Fingertip replantation: Technical considerations and outcome analysis of 24 consecutive fingertip replantations

Unique Idea: Using the KliniTray "Breast Board" for Immobilization of Digital Amputates During Replantation

The KliniTray "breast board" used by many oncological breast surgeons is an innovative idea to succor microsurgical digital replantation. This piece of sterile equipment is readily available and provides excellent immobilization and retraction of the skin of digital amputates with minimal trauma. The fine metal pins are the key to its efficacy. They provide the flexibility to alter the position of the amputated part and alter the retraction of skin edges as many times as necessary. The construct acts as a tremor-free assistant for a single surgeon to efficiently prepare the amputated part of a digit, saving time including expensive theatre time.

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival

INTRODUCTION

A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates.

METHODS

The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval.

RESULTS

Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05).

DISCUSSION

Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

Distal fingertip replantation: indications, strategy and postoperative management

Distal fingertip replantation is associated with being a technically demanding procedure and dubious outcomes, although it is now performed more frequently across the world. However, the technique and outcomes remain controversial with disagreement among replantation surgeons due to lack of consensus about the indications, intraoperative strategy and postoperative regimes. In this article, we asked six experienced hand surgeons several pertinent questions that every replantation surgeon performing distal fingertip replantation would face in their clinical practice. The article summarizes their responses, which might provide valuable insight to every replantation surgeon in different parts of their career while managing these injuries.

Hand Reconstruction Using Anterolateral Thigh Free Flap by Terminal Perforator-to-Digital Artery Anastomosis: Retrospective Analysis

This study aimed to analyze cases of anterolateral thigh (ALT) free flap used for hand reconstruction with terminal perforator-to-digital artery anastomosis. Patients who underwent ALT free flap placement with terminal perforator-to-digital artery anastomosis for hand reconstruction between January 2011 and August 2021 were included. The number, length, and diameter of the perforators and veins, flap size, and operative time were investigated through a retrospective review of charts and photographs. The occurrences of arterial thrombosis, venous thrombosis, arterial spasm, and flap necrosis were analyzed. In total, 50 patients were included in this study. The mean diameter and length of the perforators were 0.68 mm and 3.25 cm, respectively, and the mean number of veins anastomosed was 1.88, with a mean diameter of 0.54 mm. Complications included four cases of arterial thrombosis, one case of venous thrombosis, seven cases of partial necrosis, and one case of total flap failure. Regression analysis showed that a longer perforator was associated with arterial thrombosis whereas larger flap size and number of anastomosed veins were associated with partial necrosis ( p  < 0.05). The terminal perforator-to-digital artery anastomosis offers advantages in using compact free flaps with short pedicle lengths to cover small hand defects.

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6 months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes-Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3 months) as compared with adult patients (4.1 months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable.Level of evidence: IV.

Variation in Surgeon Proficiency Scores and Association With Digit Replantation Outcomes

IMPORTANCE

Risk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes.

OBJECTIVE

To assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure.

EXPOSURES

Digit replantation and revascularization.

MAIN OUTCOMES AND MEASURES

Digit survival at 1-month follow up (case success) and number of complications.

RESULTS

A total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93.

CONCLUSIONS AND RELEVANCE

Operative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.

The Promising Role of a Superb Microvascular Imaging Technique in the Evaluation of Raynaud's Syndrome in Systemic Sclerosis: Theory and Practical Challenges

In recent years, a novel Doppler ultrasonography (US) modality—superb microvascular imaging (SMI)—has been presented as a reliable method to evaluate small vessel blood flow with minimised motion artefacts. In this review, we present the challenges of incorporating SMI in daily practice with detailed and comparable US images of a fingertip. The main focus of this paper is the discussion of all tested US techniques, artefacts, and practical challenges for evaluating Raynaud’s syndrome in systemic sclerosis. Despite a few reports on SMI use in assessing nailfold capillaries, there is still a need for more evidence of its value and possibilities for its standardisation.

Effects of Standardized Patient-Based Training on Surgical Nurses' Competencies for Managing Hand Injuries

BACKGROUND

The competence of nurses who care for patients with finger replantation is critical for positive patient outcomes. This study sought to identify the effects of standardized patient (SP)-based training on surgical ward nurses' knowledge, clinical performance, and self-efficacy regarding finger replantation.

METHOD

A wait-list control group with a crossover design was used for this study. Nurses were randomly assigned to group A (n = 10) or to the wait-list control group B (n = 10). Training consisted of a lecture, task training, and SP-based training. Knowledge, clinical performance, and self-efficacy data were collected at baseline, after the first intervention, and after 1 month at group crossover and second intervention. Data were analyzed using repeated measures ANOVA.

RESULTS

Nurses demonstrated greater knowledge, better clinical performance, and higher self-efficacy scores after the SP-based training. Following crossover, knowledge, clinical performance, and self-efficacy scores were retained 1 month after the training in group A.

CONCLUSION

SP-based training produced improvement and retention in knowledge, clinical performance, and self-efficacy. [J Contin Educ Nurs. 2020;51(4):189-196.].

A Unique Case of Replantation of Previously Replanted Fingers

Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of “repeat amputation of the replanted finger.” Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be attempted especially in the event of multiple digit amputations.

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

Non-microsurgical Composite Grafting for Acute Management of Fingertip Amputation

Following a fingertip amputation, if vessels are present and of adequate condition, microsurgical replantation is the preferred technique for management. Composite grafting has a limited role in the management of fingertip amputations due to its unreliable nature but can be an option when an amputated fingertip is not replantable and the patient desires restoration of fingertip length and aesthetics. When composite grafting is selected as the treatment of choice for a particular patient, there are methods of optimizing the chances of graft revascularization and survival, including early grafting, graft cooling, and a moist wound healing environment.

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.

Supermicroscopy and arterio-venolization for digit replantation in young children after traumatic amputation: Two case reports

BACKGROUND

To report the application of supermicroscopy combined with arterio-venolization without venous anastomosis for replantation of digits following traumatic amputation in young children.

CASE SUMMARY

In March 2016, we treated two children aged 2 years and 7 years with traumatic digit amputation, no venous anastomosis, and bilateral digital inherent arteries on the palmar side. Supermicroscopy combined with an arteriovenous technique was adopted to improve the replantation surgery. Postoperative management involved auxiliary treatments such as anticoagulation, composure, anti-inflammatory drugs, and insulation. After treatment, the amputated fingers survived completely without major complications, with good recovery.

CONCLUSION

Supermicroscopy combined with arterio-venolization is a safe and effective approach to treat traumatic digit amputation in young children without venous anastomosis.

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.

Arteriography and Histopathology of Vascular Beds in Traumatically Amputated Fingers

BACKGROUND

The success of replantation following traumatic amputation is determined by the quality of the vascular anastomoses. The purpose of this study was to assess the vascularity of injured arteries from traumatically amputated digits using arteriographic and histopathological analysis.

METHODS

25 amputated digits were included in the study. Crush and avulsion injuries were evaluated according to the Venkatramani classification. The amputated arteries were dissected under a microscope, and the arterial route determined with a transducer. Arteriography using fluoroscopy was evaluated by a radiologist. The area thought to be damaged was dissected and 2-mm slices taken for histopathological examination, and scored using the parameters of fibrin accumulation, oedema, separation, and bleeding.

RESULTS

Arterial flow was observed in 6 of 7 in the avulsion group. In the crush group, arterial flow was observed in 11 of 16 cases. On histopathological examination in all cases there were 2 or more findings of either oedema, fibrin formation, bleeding or hernia. These findings were more common in the crush group then the avulsion group.

CONCLUSIONS

The intravascular introduction of radio contrast agents to amputated digit prior to replantation may give further information particularly in avulsion amputations.

Predictors of Digit Survival following Replantation: Quantitative Review and Meta-Analysis

Introduction Microsurgical replantation following digital amputation has variable success rates. Sociodemographic factors and surgery-related variables have been shown to influence survival rates; however, few studies have evaluated these data systematically across a combined dataset. Therefore, the objective of this study was to analyze the current literature to identify the predictors of replant survival. Materials and Methods A literature review was performed using the PubMed/Medline database focused on complete digit amputation/replantation studies. Studies were evaluated for patient and surgery-related variables and their respective effects on survival. Statistical analysis was conducted to identify predictors of survival and derive pooled estimates from the combined dataset. Results Thirty-two studies representing more than 6,000 digit amputation/replantation cases met inclusion/exclusion criteria. Statistical analysis revealed the number of venous anastomosis (0 vs. 1 vs. 2), the number of arterial anastomosis (0 vs. 1 vs. 2), and the mechanism of injury (sharp cut versus blunt cut versus avulsion versus crush) to influence replant survival ( p < 0.05). The authors failed to find a significant association between survival and the following variables: age, sex, zone of injury, digit number, tobacco use, ischemia time, method of preservation, and use of vein graft. Conclusion Patient- and surgery-related variables affect digit survival following replantation. The etiology of injury can help risk-stratify patients and assist in an informed decision making process, whereas surgery-related factors can guide surgeon practice to improve clinical outcomes following replantation.

Microvascular replantation of head and neck amputated parts: A systematic review

BACKGROUND

As opposed to upper and lower extremity amputations representing a considerable volume of admissions, the prowess of microsurgeons is seldom solicited in complex cases of head and neck replantation. Our aim was to determine the rate of successful replantation of craniofacial parts in a systematic review of the literature.

METHODS

We performed a systematic review of English literature using PubMed/MEDLINE for every replantation of a head and neck parts. Articles selected for analysis required to describe microvascular surgical techniques to be considered a replantation. The measured endpoint for a successful replantation was survival at hospital discharge.

RESULTS

From 113 articles from the literature, reported cases of replanted craniofacial parts included 90 scalps, 56 ears, 34 lips, 26 noses, 1 eyebrow, and 1 midface. A significant majority of amputations were described as an avulsion mechanism (78.4%), as opposed to cutting/sharp (17.3%) or crush-type (1.9%). The overall success rate at hospital discharge was 72.1%, with a partial failure at 20.2% and a complete failure at 7.7%.

CONCLUSION

Urgent replantation of head and neck amputated parts allow patients to recover in a timely manner and to decrease the need for secondary reconstructive procedures. The significant rate of success is a strong argument in favor of promoting access to care for replantation of craniofacial parts.

Comprehensive Analysis of Chicken Vessels as Microvascular Anastomosis Training Model

BACKGROUND

Nonliving chickens are commonly used as a microvascular anastomosis training model. However, previous studies have investigated only a few types of vessel, and no study has compared the characteristics of the various vessels. The present study evaluated the anatomic characteristics of various chicken vessels as a training model.

METHODS

Eight vessels-the brachial artery, basilic vein, radial artery, ulnar artery, ischiatic artery and vein, cranial tibial artery, and common dorsal metatarsal artery-were evaluated in 26 fresh chickens and 30 chicken feet for external diameter (ED) and thicknesses of the tunica adventitia and media. The dissection time from skin incision to application of vessel clamps was also measured.

RESULTS

The EDs of the vessels varied. The ischiatic vein had the largest ED of 2.69±0.33 mm, followed by the basilic vein (1.88±0.36 mm), ischiatic artery (1.68±0.24 mm), common dorsal metatarsal artery (1.23±0.23 mm), cranial tibial artery (1.18±0.19 mm), brachial artery (1.08±0.15 mm), ulnar artery (0.82±0.13 mm), and radial artery (0.56±0.12 mm), and the order of size was consistent across all subjects. Thicknesses of the tunica adventitia and media were also diverse, ranging from 74.09±19.91 µm to 158.66±40.25 µm (adventitia) and from 31.2±7.13 µm to 154.15±46.48 µm (media), respectively. Mean dissection time was <3 minutes for all vessels.

CONCLUSIONS

Our results suggest that nonliving chickens can provide various vessels with different anatomic characteristics, which can allow trainees the choice of an appropriate microvascular anastomosis training model depending on their purpose and skillfulness.

Algorithmic surgical enhancement of function after finger revascularisation

Secondary surgical procedures can improve the function of revascularised and replanted digits. We describe the case of a patient who underwent multidigit revascularisation and replantation following a saw injury at flexor tendon Zone II. To achieve maximal functional improvement after finger revascularisation, we performed secondary surgical procedures in an order that was determined by following a reconstructive decision procedure that covered late revascularisation, nerve reconstruction, pedicled vascularised joint transfer, staged flexor tendon reconstruction and skin revision. Performing the procedures in this manner ensured overall safety. The patient's disabilities of the arm, hand and shoulder questionnaire score improved by 45 points, and the patient was able to return to work with an almost complete range of motion.

Pushing the Boundaries of Salvage in Mutilating Upper Limb Injuries: Techniques in Difficult Situations

With the available microsurgical techniques, salvage of the limb can almost always provide a useful upper limb, even in the most complex combined injuries. Having a low threshold for revascularization of doubtfully viable extremities and making full use of the current armamentarium of soft tissue cover techniques, including flow through free flaps, will salvage many limbs. Secondary procedures, including free functioning muscle transfers and toe transfers, further increase the possible functional outcome. Even in the most complex combined injuries, intelligent reconstruction will obtain better outcomes than the best available prosthesis, making the efforts of salvage worthwhile.

Fingertip replantation (zone I) without venous anastomosis: clinical experience and outcome analysis

PURPOSE

The purpose of this study was to report our experience of fingertip replantation without venous anastomosis using alternate method to counter post-operative venous congestion.

METHODS

30 Patients (18 men and 12 women) with 30 fingertip amputations (Tamai zone I) were treated with artery-only anastomosis fingertip replantation between March 2010 and July 2014. Postoperative venous outflow was maintained by allowing bleeding through wound gaps combined with topical (12500u:250mlNS) and systemic (4000 IU SC once daily) heparin. The outcomes of replantation were evaluated using standard evaluating systems.

RESULTS

The average duration of hospital stay was 10 days (range 7-14 days). Twenty-eight (93 %) replanted fingertips survived. Five replanted fingertip experienced postoperative vascular crisis. The estimated post-operative blood loss was about 200-450 ml (mean, 292 ml). Follow-up period ranged from 12 to 24 months (average, 18 months). At final follow-up examinations, the average value of static two point discrimination test was 5.6 mm (range 3-9 mm) and Semmes-Weinstein monofilament test was 3.35 g (range 2.83-4.56 g). The mean range of motion of distal interphalangeal joint was 65.2° (range 0-90°) and all patients returned to their work within 7-18 weeks (average, 11 weeks).

CONCLUSION

Artery-only fingertip replantation can provide satisfactory cosmetic and functional results. Adequate venous outflow can be obtained by allowing minimal external bleeding through wound gaps combined with topical and systemic heparin.

Looking Ahead to Engineering Epimorphic Regeneration of a Human Digit or Limb

Approximately 2 million people have had limb amputations in the United States due to disease or injury, with more than 185,000 new amputations every year. The ability to promote epimorphic regeneration, or the regrowth of a biologically based digit or limb, would radically change the prognosis for amputees. This ambitious goal includes the regrowth of a large number of tissues that need to be properly assembled and patterned to create a fully functional structure. We have yet to even identify, let alone address, all the obstacles along the extended progression that limit epimorphic regeneration in humans. This review aims to present introductory fundamentals in epimorphic regeneration to facilitate design and conduct of research from a tissue engineering and regenerative medicine perspective. We describe the clinical scenario of human digit healing, featuring published reports of regenerative potential. We then broadly delineate the processes of epimorphic regeneration in nonmammalian systems and describe a few mammalian regeneration models. We give particular focus to the murine digit tip, which allows for comparative studies of regeneration-competent and regeneration-incompetent outcomes in the same animal. Finally, we describe a few forward-thinking opportunities for promoting epimorphic regeneration in humans.

A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps

BACKGROUND

Fingertip reconstruction using reverse-flow homodigital island flaps has been very popular over the years. However, the outcomes of reconstruction have not been clearly understood. In these circumstances, a systematic review of available literature is warranted.

OBJECTIVE

To assess the outcomes and complications of fingertip reconstruction using reverse-flow homodigital island flaps. To justify the usage of reverse-flow homodigital island flaps for fingertip reconstruction.

SEARCH METHODS

A PubMed [MEDLINE] electronic database was searched (1985 to 15 April 2015).

SELECTION/ELIGIBILITY CRITERIA

Retrospective case series that met the following criteria were included: (1) Study reported primary data; (2) Study included at least five cases of fingertip defects treated using reverse-flow homodigital island flaps; (3) Study reported outcomes and complications of fingertip reconstruction, either primary or delayed, using reverse-flow homodigital island flaps; (4) The study presented at least one of the following functional outcomes: Static two-point discrimination, return-to-work time, range of motion of distal interphalangeal joints; (5) The study presented at least one complication.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results, and two other review authors analyzed the data and resolved disagreements. The following endpoints were analyzed: survival rate of the flap, sensibility, and functional outcomes and complications.

MAIN RESULT

Eight studies were included in this review. The included studies were published between 1995 and 2014, and a total of 207 patients with 230 fingertip defects were reported. The overall survival rate of the flap was 98 % (including partial survival). The mean static two-point discrimination (2PD) was 7.2 mm. The average range of motion of the DIP joint was 63°. The average return-to-work time was 7 weeks after injury. On average, 2 % of the patient had complete flap necrosis, 5 % had partial flap necrosis, 4 % developed venous congestion, 4 % developed flexion contracture, and 12 % experienced mild-to-moderate cold intolerance.

AUTHORS' CONCLUSIONS

Survival of reconstructed fingertips (98 %) is better with reverse-flow homodigital island flaps than fingertip replantation (86 %). The sensibility outcome using sensate flaps (mean s2PD = 7.2 mm) is similar to the sensibility outcome following replantation (mean s2PD = 7 mm). The common complications include cold intolerance, venous congestion, and flexion contracture. Therefore, reverse-flow homodigital island flaps may not be the ideal choice but are a very reliable alternative for fingertip reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Effects of non-surgical factors on digital replantation survival rate: a meta-analysis

This study aimed to evaluate the risk factors affecting survival rate of digital replantation by a meta-analysis. A computer retrieval of MEDLINE, OVID, EMBASE, and CNKI databases was conducted to identify citations for digital replantation with digit or finger or thumb or digital or fingertip and replantation as keywords. RevMan 5.2 software was used to calculate the pooled odds ratios. In total, there were 4678 amputated digits in 2641 patients. Gender and ischemia time had no significant influence on the survival rate of amputation replantation (P > 0.05). Age, injured hand, injury type, zone, and the method of preservation the amputated digit significantly influence the survival rate of digital replantation (P < 0.05). Children, right hand, crush, or avulsion and little finger are the risk factors that adversely affect the outcome.

THE LEVEL OF EVIDENCE

Level 5*.

Injuries to appendage extremities and digit tips: A clinical and cellular update

BACKGROUND

The regrowth of amputated appendage extremities and the distal tips of digits represent models of tissue regeneration in multiple vertebrate taxa. In humans, digit tip injuries, including traumatic amputation and crush injuries, are among the most common type of injury to the human hand. Despite clinical reports demonstrating natural regeneration of appendages in lower vertebrates and human digits, current treatment options are suboptimal, and are complicated by the anatomical complexities and functions of the different tissues within the digits.

RESULTS

In light of these challenges, we focus on recent advancements in understanding appendage regeneration from model organisms. We pay special attention to the cellular programs underlying appendage regeneration, where cumulative data from salamanders, fish, frogs, and mice indicate that regeneration occurs by the actions of lineage-restricted precursors. We focus on pathologic states and the interdependency that exists, in both humans and animal models, between the nail organ and the peripheral nerves for successful regeneration.

CONCLUSIONS

The increased understanding of regeneration in animal models may open new opportunities for basic and translational research aimed at understanding the mechanisms that support limb regeneration, as well as amelioration of limb abnormalities and pathologies.

Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations

BACKGROUND

The fingertip is the most frequently injured and amputated segment of the hand. There are controversies about defining clear indications for microsurgical replantation. Many classification systems have been proposed to solve this problem. No previous study has simultaneously correlated different classification systems with replant survival rate. The aim of the study is to compare the outcomes of fingertip replantations according to Tamai and Yamano classifications.

MATERIALS AND METHODS

34 consecutive patients who underwent fingertip replantation between 2007 and 2014 were retrospectively reviewed with respect to the Tamai and Yamano classifications. The medical charts from record room were reviewed. The mean age of the patients was 36.2 years. There were 30 men and 4 women. All the injuries were complete amputations. Of the 34 fingertip amputations, 19 were in Tamai zone 2 and 15 were in Tamai zone 1. When all the amputations were grouped in reference to the Yamano classification, 6 were type 1 guillotine, 8 were type 2 crush and 20 were type 3 crush avulsions.

RESULTS

Of the 34 fingertips, 26 (76.4%) survived. Ten (66.6%) of 15 digits replanted in Tamai zone 1 and 16 (84.2%) of 19 digits replanted in Tamai zone 2 survived. There were no replantation failures in Yamano type 1 injuries (100%) and only two failed in Yamano type 2 (75%). Replantation was successful in 14 of 20 Yamano type 3 injuries, but six failed (70%). The percentage of success rates was the least in the hybridized groups of Tamai zone 1-Yamano type 2 and Tamai zone 1-Yamano type 3. Although clinically distinct, the survival rates between the groups were not statistically significantly different.

CONCLUSIONS

The level and mechanism of injury play a decisive role in the success of fingertip replantation. Success rate increases in proximal fingertip amputations without crush injury.

Composite grafting of a distal thumb amputation: a case report and review of literature

OBJECTIVE

We report a case in which an avulsion-amputation of the thumb proximal to the lunula was repaired by reattaching the amputated segment as a composite graft. The graft demonstrated complete survival with only a minimal sacrifice in length.

METHODS

A 23-year-old man presented 4 hours after an avulsion injury of the thumb with associated distal and proximal phalanx fractures. The amputated segment included the sterile and germinal matrix. He underwent defatting and composite grafting of the amputated segment followed by K-wire fixation of his proximal phalanx fracture.

RESULTS

In his 1-week follow-up, the patient's composite graft-including his nail bed-demonstrated complete survival. At one month, the composite graft maintained stable soft tissue coverage and showed signs of nail plate regrowth. Four months after repair, he was able to return to light duty and was advanced to full duty within 5 months. He continued to report gradually improving hypersensitivity at the margins of the graft and stiffness of the interphalangeal joint. At five months he regained full mobility of his carpometacarpal joint. The range of motion of his interphalangeal and metacarpophalangeal joint were 0 to 10 degrees and 0 to 25 degrees, respectively. He was able to oppose his thumb to all 4 digits. Six months after repair, he demonstrated protective sensation of the tip of the thumb.

CONCLUSION

Composite grafting of the thumb, even in less than ideal cases, can still provide useful length for function as a opposable post and can be considered in reconstruction of thumb amputations at or proximal to the lunula.

Nonsurgical factors of digital replantation and survival rate: A metaanalysis

The aim of this metaanalysis was to evaluate the association between nonsurgical factors and survival rate of digital replantation. A computer search of MEDLINE, OVID, EMBASE and CNKI databases was conducted to identify literatures for digital replantation, with the keywords of "digit," "finger" and "replantation" from their inception to June 10, 2014. Based on the inclusion and exclusion criteria, data were extracted independently by two authors using piloted forms. Review Manager 5.2 software was used for data analysis. The effect of some nonsurgical factors (gender, age, amputated finger, injury mechanisms, ischemia time and the way of preservation) on the survival rate of digital replantation was assessed. The metaanalysis result suggested that gender and ischemia time had no significant influence on the survival rate of amputation replantation. However, the survival rate of digital replantation of adults was significantly higher than that of children. The guillotine injury of a finger was easier to replant successfully than the crush and avulsion. The little finger was more difficult for replantation than thumb. Survival rate of fingers stored in low temperature was higher than that in common temperature. The present metaanalysis suggested that age, injury mechanism, amputated finger and the way of preservation were significantly associated with the survival rate of digital replantation.

Management of fingertip amputations

Injuries to the fingertips are among the most common injuries to the hand and result in approximately 4.8 million emergency department visits per year. Most injuries are lacerations or crushes; amputations represent a small but complex spectrum of injury. Treatments available cover a broad range of techniques with no single recommended reference standard for treatment. Although there is no consensus on how these injuries should be treated, the goals of treatment should include minimization of pain, optimization of healing time, preservation of sensibility and length, prevention of painful neuromas, avoidance or limiting of nail deformity, minimization of time lost from work, and provision of an acceptable cosmetic appearance. In this review we present a variety of options in caring for these injuries to help achieve these goals, and the available data that support the various treatment plans.

Microsurgery in the urgent and emergent management of the hand

Appropriate use of microsurgical techniques in the emergency management of injured hands increases the salvage rate of complex upper limb injuries. Over time, the indications for replantation, both major and minor, have expanded and techniques refined to get better functional outcomes. The wide choice of free flaps available has made primary reconstruction possible to obtain a good functional and aesthetic outcome. The benefits microsurgery offers in the emergent management of the injured hand are now firmly established. The challenge is to create and maintain centers which can provide around-the-clock, high quality microsurgery services. The issues of adequate training opportunities, obtaining adequate work load to maintain high skill levels, attracting talent into the field are the challenges faced in maintaining high levels of service. In the developing countries, in addition to these issues, increasing the awareness of the potential of microsurgical services among the medical personal and the public has to be addressed.

A systematic review of outcomes of revision amputation treatment for fingertip amputations

PURPOSE

The purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.

METHODS

A MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.

RESULTS

Thirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.

CONCLUSIONS

On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.

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.