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

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.

Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure.Level of evidence: IV.

Hand Bionic Score: a clinical follow-up study of severe hand injuries and development of a recommendation score to supply bionic prosthesis

Background

Severe hand injuries significantly limit function and esthetics of the affected hand due to massive trauma in skeletal and soft tissues. Surgical reconstruction is often unsatisfactory, so bionic prostheses are a consideration. However, assessment of functional outcomes and quality of life after surgical reconstruction to guide clinical decisions immediately after injury and in the course of treatment remain difficult.

Methods

We conducted a prospective follow-up analysis of patients with severe hand injuries during 2016–2018. We retrospectively evaluated initial trauma severity and examined current functional status, quality of life, general function, and satisfaction in everyday situations of the hand. We also developed a novel Hand Bionic Score to guide clinical recommendation for selective amputation and bionic prosthesis supply.

Results

We examined 30 patients with a mean age of 53.8 years and mean initial severity of hand injury (iHISS) of 138.4. Measures indicated moderate quality of life limitations, moderate to severe limitation of overall hand function, and slight to moderate limitation of actual hand strength and function. Mean time to follow-up examination was 3.67 years. Using the measured outcomes, we developed a Hand Bionic Score that showed good ability to differentiate patients based on outcome markers. Appropriate cutoff scores for all measured outcome markers were used to determine Hand Bionic Score classifications to guide clinical recommendation for elective amputation and bionic prosthetic supply: < 10 points, bionic hand supply not recommended; 10–14, bionic supply should be considered; or > 14, bionic supply is recommended.

Conclusions

While iHISS can guide early clinical decisions following severe hand injury, our novel Hand Bionic Score provides orientation for clinical decision-making regarding elective amputation and bionic prosthesis supply later during the course of treatment. The score not only considers hand function but also psychological outcomes and quality of life, which are important considerations for patients with severe hand injuries. However, future randomized multicenter studies are needed to validate Hand Bionic Score before further clinical application.

Level of evidence: Level III, risk/prognostic study.

Cost-effectiveness of Finger Replantation Compared With Revision Amputation

IMPORTANCE

Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown.

OBJECTIVE

To assess the cost-effectiveness of finger replantation compared with revision amputation.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis.

EXPOSURES

Revision amputation or replantation of traumatic finger amputations.

MAIN OUTCOMES AND MEASURES

Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness.

RESULTS

Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns.

CONCLUSIONS AND RELEVANCE

With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.

Functional Outcomes of Secondary Procedures in Upper Extremity Replantation and Revascularization

Introduction

Traumatic amputation of the upper limb has significant associated morbidities and disabilities. After successful replantation surgery, the micro-surgeons’ tasks are far from over. The replanted and revascularized segments have numerous functional restrictions and need various corrective secondary procedures. The aim of our study was to compare the functional results after secondary procedures by administering the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire to patients who had successful upper limb replantation and revascularization.

Materials and methods

This prospective observational study involved 40 patients who had a partial or complete amputation of the upper limb and underwent secondary procedures to correct function after successful replantation and revascularization surgery. The patients’ functional outcomes after various secondary procedures were recorded using the QuickDASH questionnaire.

Results

The mean QuickDASH score for thumb injuries was 42.3 pre-surgery but improved to 29.5 after secondary procedures, which was statistically significant (CI 11.12-14.87, p<0.01). The mean difference in the QuickDASH scores for finger injuries was also statistically significant: 45.5 preoperation and 33.7 postoperation (CI 9.89-13.70, p<0.01). For wrist injuries, the mean QuickDASH score was 52.8 presurgery and was 46.3 postoperatively (CI 1.81-6.58, p=0.0023). The QuickDASH scores of the patients with arm and forearm injuries showed no statistically significant improvement, with a preoperation score of 58.3 declining to 55.2 (p=0.98). The overall replantation and revascularization scores were 49.725 and 41.175 pre and postoperation, respectively (CI 8.35-8.75, p<0.01).

Conclusion

The study finds that the level and mechanism of injury are important predictors of the functional outcomes of the replantation and revascularization of amputated upper-limb appendages. Most replanted and revascularized upper limbs have numerous functional limitations, and achieving good functional results requires one or more secondary procedures, whose type depends on various factors such as the injury type and mechanism. The QuickDASH results for functional outcomes before and after secondary procedures indicate that it is an easy-to-use, reliable, and effective measure of functional outcomes.

Outcomes Following Replantation/Revascularization in the Hand

The variability in reported outcomes and outcome measures used in digit replantation makes it difficult to compare results among studies. This article reviews the principles of measuring functional and patient-reported outcomes after replantation, and describes the recommended instruments to use and ways to report results.