Macro- and microcirculatory assessment of cold sensitivity after traumatic finger amputation and microsurgical replantation

INTRODUCTION: Finger replantations after traumatic amputation are associated with good prognosis and acceptable functional results. However, cold sensitivity is a common and sometimes disabling sequelae after digital replantation. The exact causes of cold intolerance are still unclear; neural as well as vascular mechanisms have been discussed. We examined the macro- and microvascular performance of replanted fingers using high-resolution color-coded sonography for the assessment of skin vessel density of the fingertips as well as nailfold capillary microscopy and laser Doppler anemometry. Subsequently, we correlated these findings with the presence of cold sensitivity of the replanted digits. PATIENTS AND METHODS: Thirty-seven patients (mean age 45 years; range 19-72) with 40 traumatic finger amputations and microsurgical replantations were studied. The mean time interval between amputation and examination was 57.7 months (range 13-95). Macro- and microvascular examination consisted of electronic oscillograms of both arms, photoplethysmograms of all fingers before and after cold test, duplex ultrasound of the finger arteries, high-resolution color-coded sonography of the fingertips and nailfold capillary microscopy with laser Doppler anemometry. RESULTS: Cold sensitivity was present in 33 (83%) of the 40 replanted fingers. Peripheral arterial disease of the upper extremity could be excluded as all oscillograms showed normal findings. A vasospastic reaction after cold test was documented in 74% (30 of 38) of the replanted fingers, compared to 24% (9 of 38) of the contralateral uninjured fingers. Raynaud's phenomenon was restricted to replanted fingers and occurred in 10 of 40 patients (25%). Compared with the contralateral fingertips, reduced skin vessel density was found in 27 of 36 (75%) replants. Nailfold capillary microscopy revealed uncharacteristic morphologic patterns. The capillary flow velocity was 0.28 +/- 0.12 mm/s in the replanted fingers and 0.48 +/- 0.23 mm/s in their unaffected counterparts (P < 0.001). Correlating these findings with the presence of cold intolerance, reduced skin vessel density in the fingertips was significantly different between cold-sensitive replants and those without cold sensitivity (P = 0.05). Reduced skin vessel density was not related to the extent of reconstruction of nerves (P = n.s.), arteries (P = n.s.) and veins (P = n.s.). CONCLUSIONS: Our results do not confirm hypotheses that cold sensitivity after finger replantations is caused by macrovascular problems nor do they support assumptions of a primary capillary microcirculatory failure. Our findings of reduced vessel density point towards diminished thermoregulatory capacities in the fingertips of cold-sensitive replanted digits.     

手指多段离断再植的临床研究

目的回顾性分析手指多段离断再植的临床效果。方法对于手指末节、指尖部的断指再植，吻合1条动脉及1条指腹静脉或者吻合1条动脉加拨甲、小切口放血处理，或者行动静脉转流等方法恢复断指血循环；手指中节和近节的离断再植吻合两侧指动脉和2条以上指背静脉，如血管损伤严重，可行浅静脉移植或者邻指动脉移植桥接。结果再植45例81指165段，成活150段，成活率91％。结论手指多段离断再植技术要求高，术中高质量的血管吻合及对血管损伤的有效处理，可以提高断指再植的成活率。加强功能锻炼是再植手指功能恢复的重要环节。     

多指再植与功能恢复的关系

目的 探讨多指再植与功能恢复的关系。方法 对断指再植成活在３个手指以上的２２例患者进行１￣７年随访,从再植手指的关节活动范围、感觉恢复程度、血液循环状况、外观及日常生活等５个方面对再植手指功能进行疗效评定。结果 ２２例１０２个再植手指中,８９个手指功能疗效评定为优良;１３个手指评定为差和劣,其中关节强直８例,手术萎缩并缺乏感觉３例,有旋转畸形伴有神经瘤形成２例。结论 多指再植属特殊断指再植,其功能     

多指再植与功能恢复的关系

目的 探讨多指再植与功能恢复的关系。方法 对1980年以来,共收治断指再植成活在3个手指以上的22个病例进行随访,内容包括：再植手指的关节活动范围、感觉恢复程度、血液循环状况、外观及日常生活共5个方面对再植手指功能疗效评定。结果 22例102个再植手指中,89个手指功能疗效评定为优良：13个手指评定为差和劣,其主要原因为关节强直8例,3例为手指萎缩并缺乏感觉,2例再植手指有旋转畸形伴有神经瘤形成。结论 多指再植属特殊断指再植,其功能恢复有赖于损伤关节面完整性修复,解剖性一期缝接神经、肌腱;而术后阶段性、指导性、持续性、康复性训练,为再植手指获得理想功能的必备手段。     

Penile replantation after self-inflicted amputation.

In 4 men with self-inflicted penile amputation, replantation was successful using microsurgical technique. Postoperative complications were minimal. In 1 man who had amputated his penis and then amputated his scrotum and testicles, a small skin graft was necessary to close a portion of the defect. A mild urethral stricture that developed in this man responded to dilation. Return of sensation was excellent. Normal erections were reported by all men. Microsurgical replantation is the treatment of choice for this injury and is superior to other techniques of penile reattachment, which have a high incidence of distal necrosis, fistula and stricture formation, as well as incomplete or absent sensation and compromised erectile function. Of concern in this group of men is the high incidence of previous or subsequent penile mutilation. Two of the 4 men have a history of recurrent self-mutilation. The follow-up in this series is longer than previously reported and the overall psychiatric pathology appears to be quite severe and persistent.     

不同原因致手指多段离断再植效果临床分析

目的 报道不同原因致手指多段断指再植的临床效果。方法 对不同原因致多段离断手指45例81指165段施行离断再植和进行随访，并对不同的致伤原因与多段离断指再植成活率和功能效果的关系进行临床分析。结果 再植45例81指165段，术后成活150段，成活率91％。其中锐器切割伤及电锯伤离断91段，成活87段，成活率95％；挤压、绞压伤离断74段，成活63段，成活率85％。术后随访3～18个月，按断指再植功能评定标准标定，结果优27指，良43指，可6指，差5指，总优良率86．4％。其中锐器切割伤优良28指，优良率94％；电锯伤优良18指，优良率90．4％；挤压、绞压伤优良24指，优良率80％。结论 锐器切割伤电锯伤的多段离断手指再植成活高，功能效果满意，而挤压伤、绞压伤的多段离断指再植成活率低，功能差，要提高其治疗效果需要采取更有效方法。     

Long term follow-up after finger replantation

The aim of this retrospective study was to assess objective and subjective aspects of the long-term results of finger replantations and revascularisations. Forty patients with 59 successfully replanted or revascularised fingers, who had a mean age of 38 years, were followed-up over an average of 3.5 years. The assessment included: the profile of the blood flow in the digital arteries of replanted fingers with Doppler ultrasound, active range of motion, total grip strength, pinch grip, static two-point discrimination test and Semmes-Weinstein monofilament testing. The dexterity of the hand was evaluated subjectively with the Carlsson's questionnaire and cold intolerance with a modified McCabe's questionnaire. Statistical analysis was performed and a statistically significant correlation was found between the Carlsson's functional score, active range of motion and total grip strength. In 28 fingers (74%), blood flow in the digital arteries showed an undisturbed profile, while ten fingers showed mild stenosis or impaired microcirculation.     

Distal digital replantation after guillotine amputation]

Results of 8 distal digital replantations in 4 patients (2 females, 2 males) aged 13-45 (mean 32.5 years) are presented. Treatment was successful in 7 cases. Regional or local Oberst anesthesia was employed at surgery. Various modifications of the procedure were attempted to improve it and shorten operating time. Mean time of one digit replantation was 4 hours. At 6 months follow-up results were excellent.     

Late arteriovenous fistula after finger replantation

The occurrence of arteriovenous fistula (AV) after finger replantation is a very rare complication. Since the first replantation performed in the Czech Republic in 1979, there has been one such case. A four-finger replantation was done for an injury on the right dominant hand on a 29-year-old patient. After 6 months, an arteriovenous fistula developed on the fourth finger. The other fingers were not affected. Following examination by digital subtraction angiography, selective ligature of the common digital artery for the fourth interdigital space was performed. Catheterization and embolization methods were not used. After detailed analysis of the factors which may have caused this complication, the following preventative and therapeutic approach is proposed. It is necessary to avoid tissue damage caused by cold. The advisable rate should be at least 1:1 between venous drainage of the finger in the area of the basic phalanx and the arterial supplementation. It would be better, however, to have the ratio at 2:1 or more. In case of the AV fistula formation before radical intervention, selective ligation of an artery causing vascular dilatation is advantageous.     

Heterotopic replantation of fingers after traumatic amputation]

Available are the results of the treatment of 93 patients with multiple traumatic amputations of the fingers, in whom the heterotopic digital replantation was carried out. A total of 367 fingers were amputated, 187 of them have been replanted, which made up 51% of replantability. 148 fingers (79.1%) were replanted heterotopically and 39 (20.9%)--orthotopically. The viability was restored in 167 fingers, which made up 89.3%. Of 148 fingers, which have been replanted heterotopically, 88.6% have survived, and of 39 fingers, being replanted orthotopically, 92.4% survived. The analysis of functional results of the digital replantations in hand comprised the study of the hand biomechanics, blood supply and innervation. A total of 31 patients was followed up and examined in long term period from 8 months to 6 years after replantation. The biomechanics of the hand was assessed according to its capacities for seize and pinch as well as to the extent of movements in the joints of the restoration of digital innervation was assessed by the study of temperature and discrimination sensitivity. For evaluation of blood supply the US dopplerography and scintigraphy were used. The authors came to the conclusion that there was no substantial difference in the function of operated fingers both in orthotopic and heterotopic replantations. Taking into account that heterotopic replantation of the fingers resulted in more active digital function, it is safe to speak about more pronounced increase in the function of the hand in cases of heterotopic replantations of fingers in their multiple traumatic amputation.     

断指再植术后动脉危象的处理

目的　介绍断指再植术后动脉危象的处理。方法　 4 6例 ( 4 6指 )断指再植在术后 6～ 72小时内出现动脉危象 ,经采用罂粟碱 3 0 mg肌肉注射等保守治疗 1小时后 ,动脉危象仍未解除。即行手术探查 ,发现动脉吻合口血管内膜损伤或缺损 2 8例 ,血管吻合技术差 11例 ,血管远端分支未结扎 2例 ;动脉痉挛 5例。血管均严重痉挛、变细、无血液通过吻合口。机械解除动脉痉挛 5例 ;动脉栓塞 4 1例 ,切除吻合口后动脉直接吻合 6例 ,静脉移植 3 5例。结果　 4 6指成活 4 3指 ,成活率为 93 .5 %。结论　精细的显微外科技术是断指再植获得成功的关键 ,正确判断动脉危象 ,及时手术探查是提高该类断肢再植成活率的有效手段。     

Functional results after a Krukenberg amputation

This case report presents a 51 year old female patient who had a train accident in 1999. She suffered bilateral trans-tibial and bilateral trans-radial amputations. In this paper, the evolution of the right transradial amputation where eventually a Krukenberg procedure was performed, is described as is its good functional outcome after rehabilitation treatment. After this first procedure the patient also asked for the Krukenberg procedure for her left arm.     

Long-term functional,subjective and psychological results after single digit replantation

Objective

The aim of this study was to analyse the long-term functional, subjective, and psychological results after single-digit replantation.

Long-term results of replantation of the proximal forearm following avulsion amputation

This study reports on the long-term functional outcomes of a homogeneous series of 10 cases of successful replantation of an avulsed proximal forearm and its acceptance on the part of patients. After a minimum follow-up of 3 years (average, 4.7 years), muscular and sensory recovery was evaluated with the Medical Research Council scale, and global function according to the demerit score system of Chen (China Med 5:392-397, 1967). Subjective evaluation and patient satisfaction were investigated by means of a questionnaire. One patient was classified as grade 2, 4 patients as grade 3, and 5 patients as grade 4 according to Chen (China Med 5:392-397, 1967). However, in spite of the poor objective results, patient satisfaction was obtained in 90% of cases, and the replanted extremity was considered of help for common activities of daily living. In conclusion, replantation of an avulsed proximal forearm should be considered only in patients who are strongly motivated to maintain body integrity, and who are aware of the expected functional limitations.     

A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations

PURPOSE: To compare the functional outcome of successful microsurgical replantation versus amputation closure for single fingertip amputations. METHODS: Forty-six fingertip amputations in 46 patients (23 were replanted successfully, 23 had amputation closure) were included in this study. Thumb amputations were excluded. Grip strength and active range of motion of the proximal interphalangeal joint were evaluated. The patients were questioned about their symptoms of pain, paresthesia, and cold intolerance. The Disabilities of the Arm, Shoulder, and Hand questionnaire was given and the disability/symptom score was evaluated. Patients' satisfaction with the surgical result was assessed. Time spent in the hospital and time off from work were reviewed. RESULTS: Active range of motion of the proximal interphalangeal joint was greater in the successful replantation group. Although the existence of paresthesia and cold intolerance were not statistically different between the 2 groups, pain in the affected fingers was more frequent in the amputation closure group. The average Disabilities of the Arm, Shoulder, and Hand score of the successful replantation group was statistically better. All patients in the successful replantation group were highly or fairly satisfied with the surgical results, whereas 14 patients in the amputation closure group were highly or fairly satisfied. The time spent in the hospital and the time off from work for the successful replantation group were longer. CONCLUSIONS: Successful replantation of single fingertip amputations can result in minimal pain, better functional outcome, better appearance, and higher patient satisfaction. We recommend attempting fingertip replantation not only to obtain the best appearance but also to gain better functional outcome. If the patient requests the simple surgery and earlier return to work amputation closure is an accepted method despite the disadvantage of digital shortening and the risk for a painful stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Rehabilitation of a patient following hand replantation after near-complete distal forearm amputation

Study designCase report.IntroductionReports of comprehensive rehabilitation following hand replantation are limited.Purpose of the studyTo describe hand therapy of a patient following hand replantation.MethodsRight hand dominant 55 year-old male assessed 9 days following left hand replantation to treat distal forearm amputation. Patient presented with dorsal blocking orthotic. Initial status: AROM digits and thumb 0–20° extension, 0–40° flexion; absent light touch sensation; 0–1/5 hand strength. Patient underwent 70 hand therapy sessions over 13 months focusing on A/PROM, therapeutic exercise, neuromuscular re-education, and modalities to address functional limitations.ResultsHand therapy discharge status: AROM digits and thumb form composite fist, thumb opposition to digit 3, light touch sensation (monofilament) 4.03 (digits 2, 4) and 4.17 (digits 1, 3, 5); 3− to 4−/5 hand strength.DiscussionHand therapy allowed for near complete functional return of the hand following replantation.ConclusionComprehensive Hand therapy aided restoration of adequate sensation and strength for functional use of the replanted hand.Level of evidence4