Successful replantation in ten-digit complete amputations

The authors report a case of successful replantation of all fingers in a ten-finger complete amputation. Among the factors responsible for the successful outcome were an adequate number of microsurgically-trained resident surgeons and staff, good organization and supervision by senior staff, emphasis on precision and perseverance in the operative procedures, and postoperative management. Follow-up is 15 months, and the patient now has a pair of functionally and cosmetically good hands.     

Finger replantations after ring avulsion amputations

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

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.     

Long-term results of transmetacarpal replantation.

The aim of this study was to evaluate subjective, functional and occupational outcome after transmetacarpal amputations. PATIENTS AND METHODS: Forty-three patients (mean age 34, range 1-71) with a transmetacarpal injury devitalizing three or more finger rays were treated with revascularization (22 patients) or replantation (21 patients). Most of the injuries (60%) were caused by a circular saw. Altogether 174 rays were injured of which 14 were doomed unsalvageable. An attempt was made to save the rest (n=160). Metacarpals were shortened on average 8 (range 0-22)mm. The number of arteries repaired varied from 2 to 5 and a vein graft was used in 16 patients. Thirty-eight patients (88%) attended a clinical follow-up examination performed by an independent observer at mean 9 years (range 2-24 years) after the injury. Subjective result was documented. Sensation was tested by two-point discrimination and Semmes-Weinsten filaments. Total active motion of MP- and IP-joints was measured. Grip and pinch strength was recorded. Functional results were assessed by Tamai's and Chens scoring systems. Cold intolerance and occupational history was registered. RESULTS: Primary survival of the replanted or revascularized digital rays was 86% (137/160). Subjective result was excellent in 11, good in 11, fair in 10 and poor in 6 patients. Out of 110 revascularized/replanted digits 86 (78%) achieved 2PD, among those the mean 2PD was 14.7 mm (range 6-25 mm). Total active motion (TAM) was on average 154 degrees (range 20-270 degrees ) per injured digit. The mean grip strength measured 56% (range 3-100%, n=33) and pinch strength 58% (10-100%, n=30) of the uninjured side. Using Tamai's scoring system the outcome was excellent in eight, good in 11, fair in 12 and poor in seven patients. According to Chen's criteria the result was excellent in seven, good in eight, fair in 18 and poor in five patients, respectively. The majority experienced cold intolerance. Sixteen of the 30 manual workers resumed to their previous or related occupation, ten were re-educated and four retired. CONCLUSIONS: The majority of transmetal carpal injuries with devascularized rays can be revascularized/replanted with a good subjective and satisfactory functional end result. Most patients can resume their old occupations or be employed after re-education.     

Microsurgical replantation of complete scalp avulsion: a five year follow-up

Summary A 19-year-old woman sustained total scalp avulsion. Replantation of the avulsed scalp by microvascular anastomoses was successfully performed on October 10, 1976. A follow-up evaluation after 5 years is presented.     

The management of the complete ring avulsion injury.

The complete ring avulsion injury presents a difficult choice between microvascular repair and further amputation. The former is technically difficult and the latter leaves an undesirable result. We describe an alternative method whereby a thinned groin flap is applied to volar surface and sides of the finger and a full-thickness skin graft covers the dorsum. This provides good quality cover to the volar aspect and avoids bulk on the dorsum.     

Long-term results of replantation of 10 upper extremities

From February, 1974 to June, 1976, replantation of 11 severed arms was performed at Chukyo Hospital, and 10 of these replantations were successful. Follow-up studies were performed regarding the status of the circulation, length and girth, motor function, sensory function, and autonomic nerve function. The peripheral circulation of the replanted arms was relatively poor, but did not correlate closely with function of the arm. Useful sensation returned in 8 patients and effective pinch and grasp returned in 6 patients. When observed objectively, 6 of 10 patients recovered satisfactory function. Subjectively, however, 8 patients were satisfied with their results and in the remaining 2 patients, satisfactory function in the future is anticipated. The most important factors in functional prognosis were the level of severance and the severity of crushing. In order to obtain satisfactory results, replantation should be confined to young patients with a non-crushing amputation.

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Résumé Entre Février, 1974 et Juin, 1976, 11 réimplantations de bras ont été réalisées au Chukyo Hospital: 10 ont réussi. Les études postopératoires ont porté sur l'état circulatoire, la longueur et la circonférence, les fonctions motrices et sensibles et le système nerveux autonome. La circulation périphérique des bras réimplantés est assez pauvre, mais est sans rapport étroit avec l'état functionnel du membre. Une sensibilité utile est réapparue chez 8 malades et 6 ont récupéré la fonction de préhension. L'examen objectif révèle que 6 malades ont retrouvé une fonction satisfaisante. Au point de vue subjectif, 8 malades sont satisfaits des résultats et nous espérons obtenir une fonction satisfaisante chez les 2 autres. Les facteurs les plus importants pour le pronostic fonctionnel sont le niveau de section et la gravité des lésions d'écrasement. Pour obtenir des résultats satisfaisants, la réimplantation ne devrait être faite que chez des malades jeunes, avec une section franche, non contuse.

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Presented at the XXVIIth Congress of the Société Internationale de Chirurgie, Kyoto, Japan, September 3–8, 1977.     

Long-term functional and subjective results of thumb replantation

The aim of this follow-up study was to evaluate the functional and subjective results after thumb replantation. Twenty-four patients with replantation of the thumb, performed during the period 1992-1997, were reexamined after 6.5 years (range, 4.2-9.1 years post-injury). In 10 cases the amputations were isolated, 14 amputations were combined with other injuries of the hand, 15 amputations resulted from crush/avulsion injuries, and 9 amputations were sharp. Range of motion, grip strength, cutaneous sensibility, and upper-extremity functioning using the DASH questionnaire were determined. A correlation analysis with important variables was performed. Average range-of-motion in the metacarpophalangeal joint was 44 degrees (+/-24.2) and in the interphalangeal joint was 12 degrees (+/-8.4). Grip-strength of the injured hand was 70% (+/-31.4) and pinch strength was 68% (+/-28.7) in comparison to the non-injured hand. DASH-scores correlated with grip-strength, pinch-strength, and cutaneous sensation but no correlation was found between DASH and the level of amputation. Functional results were independent of amputation levels and patient age. Although the results of cutaneous sensibility were only moderate, patients were able to use their thumb to perform work and daily living activities. The majority of patients had returned to their previous occupation.     

拇指旋转撕脱离断的再植术式改进

目的 对拇指旋转撕脱离断再植术进行改良,并评估其近期临床疗效.方法 2007年1月至2009年7月,对拇指旋转撕脱离断患者7例实施再植术.男6例,女1例;年龄21～47岁,平均28.3岁.离断平面均为掌指关节水平.设计改良拇指旋转撕脱离断再植术,根据软组织条件短缩指骨后融合固定掌指关节;保留拇长屈、伸肌腱5～6 cm,将其断端与腱鞘或周围软组织缝合,拇指指间关节腱固定于屈曲15°位;取前臂掌侧静脉桥接桡动脉腕背支和拇尺掌侧固有动脉;背侧静脉直接吻合6例,静脉移植修复1例;双侧指固有神经均绕至掌骨背侧与桡神经浅支吻合.结果 7例再植拇指全部成活.1例于术后出现动脉危象,经手术和药物治疗后成活.术后随访3 ～24个月,再植拇指外形良好,对掌功能满意,指端感觉恢复S4级4例、S3级3例,两点辨别觉8～12 mm.结论 前臂掌侧静脉桥接桡动脉腕背支和拇尺掌侧固有动脉重建拇指血供的方法操作简便,效果可靠,是治疗拇指旋转撕脱离断一种比较理想的方法.     

Rotating shaft avulsion amputations of the thumb

In a three-year period twenty-nine patients were treated for rotating shaft avulsion amputations of the thumb. Twenty-three thumbs were considered suitable for replantation. A staged approach, consisting of primary replantation and secondary nerve grafting and tendon reconstruction, was used because of concern that survival rates would be low. Survival was achieved in nineteen of twenty-three replantations. At mean follow-up of 20.5 months grip strength was 94.6% of the unaffected side and key pinch was 77.1%. Five patients achieved a two-point discrimination less than five millimeters. Success was better anticipated and now a full reconstruction is carried out in a single-stage procedure.     

Per Primam thumb replantation for all patients with traumatic amputations

Forty-two complete thumb replantations performed between 1980 and 1984 were reviewed. The mean follow-up time was 14 months. Replantation was attempted for all thumb amputations regardless of mechanism or severity of injury. Sixteen (38%) failed intraoperatively or postoperatively. Thumbs with narrow zones of injury showed a significantly higher survival rate than those with wide zones of injury. Eighty percent of those with poor arterial flow intraoperatively ultimately failed, despite pharmacologic treatment and multiple vein-graft anastomoses. Two thumbs with no vein repairs ultimately survived. Reexploration for loss of perfusion succeeded in 60% of cases. Total metacarpophalangeal and proximal interphalangeal active motion postoperatively averaged 68 degrees. Median static two-point discrimination returned to 11 mm. Avulsed thumbs survived in 46% of cases. Replantation should be attempted in all cases of thumb amputation, as success cannot be predicted by mechanism or severity of injury. Thumbs with poor intraoperative flow (20%) or no venous return (50%) can survive and should not be primarily amputated. Vein grafting is not mandatory if shortening allows anastomoses to be tension free. Prompt reexploration of acute vascular occlusions is worthwhile.     

Primary ray resection as an alternative to microsurgical replantation in the management of ring finger avulsion

ObjectivesRay resection of the metacarpal with conservation of the proximal end is a technique of management of complete ring avulsion injuries in the emergency situation. This study is a functional evaluation of the technique in comparison to replantation.MethodsThe present series includes 11 patients, average age of 35 years, predominantly manual workers, operated between October 2005 and July 2007. It consisted of two grades IVA, six grades IVB, and three grades IVC (classification of Merle–Michon). Cases were assessed according to grip and pinch strength, quantitative 400 points score and a work evaluation.ResultsTen patients were evaluated with an average follow-up of nine months (range: three to 19 months). There were no complications apart from four patients with phantom pain. The time to return to work was three months (range: 10–219 days). All patients were satisfied with the cosmetic appearance, however eight of them suffered from psychological problems, finding it difficult to accept a four-fingered hand. Secondary surgery was unnecessary in the majority of the patients (80%). The grip strength was measured as 30% of grip strength of the unaffected side (range: 3–70%). The result of the 400 point score was 75,94% (range: 55–99%).ConclusionRay resection of the metacarpal with conservation of the proximal end is a reliable procedure. Strength is decreased but this does not stand in the way of a rapid return to previous work. However, the choice of strategy (ray resection versus microsurgical replantation) should be discussed in detail with the patient prior to selecting the appropriate option.     

Microsurgical replantation of total upper eyelid avulsion

We present a unique case in which a dog bite resulted in total full-thickness upper eyelid avulsion in a young Caucasian female. The eyelid was replanted using meticulous microsurgical techniques reanastamosing the arterial supply. To our knowledge, this is the first reported case of a successful microvascular replantation of a completely avulsed upper eyelid. The details of the case and the photographic clinical improvement are described and discussed.     

Distally based cross-finger flaps for amputation stumps in avulsion amputations

Background:

Though advances in microsurgery have resulted in better survival rates of replants, replanting crushed and avulsed digits are difficult. If replantation is not possible these digits need local tissue cover to retain length.

Patients and Methods:

Twenty seven patients underwent distally based cross finger flaps for coverage of exposed vital structures over the amputation stumps.

Results:

All the flaps survived well. They provide good quality thin pliable tissue over the fingertips and help in achieving near normal range of movements in injured digits.

Conclusion:

Distally based cross finger flap gives tissues of right dimensions, at the most desired site, making reconstruction of these difficult problems quiet easy.KEY WORDS: Coverage of terminal finger defects, cross-finger flaps, distally based flaps     

The replantation of the thumb in avulsive amputations]

A comparative assessment of results of operations was made in 2 groups of patients with abruption of the first finger. An analysis of immediate and long-term results of operations has shown advantages of the method of replantation with heterotopic revascularization of the replanted first finger and reinnervation by means of plasty of the palmar digital nerve.     

拇指旋转撕脱离断伤再植方式的探讨和选择

目的：探讨拇指旋转撕脱离断再植方法的选择、各种术式的优缺点及临床疗效。方法：2009年2月至2012年3月治疗21例拇指旋转撕脱离断伤患者,男16例,女5例;年龄16～45岁,平均32岁。根据患者手指撕脱情况应用不同方法行断指再植术,术后观察患者成活情况及再植指术后功能康复情况。结果：21例再植指,成活19例,失败2例。成活的19例进行随访,时间3～14个月,平均8个月。根据中华医学会手外科学会断指再植功能评定试用标准评定：优13例,良5例,差1例。结论：按照拇指旋转撕脱离断伤不同情况采用不同再植方法,可获得较高的成活率,并能恢复较好的外形与功能。     

拇指旋转撕脱性离断再植的临床研究

目的 探讨拇指旋转撕脱性离断再植的临床治疗方法及疗效.方法 对28例拇指旋转撕脱性离断患者,采用环指浅屈肌腱转位修复拇长屈肌腱,重建拇指屈曲功能,食指固有伸肌腱转位修复拇长伸肌腱,重建拇指伸指功能,环指桡侧指动脉、神经修复拇指指动脉、神经,食指指背静脉修复拇指静脉.结果 术后28例再植拇指全部成活.随访1～6年,再植拇指屈伸功能及外形恢复满意,两点辨别觉为5～9 mm.根据中华医学会手外科学会手功能评定试用标准,综合评价全部为优良.结论 此种转位方法对拇指旋转撕脱性离断再植,术后功能恢复满意,是一种安全有效的治疗方法.     

脱套性断指的临床特点及再植

目的 探讨脱套性断指的损伤特点及再植的可行性。方法 回顾性分析２３例２７指脱套性断指的损伤特点，并结合 特点采取相应的措施进行修复。结果 ２３例２７指成活２２指。１７例中９指随访６￣２４个月，按断旨再植功能评价，优１０指，良７指，可２指。结论脱套性断指血管、神经、肌腱的断面常不在一个平布，表现为长距离的撕脱伤；仔细观察伤情后，采取灵活恰当的手术方法，同时可获得良好的治疗效果。     

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.