External bleeding versus dermal pocketing for distal digital replantation without venous anastomosis

A case series study in new restorative surgery in thumb amputation: The Adiposofaciocutaneous flap technique for distal thumb amputation replantation

Thumb distal amputation refers to the loss of a portion of the thumb at or near the tip, which can be caused by various injuries such as crush injuries, lacerations, or avulsions. Several surgical methods can be used to repair thumb distal amputations, including composite graft, flap reconstruction, replantation, and amputation revision. In this case report, we describe a successful surgical procedure performed on three healthy men (19, 26, and 44 years old) who suffered a sharp amputation of their left and right hands thumb. In one case initial fixation of the amputated part was performed by a general orthopedic surgeon as a composite graft, two other cases were referred us without any procedure. The procedure involved irrigation and minimal debridement and deepithelializing the amputated part and fixation it with one or two 1.5 mm steinman pins and repairing the nail bed with7/0 absorbable sutures. An adiposofaciocutaneous flap from the index finger was used to cover the pulp of the thumb and the nail bed, while a full-thickness grafts from the same wrist in one case and medial part of ipsilateral arm in others were used to repair the defect on the dorsal side of the index finger. The wound was dressed, and the sutures were removed after two weeks. The base of the flap was detached from the index finger after three weeks, and the kwires were removed after six weeks. The flap and graft were successfully taken, except for a small part of the tip of the thumb. Two years after the operation, in two patients and 3 months in whom was operated recently, all the patient's thumbs had a reasonable shape and length with minimal nail deformity. The use of an index finger based adiposofaciocutaneous flap and full-thickness graft in these cases allowed for successful reconstruction of the thumb and, improving both function and appearance.

Limiting Levels of Fingertip Replantation Without Venous Anastomosis

PURPOSE

This study aimed to compare the success rates of fingertip replantation with and without venous anastomosis.

METHODS

This retrospective study included 132 patients with 148 fingertip injuries who had undergone fingertip replantation (Ishikawa's classification I‒IV) between 2003 and 2020 at our hospital. Among them, 117 and 15 were men and women respectively, and their mean age was 43 years. There were 53, 44, and 51 fingertips with Ishikawa subzone II, III, and IV amputations respectively, and no cases were classified as Ishikawa subzone I. Venous anastomosis was performed on 64 fingertips (group A). This was not possible in the remaining 84 fingertips; thus, an external bleeding method was used (group B). Our external bleeding protocol consisted of 4-hourly skin pricks of the distal pulp with a 23-gauge needle for the first 5 days. The analyses included survival rates, hemoglobin levels (Hb), and blood transfusions administered.

RESULTS

The overall survival rate was 90.5% (134 of 148). In group A, survival was achieved in 92.3%, 100%, and 94.3% of those with subzones II, III, and IV amputations, respectively. In group B, survival was achieved in 100%, 82.1%, and 62.5% of those with subzones II, III, and IV, respectively. Subzone IV in group B showed a significantly lower rate of replantation success. In groups A and B, the preoperative and 7-day postoperative Hb levels were 14.5 g/dL and 14.6 g/dL, and 11.3 g/dL, and 11.6 g/dL, respectively. In addition, blood transfusion was required for five patients (7.9%) in group A and six patients (7.9%) in group B. Thus, the Hb levels and blood transfusion administered were similar between the two groups.

CONCLUSIONS

Subzone IV is an important threshold for artery-only replantation. Furthermore, our external bleeding protocol is a safe and effective method.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of Artery-Only Digit Replantation: A Systematic Review of the Literature

BACKGROUND

Artery-only replantation may be necessary in circumstances when venous repair cannot be performed due to their size or vessel injury. Venous congestion of the replanted part is inevitable. A systematic review was performed to identify techniques for mitigating congestion and analyze the outcomes of those techniques.

METHODS

A comprehensive literature search was performed to identify relevant articles related to artery-only replantation. An initial query identified 1286 unique articles. A total of 55 articles were included in the final review. Included studies were categorized by decongestive technique. Data from each article included the number of patients treated, level of amputation, graft use, anticoagulation or antiplatelet therapy, replant viability, and follow-up duration. Weighted averages were determined from studies that reported five or more digits.

RESULTS

A total of 1498 individual digital replantations were described. Very rarely did studies report artery-only replantation proximal to the distal interphalangeal joint. An overall survival rate of 78.5 percent was found irrespective of technique but was variable based on each particular study. Studies utilizing medicinal leech therapy were more likely to report use of intravenous anticoagulation, whereas surface bleeding techniques were more likely to report use of topical or local anticoagulant.

CONCLUSIONS

Lack of a vein for anastomosis should not be regarded as a contraindication to replantation. These digits instead require a method to establish reliable drainage sufficient to allow for low resistance inflow and maintain a physiologic pressure gradient across capillary beds. The surgeon should select a decongestive technique that best suits the patient and their specific injury.

Pulp De-epithelialization for Venous Outflow Augmentation after Digital Replantation

Traumatic amputation injuries account for a substantial portion of emergency department visits. This includes digital amputations that may be considered for replantation. Following surgery, venous congestion is the most common cause of replant failure. To address this, several methods have been proposed to augment venous outflow. In this article, a simple and straightforward method that can be utilized to establish or augment venous outflow in cases of venous insufficiency is described. This method entails de-epithelization of the replanted digit pulp skin with use of postoperative anticoagulation. The area can be further expanded or stimulated to increase bleeding as needed and is allowed to heal by secondary intention. This method allows for reliable venous outflow with relative ease of implementation.

Fingertip Replantation: Technique Details and Review of the Evidence

Fingertip replantation is technically challenging, but in a motivated patient excellent aesthetic and functional outcomes can be achieved. Fingertip microanatomy by zone is described to facilitate the classification and treatment of these injuries. In this article, we outline our preferred techniques for fingertip replantation and review the current body of evidence surrounding indications, techniques, and outcomes while highlighting opportunities for future study.

Survival and Comparison of External Bleeding Methods in Artery-Only Distal Finger Replantations

PURPOSE

If there are no veins available in a distal amputation, an artery-only replantation is performed, and an external bleeding method is commonly used. We conducted a survival analysis in a large series of artery-only replantations and compared 2 different external bleeding methods in artery-only distal replantations: nail matrix or hyponychial area bleeding and pulp skin area bleeding, which we have called the crater method.

METHODS

Two hundred twenty-eight artery-only distal finger replantations in 199 patients were included in the study. The replanted digits were divided into 2 groups according to the external bleeding methods. One group (n = 94; 41.2%) included the patients in whom the external bleeding was performed using a traditional nail bed incision and the second group (n = 134; 58.8%) included the patients in whom external bleeding was performed using the crater method. The finger survival rates and postoperative circulatory problems were examined. The impact of the injury mechanism, injury level, and external bleeding method on survival were evaluated.

RESULTS

Clinical findings indicating venous insufficiency were observed in 198 (86.8%) replanted fingers. One hundred eighty-two (79.8%) survived, and complete necrosis developed in 46 (20.2%). Viability was maintained in 84% of patients treated with the nail bed bleeding method and 76.9% of patients treated using the crater method. Clean-cut cases had the best results and subzone 3 cases had the worst results.

CONCLUSIONS

The artery-only replantation was associated with a 79.8% survival rate. The method of achieving venous outflow did not appear to have an impact on survival.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.