Reverse Distal Transverse Palmar Arch in Distal Digital Replantation

Fingertip Replantation: Surgical Technique, Tips, and Tricks

SUMMARY

Replantation of fingertip amputations restores the original tissue and is the ideal treatment to provide the best aesthetic and functional outcome. However, successful fingertip replantation is considered challenging because it requires supermicrosurgery techniques. This article provides a detailed surgical technique for fingertip replantation and the authors' preferences and recommendations. In the authors' experience, the most important factors for successful fingertip replantation are meticulous vascular dissection, reliable arterial repair, and venous anastomosis to avoid postoperative venous congestion. Proximal arterial dissection until pulsatile bleeding is encountered avoids the zone of vascular injury, and is particularly important in crush or avulsion amputations. Distal arterial dissection is performed until undamaged intima is identified. The authors believe anastomosis to the central artery is reliable even in a Tamai zone II amputation. When an arterial defect is present, the authors recommend using a vein graft to anastomose to the central artery. In addition, the authors highly recommend at least one venous anastomosis to avoid postoperative venous congestion. In Tamai zone I, available veins can be found on the palmar side of the pulp. It is important to search directly below the dermis and remove adipose tissue around the vessels to secure space for anastomosis. The authors consider nerve suture in Tamai zone I and II replantations inessential, because spontaneous sensory recovery can be expected. Postoperative management of venous congestion, spasm in artery, and arterial thrombosis are as important as surgery.

Negative-Pressure Wound Therapy Application in Fingertip Replantations and a Systematic Review

BACKGROUND

Fingertip replantation is technically challenging. Venous congestion is one of the most common causes of replantation failure. Therefore, various venous drainage procedures and salvage techniques have been used in venous congestion. Negative-pressure wound therapy has proven beneficial in limb injuries, yet limited studies of fingertip replantation exist. This study aims to analyze risk factors in fingertip replantation and to evaluate the feasibility and clinical benefits of negative-pressure wound therapy compared with other salvage techniques.

METHODS

From January of 2015 to December of 2019, 27 patients (27 digits) who experienced fingertip amputation over Tamai zone I or II underwent replantation. Salvage negative-pressure wound therapy was applied for venous congestion postoperatively. Replantation data were collected for further analysis.

RESULTS

The overall survival rate of digit replantation with salvage negative-pressure wound therapy was 92.6 percent (25 of 27). The blood transfusion rate was 11.1 percent (three of 27). The average hospitalization time was 8.04 ± 1.43 days and the median duration of negative-pressure wound therapy was 6 days (range, 4 to 8 days; interquartile range, 2 days). There is no significant difference between the survival and failure groups for all risk factors evaluated.

CONCLUSION

Negative-pressure wound therapy is a simple and effective salvage option to relieve venous congestion in fingertip replantation with a satisfactory survival rate, low blood transfusion rate, and short inpatient stay.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

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.

Retrograde versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis

BACKGROUND/OBJECTIVES

The advance in the microvascular surgeries has made successful replantation of amputee fingertip or toe. Anterograde palm venous anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is technically challenging. The retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries. The purposes of the analysis were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgery.

METHODS

Digits were replanted by retrograde palm venous anastomosis (n = 130, RPVA cohort) or anterograde palm venous anastomosis (n = 220, APVA cohort). The data regarding the survival of transplanted tissues, analgesia, 2-points discrimination, and total active movement after 2-years of surgeries were collected and analyzed.

RESULTS

A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (p = 0.004). 2-points discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p = 0.014). The pain was fewer in the RPVA cohort than the APVA cohort (p = 0.041). A total active motion was higher in the RPVA cohort than the APVA cohort (p = 0.025). Anterograde palm venous anastomosis (p = 0.021) were associated with the failure of transplanted digits tissues.

CONCLUSIONS

Retrograde palm venous anastomosis had better functional and therapeutic outcomes than anterograde palm venous anastomosis in avulsion distal fingertip trauma.

LEVEL OF EVIDENCE

III.