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Fijany AJ, Chaker SC, Egozi HP, Hung YC, Hill BJ, Bhandari L, Thayer WP, Lineaweaver WC. Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival. Ann Plast Surg 2024; 92:667-676. [PMID: 38725110 DOI: 10.1097/sap.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
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.
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Affiliation(s)
- Arman J Fijany
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Hunt TJ, Powlan FJ, Renfro KN, Polmear M, Macias RA, Dunn JC, Wells ME. Common Finger Injuries: Treatment Guidelines for Emergency and Primary Care Providers. Mil Med 2024; 189:988-994. [PMID: 36734106 DOI: 10.1093/milmed/usad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/10/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care. MATERIALS AND METHODS The Armed Forces Health Surveillance Branch operates the Defense Medical Surveillance System, a database that serves as the central repository of medical surveillance data for the armed forces. The Defense Medical Surveillance System was queried for ICD-10 codes associated with finger injuries from 2015 to 2019 among active duty service members across the major branches of the military. RESULTS The most commonly reported finger injuries were open wounds to fingers without damage to nails, metacarpal fractures, phalanx fractures, and finger subluxation/dislocation. Emergency departments were the most commonly reported treatment facility type accounting for 35% of initial finger injuries, followed by 32.2% at orthopedic surgery clinics, 22.2% at family medicine clinics, and 10.8% at urgent care centers. CONCLUSIONS Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.
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Affiliation(s)
- Tyler J Hunt
- Jack Hughston Memorial Hospital, Phenix City, AL 36867, USA
| | - Franklin J Powlan
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Kayleigh N Renfro
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Michael Polmear
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Reuben A Macias
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - John C Dunn
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Matthew E Wells
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
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Hegeman EM, Fisher MWA, Cognetti DJ, Plucknette BF, Alderete JF, Wilson D, Causey MW. Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report. Mil Med 2024; 189:e27-e33. [PMID: 37192200 DOI: 10.1093/milmed/usad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/19/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.
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Affiliation(s)
- Erik M Hegeman
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - Miles W A Fisher
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - Daniel J Cognetti
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - Benjamin F Plucknette
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - Joseph F Alderete
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - David Wilson
- Department of Orthopedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
| | - Marlin Wayne Causey
- Department of Vascular Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78314, USA
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Retrouvey H, Franks A, Dunn T, Novoa K, Ipaktchi K, Lauder A. Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review. J Hand Surg Am 2023; 48:993-1002. [PMID: 37589622 DOI: 10.1016/j.jhsa.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/17/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. METHODS Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. RESULTS Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. CONCLUSIONS The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapy/Prevention/Etiology/Harm V.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO.
| | - Amy Franks
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Thom Dunn
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kenneth Novoa
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
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Retrouvey H, Lauder A, Ipaktchi K. Is self-inflicted amputation to the upper extremity a contraindication to replantation? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03669-w. [PMID: 37581643 DOI: 10.1007/s00590-023-03669-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. METHODS The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. RESULTS The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. CONCLUSION The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA.
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
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Chen Z, Li M, Huang S, Wu G, Zhang Z. Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization? Clin Orthop Relat Res 2023; 481:1583-1594. [PMID: 36795073 PMCID: PMC10344486 DOI: 10.1097/corr.0000000000002578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Ensuring the patency of repaired vessels is pivotal in improving the success rate of digit replantation. There is no consensus on how to best approach postoperative treatment for digit replantation. The influence of postoperative treatment on the risk of failure of revascularization or replantation remains unclear. QUESTIONS/PURPOSES (1) Is there an increased risk of postoperative infection with early discontinuation of antibiotic prophylaxis? (2) How are anxiety and depression affected by a treatment protocol consisting of prolonged antibiotic prophylaxis and administration of antithrombotic and antispasmodic drugs and by the failure of a revascularization or replantation procedure? (3) Are there differences in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins? (4) What factors are associated with failure of revascularization or replantation? METHODS This retrospective study was conducted between July 1, 2018, and March 31, 2022. Initially, 1045 patients were identified. One hundred two patients chose revision of amputation. In all, 556 were excluded because of contraindications. We included all patients in whom the anatomic structures of the amputated part of the digit were well preserved, and those with an ischemia time for the amputated part that did not exceed 6 hours. Patients in good health without any other serious associated injuries or systemic diseases and those without a history of smoking were eligible for inclusion. The patients underwent procedures that were performed or supervised by one of four study surgeons. Patients were treated with antibiotic prophylaxis (1 week); patients treated with antithrombotic and antispasmodic drugs were categorized into the prolonged antibiotic prophylaxis group. The remaining patients treated with antibiotic prophylaxis for less than 48 hours and no antithrombotic and no antispasmodic drugs were categorized into the nonprolonged antibiotic prophylaxis group. Postoperative follow-up was for a minimum of 1 month. Based on the inclusion criteria, 387 participants with 465 digits were selected for an analysis of postoperative infection. Twenty-five participants with a postoperative infection (six digits) and other complications (19 digits) were excluded from the next stage of the study, in which we assessed factors associated with the risk of failure of revascularization or replantation. A total of 362 participants with 440 digits were examined, including the postoperative survival rate, variation in Hospital Anxiety and Depression Scale scores, the association between the survival rate and Hospital Anxiety and Depression Scale scores, and the survival rate based on the number of anastomosed vessels. Postoperative infection was defined as swelling, erythema, pain, purulent discharge, or a positive bacterial culture result. Patients were followed for 1 month. The differences in anxiety and depression scores between the two treatment groups and the differences in anxiety and depression scores based on failure of revascularization or replantation were determined. The difference in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins was assessed. Except for statistically significant variables (injury type and procedure), we thought that the number of arteries, number of veins, Tamai level, treatment protocol, and surgeons would be important. A multivariable logistic regression analysis was used to perform an adjusted analysis of risk factors such as postoperative protocol, injury type, procedure, number of arteries, number of veins, Tamai level, and surgeon. RESULTS Postoperative infection did not appear to increase without prolonged use of antibiotic prophylaxis beyond 48 hours (1% [3 of 327] versus 2% [3 of 138]; OR 2.4 [95% confidence interval (CI) 0.5 to 12.0]; p = 0.37). Intervention with antithrombotic and antispasmodic therapy increased the Hospital Anxiety and Depression Scale scores for anxiety (11.2 ± 3.0 versus 6.7 ± 2.9, mean difference 4.5 [95% CI 4.0 to 5.2]; p < 0.01) and depression (7.9 ± 3.2 versus 5.2 ± 2.7, mean difference 2.7 [95% CI 2.1 to 3.4]; p < 0.01). In the analysis based on the failure of revascularization or replantation, the Hospital Anxiety and Depression Scale scores for anxiety (11.4 ± 4.4 versus 9.7 ± 3.5, mean difference 1.7 [95% CI 0.6 to 2.8]; p < 0.01) and depression (8.5 ± 4.6 versus 7.0 ± 3.1, mean difference 1.5 [95% CI 0.5 to 2.5]; p < 0.01) were higher in the failed revascularization or replantation group than in the successful revascularization or replantation group. There was no increase in the artery-related risk of failure (one versus two anastomosed arteries: 91% versus 89%, OR 1.3 [95% CI 0.6 to 2.6]; p = 0.53). For patients with anastomosed veins, a similar outcome was observed for the two vein-related risk of failure (two versus one anastomosed vein: 90% versus 89%, OR 1.0 [95% CI 0.2 to 3.8]; p = 0.95) and three vein-related risk of failure (three versus one vein anastomosed: 96% versus 89%, OR 0.4 [95% CI 0.1 to 2.4]; p = 0.29). Factors associated with failure of revascularization or replantation included the mechanism of injury (crush: OR 4.2 [95% CI 1.6 to 11.2]; p < 0.01, avulsion: OR 10.2 [95% CI 3.4 to 30.7]; p < 0.01). Revascularization had a lower risk of failure than replantation (OR 0.4 [95% CI 0.2 to 1.0]; p = 0.04). Treatment with a protocol of prolonged antibiotics, antithrombotics, and antispasmodics was not associated with a lower risk of failure (OR 1.2 [95% CI 0.6 to 2.3]; p = 0.63). CONCLUSION With proper wound debridement and patency of repaired vessels, prolonged use of antibiotic prophylaxis and regular antithrombotic and antispasmodic treatment may not be necessary for successful digit replantation. However, it may be associated with higher Hospital Anxiety and Depression Scale scores. Postoperative mental status is associated with digit survival. Well-repaired vessels, instead of the number of anastomosed vessels, could be critical to survival and decrease the influence of risk factors. Further research on consensus guidelines that compare postoperative treatment and the surgeon's level of expertise after digit replantation should be conducted at multiple institutions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Zhiying Chen
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Muwei Li
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Shaogeng Huang
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Gong Wu
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Zhe Zhang
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
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Wong S, Banhidy N, Kanapathy M, Nikkhah D. Outcomes of single digit replantation for amputation proximal to the flexor digitorum superficialis insertion: A systematic review with meta‐analysis. Microsurgery 2022; 43:408-417. [PMID: 36285787 DOI: 10.1002/micr.30980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/02/2022] [Accepted: 10/14/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND A single digit amputated proximal to the flexor digitorum superficialis (FDS) insertion is a relative contraindication to replantation. The aim of this study is to conduct a systematic review on replantation of these injuries to synthesize best available evidence on outcomes. METHODS This review was registered in PROSPERO under registration number CRD42021277305. A MEDLINE, CENTRAL, and EMBASE databases search yielded 1536 studies. Primary clinical studies on single digit replantation and functional outcome with at least 10 cases were included. Data on revision amputation and replantation distal to the FDS were collected as comparators. Data extracted included demographics, type of digit, level of injury, secondary surgeries, duration of sick leave, survival, function, and patient-reported outcomes. All studies were assessed using the Risk of Bias In Non-randomized Studies of Intervention (ROBINS-I) tool and data synthesis was completed using RevMan and Microsoft Excel. RESULTS Six studies representing 182 replanted single digits that were amputated proximal to the FDS insertion were included. The average PIPJ motion of replanted single digits was 50° in those amputated proximal to the FDS insertion compared to 82.5 in those amputated distal to the FDS. The average Michigan Hand Questionnaire (MHQ) score was 84.78 in replantation group versus 76.81 in the amputation group which was statistically significant (p < .00001). Mean Disability of Arm, Shoulder, and Hand Questionnaire (DASH) score was 12 in replantation group compared to 18.5 in amputation group, however this was not statistically significant (p = .17). CONCLUSION Few studies exist on outcomes of single digit replantations proximal to FDS insertion. Although range of motion is inferior in the replant group, this has increased since initial studies were performed, and patient satisfaction and patient reported outcomes are high. This is promising evidence for achieving reasonable outcomes in replantation of single digits amputated proximal to the FDS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shifa Wong
- Department of Plastic and Reconstructive Surgery Royal Free NHS Foundation Trust Hospital London UK
| | - Norbert Banhidy
- Department of Plastic Surgery Royal London Hospital London UK
| | - Muholan Kanapathy
- Department of Plastic and Reconstructive Surgery Royal Free NHS Foundation Trust Hospital London UK
- Division of Surgery & Interventional Science University College London London UK
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery Royal Free NHS Foundation Trust Hospital London UK
- Division of Surgery & Interventional Science University College London London UK
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Catena N, Baldrighi C, Jester A, Soldado F, Farr S. Microsurgery in pediatric upper limb reconstructions: An overview. J Child Orthop 2022; 16:241-255. [PMID: 35992521 PMCID: PMC9382710 DOI: 10.1177/18632521221106390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/13/2022] [Indexed: 02/03/2023] Open
Abstract
The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.
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Affiliation(s)
- Nunzio Catena
- Reconstructive Surgery and Hand Surgery
Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy,Nunzio Catena, Reconstructive Surgery and
Hand Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo G. Gaslini 5, 16121
Genova, Italy.
| | - Carla Baldrighi
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Andrea Jester
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Francisco Soldado
- Pediatric Hand, Nerve and Microsurgery
Institute, Vall d’Hebron Instituto de Oncologia, Barcelona, Spain
| | - Sebastian Farr
- Pediatric Orthopedics and Foot and
Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
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Florczynski M, Khan S, Retrouvey H, Solaja O, Baltzer H. Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study. J Hand Surg Eur Vol 2022; 47:446-452. [PMID: 34384294 DOI: 10.1177/17531934211028155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
| | - Shawn Khan
- Department of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada
| | - Helene Retrouvey
- Department of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada
| | - Ogi Solaja
- Department of Plastic and Reconstructive Surgery, McMaster University, Hamilton, Canada
| | - Heather Baltzer
- Department of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada
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Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Follow-up. Strategies Trauma Limb Reconstr 2022; 16:179-183. [PMID: 35111259 PMCID: PMC8778723 DOI: 10.5005/jp-journals-10080-1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Amputation in the upper extremities influenced the quality of life a lot adversely. So, replantation was tried in many cases of amputation. Especially, due to good plasticity and healing capacity, replantation in children should be actively attempted. On the contrary, owing to growth potential in children, there are several late complications to happen like shortening and synostosis. There are only a few longterm follow-up reports of paediatric patients after replantation of upper extremities. We report a case of successful distal forearm replantation in a 2-year-old child who sustained a wringer injury by a sawing machine with a follow-up of 30 years. Case description A 2-year-old female patient was brought to our institution after a wringer injury to the distal forearm by a sawing machine. She sustained a near-total amputation at the distal forearm level with only a skin tag. Replantation was performed 4 hours after the injury. Radius and ulnar fractures were fixed with Kirschner and roll wires. The radial and ulnar arteries were anastomosed and three veins were anastomosed too. The median, ulnar, and radial nerves were managed by epi-perineurorrhaphy. The muscles were readapted, flexor tendons were performed tenorrhaphy each by each, and extensor tendons were performed grouping tenorrhaphy. Ten years after the replantation, a supination motion block was developed but successfully managed. Conclusion Replantation of upper limbs in children is an eceedingly worthwhile procedure. Though due to growth potential several complications were developed unlikely in adults. But those can be improved with additional procedures. Good plasticity and healing capacity of children make good functional outcomes in long-term follow-up. So, replantation of upper limbs in children should essentially be considered and aggressively performed. How to cite this article Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Followup. Strategies Trauma Limb Reconstr 2021;16(3):179–183.
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Affiliation(s)
- Lee S Hee
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Kim Hyung-Sik
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Lim Hong-Chul
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
- Lim Hong-Chul, Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea, e-mail:
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O'Brien AL, Diaz A, Jefferson RC, Pawlik TM, Moore AM. Geospatial Inefficiencies Associated With Digital Replantations at High-Volume Centers and Optimal Allocation Model for Centralization of Replantations. J Hand Surg Am 2021; 46:731-739.e5. [PMID: 34148787 DOI: 10.1016/j.jhsa.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/02/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Digit replantation can improve dexterity, functionality, patient satisfaction, and pain following amputation, but rates continue to fall nationally. This study aimed to describe the effects of travel time and distance as barriers to high-volume hospitals, identify geospatial inefficiencies in the presentation of patients to replantation care, and provide an optimal allocation model in which cases are redistributed to select centers to reduce geospatial redundancies and optimize outcomes. METHODS We reviewed the California Office of Statewide Health Planning and Development hospital discharge database to identify cases of digital amputation and determine outcomes of replantation. Using residential zip codes, risk- and reliability-adjusted multivariable logistic regression was used to assess the relationship of hospital volume and travel time on replantation success. Geospatial analysis assessed the travel burden of patients as they presented for care, and optimal allocation modeling was used to create a model of centralization. RESULTS We identified 5,503 patients during the study period; 1,060 underwent replantation with an overall success rate of 70.2%. Ninety-three hospitals were found to perform replantations, of which only 4 were identified as high-volume hospitals. Patients routinely traveled farther to reach high-volume hospitals, and decreasing the travel time predicted a 15% increase in odds of replantation at a low-volume center. Twenty-one percent of patients presented to a low-volume hospital when a high-volume hospital was closer, and differencein payer type and race/ethnicity existed between those who presented to the closest center compared to those who bypassed high-volume centers. The optimal allocation modeling allocated all cases into 8 centers, which increased the median annual volume from 1 case to 9.6 cases and decreased patient travel time. CONCLUSIONS Travel burden and geospatial inefficiencies serve as barriers to high-quality and high-volume replantation services. Optimized allocation of digital replantation cases into high-quality centers can decrease travel times, increase annual volumes, and potentially improve replantation outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis III.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Ryan C Jefferson
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Kotamarti VS, Heiman AJ, Camargo L, Ricci JA. Identifying Factors Affecting Outcomes in Scalp Replantation: A Systematic Review of the Literature. J Reconstr Microsurg 2021; 38:56-63. [PMID: 34010964 DOI: 10.1055/s-0041-1729876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Replantation is the ideal treatment in traumatic scalp defects to provide immediate coverage with restoration of hair-bearing skin. However, data are limited to case reports and small case series. Comprehensive analysis of techniques and outcomes is not available. Our aim was to systematically analyze the available literature to better understand management and postoperative outcomes of patients undergoing scalp replantation. METHODS A systematic review of the PubMed, Cochrane, and EBSCO databases was performed in October 2019. Search terms included "replantation," "replant," "revascularized," "revascularization," "avulsion," and "scalp." Only papers reporting microvascular replantation of completely avulsed scalps, including case reports, were included. Review articles, non-English language articles, articles discussing nonreplant coverage, incomplete scalp avulsions, and articles discussing delayed scalp replantation were excluded. Data extracted included demographics, percent of scalp affected, mechanism, operative technique, and postoperative outcomes. Statistical analysis was performed using Mann-Whitney U tests, Kruskal-Wallis, and chi-squared tests. RESULTS From a total of 704 initial results, 61 studies were included for analysis comprising 149 scalps. Complete survival was achieved in 54.7%, partial survival in 38.9%, and failure in 6.7%. Total ischemia time greater than 12 hours was associated with complete replant failure. Arterial anastomoses appeared to protect against complete loss. The number of venous repairs, proportion of venous-to-arterial repairs, use of vein grafts, thromboprophylaxis, or intraoperative complications did not affect outcomes. Patients required significant volumes of blood products, which was associated with partial success. Salvage rate after unplanned return to the operating room was 60.0%. Normal hair growth was achieved in all surviving native scalp tissue. CONCLUSION Scalp replantations, while technically challenging, are the ideal treatment for scalp avulsions. Fortunately, these have high rates of success. And as a focal point of a patient's appearance, this is invaluable in restoration of a sense of normalcy.
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Affiliation(s)
| | - Adee J Heiman
- Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | - Lauren Camargo
- Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, New York
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Abstract
Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.
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Affiliation(s)
- Matthew E Wells
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA.
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, KY 42223, USA
| | - Leon J Nesti
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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14
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Rosa S, Freitas M, Pegado A, Martins D, Moura M. Rehabilitation after forearm/hand replantation. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm.jisprm_59_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Hand replantation using loupe magnification in a resource constrained environment: Case report. JPRAS Open 2020; 27:17-22. [PMID: 33299921 PMCID: PMC7704419 DOI: 10.1016/j.jpra.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/02/2020] [Indexed: 11/21/2022] Open
Abstract
Hand replantation is a common surgical procedure worldwide. However, this practice is underdeveloped in many resource-constrained countries in part due to a lack of surgical microscopes. We present a patient successfully managed using loupe magnification. A 17-year-old patient presented with an amputated right hand secondary to a chaff cutter. After an 8-hour surgical procedure, the amputated hand was successfully re-attached to the stump using loupes. The patient's functional recovery was satisfactory after two years of follow-up. In conclusion, replantation of extremities can be successfully achieved using loupe magnification. Loupes should be considered an alternative to operating microscopes for replantation of extremities especially in resource-constrained countries.
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Abstract
Traumatic digit amputations account for 1% of all trauma admissions and are an important cause of morbidity in young, working people. It is essential that patients are worked up appropriately and referred promptly to a specialist unit for consideration of replantation. This review summarises the acute management of a patient presenting to the emergency department with an amputated digit. It discusses the assessment, initial management in the emergency department, how to make the decision to replant and operative steps.
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Affiliation(s)
- T Welman
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Foundation Trust, London, UK
| | - D Popova
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Foundation Trust, London, UK
| | - S V Vamadeva
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Foundation Trust, London, UK
| | - G S Pahal
- Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Foundation Trust, London, UK
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17
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Riccelli V, Pontell M, Gabrick K, Drolet BC. Outcomes Following Mangling Upper Extremity Trauma. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Shaterian A, Sayadi LR, Anderson A, Ng WKY, Evans GRD, Leis A. Characteristics of Secondary Procedures following Digit and Hand Replantation. J Hand Microsurg 2019; 11:127-133. [PMID: 31814663 PMCID: PMC6894951 DOI: 10.1055/s-0039-1681981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022] Open
Abstract
Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.
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Affiliation(s)
- Ashkaun Shaterian
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Lohrasb Ross Sayadi
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Amanda Anderson
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Wendy K. Y. Ng
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Gregory R. D. Evans
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Amber Leis
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
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Boesch CE, Fuchsberger T, Beutler K, Bender D, Daigeler A, Medved F. Value of the Two-Point Discrimination Test: Evaluation of 238 Isolated Finger Nerve Injuries. J Hand Surg Asian Pac Vol 2019; 24:477-482. [PMID: 31690192 DOI: 10.1142/s2424835519500620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: It may be difficult to diagnose a nerve injury on a finger or a hand under emergency settings. The goal of this study was to elaborate whether the clinical testing of two-point discrimination was a safe and reliable method in the diagnosis of acute finger nerve injuries. Methods: Through a retrospective assessment, patients' records were analyzed whether the result of the two-point discrimination test corresponded with the intraoperative findings of a damaged nerve. Patients with a prolonged or missing two-point discrimination, who had undergone surgery at our institution between the years 2008 and 2017, were included in the study. The control groups were identified in the same manner and as an additional group, patients with Dupuytren's contracture were included to serve as a healthy cohort regarding finger nerves. Results: A total of 249 patients with nerve lesion were enrolled in the study; apart from this, 25 patients with Dupuytren's contracture were included. The sensitivity of the two-point discrimination test was 99%, with a positive predictive value of 0.93 and with high inter-observer reliability. Conclusions: The two-point discrimination is a valid test to use in the routine examination of suspected nerve injuries on the hands and fingers; it is very reliable and safe for indicating surgical interventions.
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Affiliation(s)
- Cedric Emanuel Boesch
- Department for Plastic, Reconstructive and Aesthetic Surgery, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Fuchsberger
- Clinic of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Traunstein, Germany
| | - Kevin Beutler
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Dominik Bender
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Adrien Daigeler
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Fabian Medved
- Departement of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
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Endo RR, Fernandes CH, Fernandes M, Santos JBGD, Angelini LC, Nakachima LR. The Role of the Hand Surgeon in Microsurgery in Brazil. Rev Bras Ortop 2019; 54:309-315. [PMID: 31363286 PMCID: PMC6597419 DOI: 10.1055/s-0039-1692433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/02/2018] [Indexed: 11/25/2022] Open
Abstract
Objective
This study evaluates the conditions for microvascular procedures found by hand surgeons in Brazilian clinical practices.
Methodology
A prospective, observational, and analytical primary clinical research conducted during the 37
th
Brazilian Congress of Hand Surgery, from March 30
th
to April 1
st
, 2017, in Belo Horizonte, in which physicians answered 12 closed, objective, multiple-choice questions regarding their geographic region, type of institution (public or private), microsurgical training, time of experience, technical conditions, the availability of a standby team for emergencies and compensation.
Results
The study analyzed 143 hand surgeons; among them, 65.7% participants were based at the Southeast region, 13.3% in the Northeast region, 11.9% in the South region, 6.3% in the Central-West region and 2.8% in the North region. Regarding the time of experience, 43.4% of the hand surgeons had less than 5 years, 16.8% had 5 to 10 years, 23.8% 10 to 20 years, and 23% had more than 20 years of practice in microvascular surgery. Seven percent of the surgeons had no training in microvascular surgery; for 63.6%, training occurred during medical residency, whereas 30.8% were trained in another institution, and 7.7% in another country. Among these surgeons, 76.9% worked at both private and public hospitals, 14.7% at private hospitals and 5.6% at public hospitals. Regarding compensation, 1.8% of the surgeons considered it adequate, and 98.2%, inadequate in public hospitals, whereas 5.0% considered it adequate, and 95.0%, inadequate in private hospitals.
Conclusion
This research shows that most surgeons were trained in microsurgery, had never performed reattachments, and considered that compensation is inadequate; moreover, standby teams were not available. There are few, unevenly distributed hand surgeons with microsurgical ability in emergency settings, and their compensation is low.
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Affiliation(s)
- Rosana Raquel Endo
- Serviço de Cirurgia de Mão e Microcirurgia, Hospital do Servidor Público Municipal, São Paulo, SP, Brasil
| | - Carlos Henrique Fernandes
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Instituto de Cirurgia da Mão, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Marcela Fernandes
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Instituto de Cirurgia da Mão, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Joao Baptista Gomes Dos Santos
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Instituto de Cirurgia da Mão, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Luiz Carlos Angelini
- Disciplina de Anatomia da Ortopedia, Universidade Metropolitana de Santos, Santos, SP, Brasil
| | - Luis Renato Nakachima
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Instituto de Cirurgia da Mão, Universidade Federal de São Paulo, São Paulo, Brasil
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Abstract
Replantation of a digit or hand is most successful when performed at a specialized, high-volume center. However, most patients with amputations initially present to local hospitals. Therefore, patients amenable to replantation frequently require expedited transfer to a tertiary center. To maximize success of digit replants, health care providers from both the referring and the referral hospital must be facile and expeditious at transferring the injured patient. The critical aspects of triage include assessment of the injury, patient communication, interfacility communication, preparation of the amputated part and patient, and a timely transfer.
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Affiliation(s)
- Shepard P Johnson
- Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Brian C Drolet
- Department of Plastic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Medical Center North, D-4219, Nashville, TN 37232, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, 1211 Medical Center Drive, Medical Center North, D-4219, Nashville, TN 37232, USA; Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 1211 Medical Center Drive, Medical Center North, D-4219, Nashville, TN 37232, USA.
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22
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Ju J, Li L, Hou R. Transplantation of a Free Vascularized Joint Flap from the Second Toe for the Acute Reconstruction of Defects in the Thumb and other Fingers. Indian J Orthop 2019; 53:357-365. [PMID: 30967709 PMCID: PMC6415561 DOI: 10.4103/ortho.ijortho_200_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to evaluate a novel surgical method for the acute reconstruction of defects in the thumb and other fingers by transplanting a free vascularized joint flap from the second toe and to determine its clinical curative effects. MATERIALS AND METHODS A free vascularized joint flap from the second toe was transplanted to reconstruct a complete defect of the thumb and other fingers accompanied by the loss of the proximal finger in 10 patients. Of these patients, three had their thumbs reconstructed with a free vascularized joint flap from the second toe and with the proximal interphalangeal joint flap, one had a thumb reconstructed with a free vascularized joint flap from the second toe, and six had their finger defects reconstructed with the proximal interphalangeal joint flap. The toes of the metatarsophalangeal joint were amputated at the foot donor site. All patients underwent one-stage emergency surgery. RESULTS The composite tissue flaps, replanted thumbs, and fingers survived well in all 10 cases. Follow-up visits were conducted for 6-28 months, with an average of 9 months of follow-up. The transplanted bone joints healed over a period of 6-16 weeks. Bone nonunions and refractures did not occur, and the walking function of the foot donor site was not visibly affected. CONCLUSION A free vascularized joint flap from the second toe can be transplanted to repair defects in the thumb and other fingers. This technique can be applied to recover the appearance and function of fingers.
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Affiliation(s)
- Jihui Ju
- Department of Orthopaedics, Ruihua Affiliated Hospital of Soochow University, Suzhou, China
| | - Lei Li
- Department of Orthopaedics, Ruihua Affiliated Hospital of Soochow University, Suzhou, China
| | - Ruixing Hou
- Department of Orthopaedics, Ruihua Affiliated Hospital of Soochow University, Suzhou, China,Address for correspondence: Dr. Ruixing Hou, Department of Orthopaedics, Ruihua Affiliated Hospital of Soochow University, No. 5 Tayun Road, Wuzhong District, Suzhou 215104, China. E-mail:
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Stevens GJ, Durning SJ, Stevens SD, Lowery DR. Regional Anesthesia in the Setting of Arm Replantation: A Case Report. A A Pract 2018; 11:38-40. [PMID: 29634554 DOI: 10.1213/xaa.0000000000000728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The perioperative implementation of continuous peripheral nerve blocks is poorly described within the literature for replantation surgeries beyond digital replantation. The management of replantation patients presents a challenging balance between pain control and limb perfusion. We report the successful use of a continuous interscalene catheter in a therapeutically anticoagulated patient after midshaft humerus arm replantation. The benefits of the continuous peripheral nerve block for the patient included improved pain control and potentially improved limb perfusion making it a valuable component of this patient's treatment.
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Affiliation(s)
- Gregory J Stevens
- From the Department of Anesthesiology, San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, Texas
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Idrissi ME, Elibrahimi A, Shimi M, Elmrini A. [Digital replantation, results and complications: study of a series of 18 cases]. Pan Afr Med J 2016; 24:184. [PMID: 27795781 PMCID: PMC5072882 DOI: 10.11604/pamj.2016.24.184.8718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 04/03/2016] [Indexed: 11/11/2022] Open
Abstract
Digital amputations are frequent injuries, the majority of them are caused by workplace accidents. Microsurgical techniques are an alternative option to repair these amputations. This study aims to report our experience in digital replantation through the examination of 18 cases. We conducted a retrospective study of 14 patients with total or subtotal fingers amputation between June 2013 and January 2015. All unidigital and multidigital replantations downstream of the distal insertion of superficial flexor tendon as well as all digital replantations upstream of the distal insertion of superficial flexor tendon were included in our study. These patients underwent surgery according to conventional digital replantation procedures. Five replantations were secondarily regularized. Among the 18 replantations, eight digital replantions evolved favorably since replantation helped restore active range of motion and passive range of motion of the finger operated without revision surgery and early and late secondary complication. In our study we achieved satisfactory results despite the difficult conditions including the initial state of the amputated finger and its delayed management. The development and mastery of microsurgery has helped change the prognosis of these amputations with serious functional and psychological consequences; the results of our study are encouraging with reference to the implementation of the SOS Hand Service in Morocco.
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Affiliation(s)
| | | | - Mohammed Shimi
- Service de Chirurgie Ostéoarticulaire B4, CHU Hassan II, Fez, Maroc
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Yaeger SK, Bhende MS. Pediatric Hand Injuries. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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