Transfer of vessels in the management of ring avulsion injury. Case report

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.

Ring Avulsion Injuries: A Systematic Review

BACKGROUND

Ring avulsion injuries can range from soft tissue injury to complete amputation. Grading systems have been developed to guide treatment, but there is controversy with high-grade injuries. Traditionally, advanced ring injuries have been treated with completion amputation, but there is evidence that severe ring injuries can be salvaged. The purpose of this systematic review was to pool the current published data on ring injuries.

METHODS

A systematic review of the English literature published from 1980 to 2015 in PubMed and MEDLINE databases was conducted to identify patients who underwent treatment for ring avulsion injuries.

RESULTS

Twenty studies of ring avulsion injuries met the inclusion criteria. There were a total of 572 patients reported with ring avulsion injuries. The Urbaniak class breakdown was class I (54 patients), class II (204 patients), and class III (314 patients). The average total arc of motion (TAM) for patients with a class I injury was 201.25 (n = 40). The average 2-point discrimination was 5.6 (n = 10). The average TAM for patients with a class II injury undergoing microsurgical revascularization was 187.0 (n = 114), and the average 2-point discrimination was 8.3 (n = 40). The average TAM for patients with a class III injury undergoing microsurgical revascularization was 168.2 (n = 170), and the average 2-point discrimination was 10.5 (n = 97).

CONCLUSIONS

Ring avulsion injuries are commonly classified with the Urbaniak class system. Outcomes are superior for class I and II injuries, and there are select class III injuries that can be treated with replantation. Shared decision making with patients is imperative to determine whether replantation is appropriate.

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.

Finger replantations after ring avulsion amputations

The aim of this retrospective cross-sectional study was to assess vascular repair modalities and function in type IV ring finger replantations. Thirty-seven of 43 patients with complete ring avulsion amputations were replanted. After resection of the damaged arterial segments under microscopic magnification the arterial flow pattern was evaluated. The type of repair was chosen according to the adequacy of arterial flow and the defect between the vessels. The methods of bridging the arterial defect consisted of digital artery transfer from adjacent digit in 21 fingers, vein graft interposition in six fingers and end to end anastomosis in ten fingers. Thirty-one of the 37 fingers survived. The failures were due to four arterial and two venous insufficiencies. In our opinion, radical resection of damaged zones of vessels is important to evaluate the proximal flow pattern and decide which treatment modality is necessary for healthy vascular anastomosis.

Limb replantation after avulsion injuries: techniques and tactics for success

Objectives

Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results.

Methods

Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries.

Results

The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction.

Conclusion

Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

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.

Unique superiority of microsurgical repair technique with its functional and aesthetic outcomes in ring avulsion injuries

Although ring avulsion injuries are not common, when they do occur their management is still a challenging problem in reconstructive surgery. In this report, we present our microsurgical experiences with Kay's class III and IV ring avulsion injuries. A total of six patients with ring avulsion injuries were operated on between 2000 and 2004. Three patients were in class III with inadequacy of both arterial and venous circulation, and the remaining three were in class IV. The study consisted of four male and two female patients whose ages ranged from 23 to 43 (mean age 32). Average ischaemic time was 2.2 h (range 1-4 h). The ring finger was involved in all cases and microsurgical repair was performed using axillary block anaesthesia. The bone was detached at the level of the distal interphalangeal joint and soft tissues at the proximal phalanx level with the preserved proximal interphalangeal joint and flexor digitorum superficialis tendon in all cases. Because the zone of injury is more extensive, we debrided the avulsed digital artery over a long distance, and used long interpositional vein grafts radically in all patients. Venous drainage was accomplished by performing at least two vein anastomoses using vein grafts when necessary. Both digital nerves were repaired primarily after debridement. Results indicated that microsurgical repair had a success rate of 100%. The authors conclude that microsurgical reconstruction of ring avulsion injuries with intact proximal interphalangeal joint and flexor digitorum superficialis tendon yields superior results, both functionally and aesthetically, even in complete amputation.