Replantation

The Mangled Upper Extremity-Algorithm for Salvage: My Workhorse Flaps

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.

Flexor Tendon Continuity and Negative X-ray: The "Combo" Negative Features in Finger Subamputation

Background: The subamputation of fingers with vascular compromise presents a surgical challenge. Although tissue continuity may be considered a favourable prognostic element, in our experience, we noticed that there is not always a direct correlation between soft tissue involvement, radiographic appearance and final outcome. Methods: We included, in our study, all cases of vascular pedicle injury in which finger salvage was attempted with microsurgical revascularisation. Exclusion criteria were: integrity of both vascular pedicles, pedicle lesion without global circulatory compromise and patients treated immediately with amputation. Results: Between May 2018 and July 2023, 27 male patients with finger subamputation injuries were treated at our institution. In 11 cases of injured fingers, the only intact tissue was the flexor digitorum profundus (FDP) or flexor pollicis longus (FPL). Our global failure rate was 49%; whereas, in the subgroup of the 11 cases with continuity of the FDP or FPL, the failure rate rose to 73% and when the fingers showed flexor tendon integrity and radiographs demonstrated minimal bone damage, revascularisation failure was observed in all cases (100%). Conclusions: The results of the study show that subamputations with devascularisation, clinically presented with the combination of flexor tendon as the only element of tissue continuity and dislocation or minimal bone/articular injury, have a worse prognosis because of their trauma mechanism. We propose to add them to the Kay-Adani Classification as a subset of the poorest prognostic injuries group (III), to help surgeons to make decisions about the management of subamputation finger injuries.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions.

MATERIALS AND METHODS

This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained.

RESULTS

This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use.

CONCLUSIONS

ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Distal Forearm Replantation in a Child: A Case Report with a 30-year Follow-up

Background

Amputation in the upper extremities influenced the quality of life a lot adversely. So, replantation was tried in many cases of amputation. Especially, due to good plasticity and healing capacity, replantation in children should be actively attempted. On the contrary, owing to growth potential in children, there are several late complications to happen like shortening and synostosis. There are only a few longterm follow-up reports of paediatric patients after replantation of upper extremities. We report a case of successful distal forearm replantation in a 2-year-old child who sustained a wringer injury by a sawing machine with a follow-up of 30 years.

Case description

A 2-year-old female patient was brought to our institution after a wringer injury to the distal forearm by a sawing machine. She sustained a near-total amputation at the distal forearm level with only a skin tag. Replantation was performed 4 hours after the injury. Radius and ulnar fractures were fixed with Kirschner and roll wires. The radial and ulnar arteries were anastomosed and three veins were anastomosed too. The median, ulnar, and radial nerves were managed by epi-perineurorrhaphy. The muscles were readapted, flexor tendons were performed tenorrhaphy each by each, and extensor tendons were performed grouping tenorrhaphy. Ten years after the replantation, a supination motion block was developed but successfully managed.

Conclusion

Replantation of upper limbs in children is an eceedingly worthwhile procedure. Though due to growth potential several complications were developed unlikely in adults. But those can be improved with additional procedures. Good plasticity and healing capacity of children make good functional outcomes in long-term follow-up. So, replantation of upper limbs in children should essentially be considered and aggressively performed.

How to cite this article

Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Followup. Strategies Trauma Limb Reconstr 2021;16(3):179–183.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Replantation of amputation at the wrist: challenges of management in sub-Saharan Africa

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.

Clinical Outcomes in Ring Avulsion Fingers and Systematic Review of the Literature

Ring avulsions continue to be a challenge in reconstructive surgery. We conducted a retrospective study and reviewed all Urbaniak-Kay type IV degloving injuries replanted at our institution between 2011 and 2018. A systematic review of the literature was also conducted to assess the survival rates, functional, and sensibility outcomes. The results of our systematic review outline a survival rate of 79.50% (101/127). With 1 artery being repaired, 79% of the fingers survived, a value that increased to 87.50% when 2 arteries were anastomosed (P = 0.484). Statistically significant differences (P < 0.001) were found when comparing the survival rates of the fingers with 2 or more veins repaired (87%) with those with only 1 vein anastomosed (51.90%). In terms of nerve reconstruction, there was a significant difference (P < 0.001) with the 2-point discrimination test in favor of the reconstructed group when nerve reparation was done (10.80 mm ± 2.95 mm) versus when digital nerves were not repaired (15.25 mm ± 0.50 mm). Fingers after secondary procedures did not obtain better mobility. The mean total active motion in nonreoperated fingers was 221 degrees (195-270 degrees), whereas the total active motion in the cases who received secondary surgeries was 152 degrees (110-195 degrees), with statistically significant differences (P = 0.02). Therefore, we recommend attempting replantation of degloved fingers. All efforts must be done to carry out 2 vein anastomoses, and our results strongly recommend attempting at least some kind of nerve reconstruction. Secondary surgeries should be reserved for selected cases only, because of the extensive scarring in this kind of injuries. Early mobilization protocols must be encouraged to achieve a good functional result.

Tendon function after replantation of complete thumb avulsion amputations

BACKGROUND

Tendon avulsion at the musculotendinous junction caused by digit avulsion amputation is still a challenging problem. We aimed to compare the tendon functional outcomes of two repair methods for tendon avulsion rupture at the musculotendinous junction in patients with complete thumb avulsion amputations.

METHODS

A retrospective study was performed to evaluate patients with complete thumb avulsion amputations whose tendons were repaired through reattachment to muscle (group I) or tendon transfer (group II) between July 2008 and October 2019. Outcomes of total range of motion, pinch strength, grip strength and reoperation rate were included.

RESULTS

A total of 23 patients met the inclusion criteria, with a mean follow-up of 16.6 ± 4.2 months. Total active range of motion was comparable between groups I and II (P = 0.095). Pinch strength of group I was lower than group II (P = 0.001). The result of grip strength was found to be similar (P = 0.075). In addition, there was no significant difference in reoperation rate (P > 0.05).

CONCLUSION

Tendon transfer can attain higher pinch strength for replantation of thumb avulsion amputations. It is recommended for patients with jobs that demand higher strength.

Major Upper Limb Replantation: An Account of Patient Tenacity

Supplemental Digital Content is available in the text.

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.

Arm reconstruction

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Comparison of Single-Dose Infraclavicular Brachial Plexus Block and Continuous Infraclavicular Brachial Plexus Block Applications in the Treatment of Finger Amputations

Introduction The aim of this study is to evaluate the replantation success of single-dose infraclavicular brachial plexus block and continuous infraclavicular brachial plexus block (CIBPB) applied with bupivacaine and prilocaine in patients with finger amputation. Materials and Methods This prospective randomized nonblinded study was conducted between January 2012 and September 2017, and 47 patients, all male, were included. Patients were randomly separated into two groups as 23 patients CIBPB applied group (group A) and 24 patients single-dose infraclavicular block applied group (group B). In group B, after the effect of block is ceased, intravenous patient-controlled (PC) opioid analgesia and, where necessary, 1 mg/kg meperidine and 75 mg diclofenac sodium intramuscularly were alternately administered at 4 to 6 hours intervals. The average ages were 30.7 ± 10.06 and 29 ± 9.08, respectively. Replantations were applied as being two venous anastomoses to one artery, where possible. Hourly skin temperatures of fingers of the hands in which both surgeries applied and no surgery applied in both the groups were measured for 3 days with an infrared thermometer. Also, Numerical Rating Scale (NRS) evaluations in both the groups were performed in 3-hour intervals for 3 days. Results Replantations were successful in 22 patients in whom CIBPB was applied (95.6%) and in 19 patients in whom single block was applied (79.16%). Regarding the finger temperatures, no significant difference was detected between both the groups for 3 days following the operation. No significant difference was found between the length of hospital stays (4.73 ± 2.21-4.71 ± 1.53) and duration of operations (2.90 ± 0.73-2.83 ± 0.58). There was no significant difference between the temperature values of both the groups. NRS scores of group A were statistically significantly lower than those of group B. Conclusion In this prospective randomized study performed by using bupivacaine and prilocaine on 24 patients, the success rate of finger replantations with CIBPB was found to be higher. CIBPB is a very beneficial method that should be taken in consideration in hand injuries with anastomosis and high risk of vasospasm. Further studies with more number of cases would help reduce the question marks related with the success of this method.

Replantation of Nine Fingers in a Patient: A case report

Amputation of multiple fingers of both hands is a rare and serious injury. We report a case of a 41-year-old male patient who presented to Khoula Hospital, Muscat, Oman, in 2015 with the amputation of nine fingers due to a workplace injury. With two teams working in tandem, all the amputated fingers were re-attached. A total of seven fingers survived and the patient regained reasonable functionality of his hands. To the best of the authors' knowledge, this is the first case of several finger amputations in Oman.

Self-amputation of the Upper Extremity: A Case Report and Review of the Literature

Indications for upper-extremity replantation include wrist-level and wrist-proximal amputations, due to the devastating loss of function incurred from these severe injuries. Decisions regarding replantation must be made expeditiously at these proximal levels in an effort to minimize ischemia time. This decision-making process becomes more complicated when a patient presents following intentional self-amputation of an extremity, especially in the setting of an associated mood disorder, psychiatric illness, and/or frank psychosis. A case report is presented involving a 28-year-old right-hand dominant male with untreated depression and recent suicidal ideation who sustained a complete left forearm amputation (distal-third forearm-level) from a self-inflicted circular saw injury. We conducted a PubMed literature search of other reported cases of intentional self-amputations of the hand and upper extremity. The patient underwent replantation of the left upper extremity. At six years postoperatively, the patient was extremely satisfied with the appearance and function of the replanted extremity. Dash score was 5.8 with a Chen Grade 1 (excellent) functional recovery. A literature search identified 16 cases of self-inflicted upper extremity amputation. One patient died at the scene. 87% (13/15) of patients presenting to the hospital were diagnosed with a psychiatric disorder (depression n = 6, bipolar n = 2, and schizophrenia n = 5). 67% (10/15) of these patients were also diagnosed with psychosis. Ten patients underwent replantation (nine at hand/wrist level and one at forearm level), all of which were viable postoperatively. Detailed functional outcome data were not reported in any of the cases. Four patients (40%) were pleased or satisfied with the outcome, but subjective outcomes were not reported for the other six patients. Intentional self-amputation of the hand/upper extremity is an extreme and uncommon act, often presenting with complex psychiatric issues. Although replantation is technically feasible in this patient population, long-term subjective and objective functional outcomes are largely unknown. Future study of this unique group of patients is needed to better assess patient-reported outcomes and functional outcomes of replantation, which could help guide decision making at the time of initial injury. 

Replantation and revascularization of amputated upper limb appendages outcome and predicting the factors influencing the success rates of these procedures in a tertiary hospital: An 8-year retrospective, cross-sectional study

PURPOSE

Worldwide advances in microsurgery have made salvaging of amputated hand via replantation and revascularization common procedures. The present study examines the outcome of these procedures in a tertiary hospital in Malaysia.

METHODS

Patients with hand amputation who underwent replantation or revascularization from 2005 to 2012 were identified and reviewed for patient characteristics, amputation characteristics and survival rates. Successfully treated patients were interviewed to assess the functional outcome using Quick Disability of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Statistical analysis was performed to evaluate outcome and elicit predictive factors.

RESULTS

Fifty-five patients were enrolled: 37 (67.3%) underwent replantation and 18 (32.7%) underwent revascularization. The overall success rate of 78% ( n = 43) was within the range of previously reported data (61.6% to 96.0%). Ischaemic time <6 h provided significantly better survival rates ( p < 0.05). Functional outcomes were successfully assessed in 34 patients (79%), at a mean follow-up of 40 months (range 11-93 months). The overall Quick-DASH and MHQ scores were 42.82 ± 23.69 and 60.94 ± 12.82, respectively. No previous reports of functional outcome were available for comparison. Both Quick-DASH ( p = 0.001) and MHQ scores ( p < 0.001) were significantly higher for finger injuries, followed by thumb, wrist and palm injuries.

CONCLUSION

Ischaemic time and level of injury are important predictors of success rate of replantation and revascularization of amputated upper limb appendages.

Flap Coverage of Dysvascular Digits Including Venous Flow-Through Flaps

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.

Recent Topics on Fingertip Replantations Under Digital Block

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

Transplantation of a Free Vascularized Joint Flap from the Second Toe for the Acute Reconstruction of Defects in the Thumb and other Fingers

BACKGROUND

This study aimed to evaluate a novel surgical method for the acute reconstruction of defects in the thumb and other fingers by transplanting a free vascularized joint flap from the second toe and to determine its clinical curative effects.

MATERIALS AND METHODS

A free vascularized joint flap from the second toe was transplanted to reconstruct a complete defect of the thumb and other fingers accompanied by the loss of the proximal finger in 10 patients. Of these patients, three had their thumbs reconstructed with a free vascularized joint flap from the second toe and with the proximal interphalangeal joint flap, one had a thumb reconstructed with a free vascularized joint flap from the second toe, and six had their finger defects reconstructed with the proximal interphalangeal joint flap. The toes of the metatarsophalangeal joint were amputated at the foot donor site. All patients underwent one-stage emergency surgery.

RESULTS

The composite tissue flaps, replanted thumbs, and fingers survived well in all 10 cases. Follow-up visits were conducted for 6-28 months, with an average of 9 months of follow-up. The transplanted bone joints healed over a period of 6-16 weeks. Bone nonunions and refractures did not occur, and the walking function of the foot donor site was not visibly affected.

CONCLUSION

A free vascularized joint flap from the second toe can be transplanted to repair defects in the thumb and other fingers. This technique can be applied to recover the appearance and function of fingers.

"Damage Control" Hand Surgery: Evaluation and Emergency Management of the Mangled Hand

Mangled hand injuries are defined as those with significant damage to multiple structures, which may be limb threatening. Historically these injuries resulted in amputation or death, but modern surgical and perioperative advances allow for complex reconstruction and the possibility of a sensate and functional limb. Evaluation begins with surveying for life-threatening injuries followed by a systematic approach to identify injured structures; management begins with preserving all parts, minimizing warm ischemia time, performing débridement, and planning an operative approach to optimize the chance of a functional limb. With careful surgical planning and a well-executed reconstruction, most limbs can be salvaged.

The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Acute Ischemia of the Upper Extremity

Ischemia of the upper extremity is uncommon but can be seen with open or closed trauma. Those dealing with traumatic injury of the upper extremity should be conversant with techniques of vascular surgery and microsurgery to address these injuries when they occur. Closed injury can occur as well, and at times these are best managed nonoperatively. This article discusses the management of both in the acute setting.

Proximal interphalangeal replantation with arthrodesis facilitates favorable esthetics and functional outcome

PURPOSE

Management of finger amputations of the proximal interphalangeal (PIP) joint is still controversial. Regrettably, injured PIP joints seldom regain normal active motion; thus, many investigators recommend revision amputation with skeletal injury at or proximal to the PIP joint. We report the functional outcome of patients with replantation or revascularization following complete or incomplete amputations of the PIP joint.

METHODS

A total of 15 digital replantations or revascularization were performed on 11 patients (9 males and 2 females, age, 26-69 years) with severe finger injuries at the PIP joint at our Medical Center from 2010 through 2012. Seven patients with 10 complete amputations underwent replantations, and 4 with 5 incomplete avulsion amputations underwent revascularization. PIP arthrodesis was performed in all cases. Routine postoperative evaluation was performed in 13 successfully treated patients.

RESULTS

The 13 successfully treated cases were tracked over a follow-up of 12 to 55 months. Arthrodesis of PIP caused significantly lower total active range of motion (TAM; 85-120°). The mean DASH score was 37/100 (range: 10-64 points). Although mobility is poorer in PIP replantations, adequate PIP joint fixation improves DASH score and hand function.

CONCLUSIONS

PIP replantation along with arthrodesis at a functional position for a finger amputation should be performed when the patient wishes to undergo replantation, which facilitates patient satisfaction.

[Estimation of regional blood flow in reimplanted segments of upper extremity]

AIM

To examine the state of regional circulation in replanted segment of upper limb and hand, to determine diagnostic and prognostic value of radionuclide scintigraphy.

MATERIAL AND METHODS

The study included 26 patients who underwent replantation of upper extremity segments. The control group included 12 patients who underwent autologous transplantation of toes on hand. All patients underwent isotope scintigraphy, ultrasound Doppler and pulse oximetry. Groups were comparable by gender, age, severity of injury.

RESULTS

Depending on postoperative course two groups were determined: with favorable (27 patients) and complicated postoperative period (11 patients). Two types of regional circulation were identified according to dynamic scintigraphy: prevalence of blood flow in operated limb (type 1); prevalence of blood flow in healthy limb, or equal volumetric blood flow in operated and healthy limbs (type 2). Favorable early postoperative period was associated with prevalence of blood flow in operated limb. Only in 2 (7.7%) patients patients in this group acute arterial thrombosis was diagnosed. At the same time thrombosis of microanastomosis occurred in 45.4% of cases in the second group what is 5.5 times higher than in the first group.

CONCLUSION

Significant prevalence of blood flow in operated limb is favorable prognostic sign of the early postoperative period. On the other hand the identity of blood flow or prevalence of such in healthy limb predispose to acute vascular complications in replantate or autoplantate. Radionuclide scintigraphy provides detailed assessment of regional blood flow in operated limb. However clinical monitoring has leading role in diagnosis of acute circulatory disorders in replantate or autoplantate.

Replantation: current concepts and outcomes

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.

Technical considerations and outcomes in penile replantation

Penile amputations are uncommon injuries, therefore, the management and outcome of these patients have been compiled from solitary case studies or short reviews. Accidental trauma during circumcision, injury inflicted by a partner following marital discord, and genital self-mutilation observed in patients with deep psychosis, account for a majority of the presentations. Initially, patients with total penile amputations were managed by resuturing the penile structures without repairing the vessels. A high incidence of skin and glans necrosis, urethral strictures, and a failure of sensory recovery were observed, though the penile shaft sometimes survived. Presently, microsurgical replantation has markedly improved the results, though issues of skin loss and urethral stricture still persist. A series of three patients with penile amputation is presented (complete = 2, partial = 1); the technical considerations and outcomes are discussed.

Modified Sauvé-Kapandji procedure for restoration of forearm rotation in devascularized hands

INTRODUCTION

The purpose of this study is to evaluate the clinical outcomes in patients with forearm rotation limitation after successful wrist-level revascularization who underwent a modified Sauvé-Kapandji (S-K) procedure.

METHODS

This was a retrospective review of the clinical records of nine patients (three women, six men) after successful wrist-level revascularization who underwent late restoration of forearm rotation. All patients were evaluated using a Mayo Modified Wrist Score. The mean patient age was 35 (range 19-45) years. Mean time to reconstruction was 2.5 (range 0.5-4) years.

RESULTS

Mean postoperative pronation was 74°; mean postoperative supination was 80°. Overall results were excellent/good in seven patients, fair in one, and poor in one. No bone bridge was formed between the pseudarthrosis in any patient. Two patients had neurapraxia. Moderate pain and snapping occurred in one patient during movement at the ulnar amputation site.

CONCLUSION

This modification of the S-K procedure can restore rotation of the forearm after hand revascularization; as such, it provides an alternative salvage procedure.

Fingertip replantation at the eponychial level with venous anastomosis: an anatomic study and clinical application

We present an anatomic study of the vein distribution at the eponychial level, in order to standardize outpatient fingertip replantation. The cross sectional anatomy of 100 fingers was studied by dissection following dye injection. The distribution of the veins >0.3 mm was recorded on a pie-chart. Thirty fingers in 27 patients with fingertip amputations at the eponychial level were replanted by anastomosis of the palmar subcutaneous veins, to reconstruct the venous reflux of the amputated digits. The operations were aided by the anatomical study and confirmed that the palmar area is the preferred site for venous anastomosis Following a distal finger amputation at the level of the eponychial fold we propose starting the search for veins between the 3 to 5 o'clock or 7 to 9 o'clock positions, as these are the areas where there are most likely to be suitable veins.

Six years of follow-up after bilateral hand replantation

Replantation is the gold standard surgical treatment of amputations of the upper limb; however, this demanding procedure is not always preformed in bilateral limb amputation. The objective of this study was to analyze, six years after surgery, the sensorimotor recovery of both replanted hands. A 21-year-old patient with bilateral hand amputation was benefited from limb replantation. Surgery included debridement of the amputated hands and recipient's stumps, bone fixation, arterial and venous anastomoses, nerve sutures, tendon sutures and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Sensory and motor evaluation was performed 6 years after replantation. At 6 years, the patient presented a good/satisfactory recovery of range of motion and strength, better at right hand. The patient was able to perform right thumb opposition. Static two-point discrimination was 20mm, sensitivity to pain and thermal stimuli and ability to sweat were present on both hands. Reinnervation was confirmed by electromyography. Functional recovery was higher at the right hand when compared to the left hand. He was highly satisfied with the result of surgery for right hand and fairly satisfied with the result for left hand. He was able to return to a secretary work 16 months after the accident. A proper functional result can be accomplished with bilateral hand replantation.

Results of replantation of 33 ring avulsion amputations

PURPOSE

Despite microsurgical advances, it is still difficult to achieve satisfactory functional results in cases of replantations following complete ring avulsion amputations. Our aim is to report the experience we have collected since the early 1990s in the treatment of this type of injury.

METHODS

We replanted 33 fingers on 33 patients (age, 15-54 y) with complete ring avulsion amputation injuries. Twenty-eight amputations were distal to the insertion of the flexor digitorum superficialis, and 5 were complete degloving injuries with intact tendons. Vascular transpositions and vein grafts were used, and in all cases, only 1 of the digital nerves was repaired.

RESULTS

The 29 successful cases were tracked over an average follow-up of 89 months. The average total active motion of the reconstructed finger was 185°. Sensibility evaluated by static 2-point discrimination varied from 9 to 15 mm and by moving 2-point discrimination from 8 to 15 mm. Five patients complained of cold intolerance.

CONCLUSIONS

Resection of the avulsed digital artery and vein is the most crucial part of the procedure.Vessels reconstruction can be performed using various methods, but vessel transfers from the middle finger appear to be the most reliable solution. The outcome of the cases demonstrates that replantation should be attempted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Defying standard criteria for digital replantation: A case series

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.

Skin graft coverage of critical marginal wounds in microsurgical cases

Skin graft coverage of critical marginal wounds in microsurgical cases is the earliest described method for coverage of exposed vessels, nerves, and other vital structures at the margins of replanted or transplanted tissue. A case of immediate graft coverage of vein and nerve graft repairs in a gunshot wound is presented with a 5-year follow-up demonstrating stable coverage, salvage of the microsurgical reconstruction, and no contracture. Compared to recently described strategies of interval biosynthetic dressings and delayed skin grafting, immediate skin grafts application remains the most effective management of these wounds.

Hand replantation: A rare case report

We report a case of a hand replantation. A 43-year-old male presented with an amputated right hand. After clinical and radiological examination of the amputated hand and the forearm stump, the patient was consented for hand replantation procedure. Both bones of the forearm were fixed using K-wires. Careful dissection, trimming and repair of the tendons, vessels (two arteries and one vein) and nerves was achieved. The patient tolerated the procedure well and 2 months later showed a progressive improvement in motor and sensory functions. We suggest that a single-vein repair is sufficient for a successful hand replantation.

Upper limb replantation

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.

Bilateral V-Y rotation advancement flap for fingertip amputations

BACKGROUND

Fingertip amputation is the most common type of injury in the upper limb. Goals in fingertip amputation reconstruction are covering the defect, establishing maximum tactile gnosis, keeping the length of the finger, protecting the joint function, acquiring a well-padded pulp tissue, providing a bed for growing nail, obtaining a satisfactory cosmetic appearance and allowing the patient to return to work as soon as possible. Adjacent skin and soft tissue are the best covers for fingertip injuries. However, local homodigital flaps lack enough tissue to cover the defect. To solve this problem, we used V-Y rotation advancement flap bilaterally in fingertip amputations which meets all the reconstruction goals. Rotation besides advancement makes this flap more mobile and easier to cover larger defects in all amputation planes.

METHODS

Between 2007 and 2009, we performed bilateral V-Y rotation advancement flap on seven male patients' pulpa (average age, 37.6 years) whose fingertips were not replantable.

RESULTS

Fourteen flaps were made on 7 fingers. There was neither total nor partial flap loss. Patients had neither cold intolerance nor scar hypersensitivity. Stiffness of the PIP joint did not occur. No obvious hooked nail occurred in patients who have remaining nail matrix. Because flaps contain neurovascular bundle, there was no difference in sensation and perfusion between the finger's pre-operative and post-operative status. The result was satisfactory with painless pinching.

CONCLUSION

In addition to the various and versatile fingertip reconstruction methods, we want to present V-Y rotation advancement flap as a quick, reliable and aesthetic method.

Artery only microanastomosis in nose replantation: a report of two cases

The nose is a central, prominent unit of the face. The surgical approach to complete nasal amputations is challenging and an experienced microsurgical team should always attempt microvascular replantation. This one-stage procedure could result in a superior clinical outcome compared to delayed reconstructive procedures. Two successful microvascular replantations of the distal half of the nose were performed. Both amputations were the result of two completely different aetiologies (sharp guillotine-like vs. avulsion trauma). However, we were not able to re-establish the venous drainage, which was managed through medicinal leeching. Both replantations resulted in an aesthetically pleasing result and no additional surgery was needed. A microsurgical replantation attempt should always be attempted in nasal amputations and the inability to perform venous anastomosis should not preclude the replant attempt.

Replantation surgery

The current concepts of replantation surgery, a procedure that has been practiced for half a century, can be discussed in terms of patients' demands and expectations, present indications for the procedure, available evidence that influences decision making, and technical refinements practiced to produce better outcomes.

Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes

PURPOSE

Recent studies presenting functional outcomes after replantation of finger avulsion injuries have challenged the historical practice of performing revision amputation for all complete finger avulsion injuries. The aim of this study is to conduct a systematic review of the English literature of replantation of finger avulsion injuries to provide best evidence of survival rates and functional outcomes.

METHODS

A Medline literature search yielded 1,398 studies, using key words "traumatic amputation" or "replantation", with limitation to humans and finger injuries. Inclusion criteria required that studies meet the following requirements: (1) primary data are presented; (2) the study includes at least 5 cases with either complete or incomplete finger avulsion injuries at or distal to the metacarpophalangeal joint; (3) the study presents survival rates, total active arc of motion (TAM), or static 2-point discrimination (2PD) data; (4) data for incomplete and complete avulsions are reported separately; (5) patients are treated with microvascular revascularization or replantation. Survival rates, TAM, and 2PD data were recorded and a weighted mean of each was calculated.

RESULTS

Thirty-two studies met the inclusion criteria. Of these 32 studies, all reported survival outcomes, 13 studies reported TAM (metacarpophalangeal, proximal interphalangeal, and distal interphalangeal), and 9 studies reported sensibility. The mean survival rate for complete finger and thumb avulsions having replantation was 66% (n = 442). The mean TAM of complete finger avulsions after successful replantation was 174° (n = 75), with a large number of patients in the included studies having arthrodesis of the distal interphalangeal joint. The mean 2PD in patients after replantation was 10 mm (n = 32).

CONCLUSIONS

We found that functional outcomes of sensibility and range of motion after replantation of finger avulsion injuries are better than what is historically cited in the literature. The results of this systematic review challenge the practice of performing routine revision amputation of all complete finger avulsion injuries.