on 1,155 Digits

PURPOSE

The purpose of this study was to determine if the use of postoperative therapeutic dose intravenous heparin (POTDIVH) was indicated in digital replantation and revascularization by assessing digit survival and complications associated with heparin.

METHODS

All patients with amputation distal to the carpal tunnel treated at our center from 2004 to 2020 were included for chart review. Digit survival and complication rates were compared between patients who received POTDIVH (group A) and those who did not (group B). Logistic regression analysis and subgroup analysis were conducted.

RESULTS

A total of 795 patients (1,155 digits) were included in this study (248 patients/374 digits in group A and 547 patients/781 digits in group B). The overall revascularization and replantation success rate was 79.9% in the POTDIVH group and 92.8% in the non-POTDIVH group. In our retrospective regression and subgroup analyses, group A demonstrated increased odds of failure compared with group B and was associated with increased bleeding-related complications. Subgroup analyses stratified by the mechanism of injury and vein grafting also showed a significantly decreased survival in the POTDIVH group.

CONCLUSIONS

Our retrospective data seem to indicate that heparin in digit replantation and revascularization appears to have no benefit on digit survival across all subgroups, including crush and avulsion injuries, and is associated with a significantly increased rate of complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Indications, anaesthesia and postoperative protocol for replantation and revascularization in the hand in Nordic countries

In this survey, we compared the current postoperative practices in the largest replantation units of four Nordic countries. The topics included were indication for surgery, anaesthesia, postoperative monitoring, use of antibiotics, anticoagulation and postoperative intravenous fluids, change of dressings, duration of bed rest and hospital stay, hand therapy and follow-up after discharge. Although there were many similarities between the units in the postoperative protocols, we found a large variety of practices. There is no robust evidence to assess or support or reject most of the strategies in postoperative care. The differences in practice warrant prospective studies in order to establish an evidence-based postoperative protocol for replantation surgery.

Use of Doppler ultrasound for early rehabilitation of replanted hand and finger

We read the article entitled "Using Duplex Ultrasound for Recipient Vessel Selection." by Hong JP, et al. with great interest. 1 They reported that Duplex ultrasound (US) could be a reliable tool for reconstructive surgeons to choose recipient vessels. Since the introduction of new types of flaps such as the perforator-to-perforator flap and superthin flap, detailed evaluation of the vascularity of flap and recipient vessels gets more and more essential and various kinds of US could be applied for preoperative evaluation. US examination is safe for patients, easy to perform, doesn't take much time, and detects very small vessels with a diameter of 0.5 mm. 2 Moreover, at our hospital Doppler US could also be applied to prevent vascular spasms during rehabilitation after finger or hand replantation. Many hand surgeons kept Replanted fingers immobilized for 5 to 7 days after fingers and hand replantation. 3 One of the reasons for this immobilization was that movement of the fingers might cause spasms or thrombosis of anastomotic vessels and lead to necrosis of tissues. However, delayed rehabilitation could cause adhesion of flexor and extensor tendon and joint contractures, and lead to impairment of hand function. Therefore, early mobilization of fingers accompanied with assessments of arterial patency is very important in the field of rehabilitation of finger and hand replantation. To overcome this challenge, we used Doppler US for the assessment of the blood flow of anastomotic vessels during the extension and flexion of joints near the anastomotic area.

Distal interphalangeal joint arthrodesis with nonaxial multiple small screws: a biomechanical analysis with axial headless compression screw and clinical result of 15 consecutive cases

Background

The axial headless compression screw (AHCS) technique is a widely used method for distal interphalangeal joint (DIPJ) and thumb IPJ arthrodesis. However, it might not be suitable for cases over 10° flexion of fusion angle and extremely small-sized phalanx. Here, the authors describe the nonaxial multiple small screws (NMSS) technique, compare the mechanical strength of the NMSS technique with the AHCS technique, and suggest clinical outcomes of the NMSS technique.

Methods

DIPJ and thumb IPJ arthrodesis models were simulated in the 4th generation composite bone hand. Fixation with three 1.5 mm cortical screws (NMSS) or one HCS (AHCS) was performed in each pair of the phalanx. The bending stiffness and load to failure were tested in 10 pairs of each specimen, and the torsional stiffness and torque to failure were tested in seven pairs of each specimen. Moreover, 15 consecutive clinical DIPJ and thumb IPJ arthrodesis cases were reviewed retrospectively.

Results

The NMSS specimens showed significantly higher bending load to failure, torsional stiffness, and torque to failure than the AHCS specimens. All 15 arthrodesis cases were united without severe complications. The mean fusion angle was 16.3° for the nine cases of the flexed target position.

Conclusions

The NMSS technique showed biomechanical stability comparable to that of the AHCS technique in DIPJ and thumb IPJ arthrodesis. Thus, the NMSS technique could be used as a feasible option in DIPJ and thumb IPJ arthrodesis, especially when a small finger is indicated and a significant flexion angle is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05473-9.

Microdialysis and CO2 sensors detect pancreatic ischemia in a porcine model

BACKGROUND

Pancreatic transplantation is associated with a high rate of early postoperative graft thrombosis. If a thrombosis is detected in time, a potentially graft-saving intervention can be initiated. Current postoperative monitoring lacks tools for early detection of ischemia. The aim of this study was to investigate if microdialysis and tissue pCO2 sensors detect pancreatic ischemia and whether intraparenchymal and organ surface measurements are comparable.

METHODS

In 8 anaesthetized pigs, pairs of lactate monitoring microdialysis catheters and tissue pCO2 sensors were simultaneously inserted into the parenchyma and attached to the surface of the pancreas. Ischemia was induced by sequential arterial and venous occlusions of 45-minute duration, with two-hour reperfusion after each occlusion. Microdialysate was analyzed every 15 minutes. Tissue pCO2 was measured continuously. We investigated how surface and parenchymal measurements correlated and the capability of lactate and pCO2 to discriminate ischemic from non-ischemic periods.

RESULTS

Ischemia was successfully induced by arterial occlusion in 8 animals and by venous occlusion in 5. During all ischemic episodes, lactate increased with a fold change of 3.2-9.5 (range) in the parenchyma and 1.7-7.6 on the surface. Tissue pCO2 increased with a fold change of 1.6-3.5 in the parenchyma and 1.3-3.0 on the surface. Systemic lactate and pCO2 remained unchanged. The area under curve (AUC) for lactate was 0.97 (95% confidence interval (CI) 0.93-1.00) for parenchymal and 0.90 (0.83-0.97) for surface (p<0.001 for both). For pCO2 the AUC was 0.93 (0.89-0.96) for parenchymal and 0.85 (0.81-0.90) for surface (p<0.001 for both). The median correlation coefficients between parenchyma and surface were 0.90 (interquartile range (IQR) 0.77-0.95) for lactate and 0.93 (0.89-0.97) for pCO2.

CONCLUSIONS

Local organ monitoring with microdialysis and tissue pCO2 sensors detect pancreatic ischemia with adequate correlation between surface and parenchymal measurements. Both techniques and locations seem feasible for further development of clinical pancreas monitoring.

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.