Transpositional digital replantation

When a functionally important digit is injured as part of a multiple digit injury, transpositional digital replantation is worth considering to preserve greater hand function and to avoid or minimize the necessity for secondary reconstructive procedures. We present two such cases with transpositional digital replantation. The indications for this technique are: 1) multiple digit injury, 2) severe crush injury, 3) the possibility of preserving more and better joints in some fingers, and 4) injury distal to Tamai's zone V (11). The benefits of this procedure are that function can be better with the more completely preserved digits replanted into the most useful positions and of similar lengths. Difficulties are encountered when there are large discrepancies in size of surviving digits, and problems with soft-tissue coverage, tendon repair, a 'step' at the fracture site after bone fixation, and with vessel anastomosis. Use of this procedure can result in preservation of hand function and fewer secondary reconstructive procedures.     

Transpositional replantation of digits. Case reports.

Heterotopic or transpositional replantation of digits is technically feasible with results similar to those of conventional replantation procedures. Occasionally in multiple digital amputations not all the digits may be replanted in their correct place as a result of complex injuries proximal to the amputation zone or severe damage to important fingers. In these circumstances the amputated digits that are in the best condition as regards undamaged tissue are used for replantation. The primary priority is an optimal functional outcome and the secondary priority the cosmetic outcome. Amputated long digits will always be used to substitute for a non-replantable thumb rather than to replace a long finger. We present 13 cases of successful transpositional digit or joint replantations in traumatic amputations of more than one digit.     

TRANSPOSITIONAL REPLANTATION OF DIGITS: Case reports

Heterotopic or transpositional replantation of digits is technically feasible with results similar to those of conventional replantation procedures. Occasionally in multiple digital amputations not all the digits may be replanted in their correct place as a result of complex injuries proximal to the amputation zone or severe damage to important fingers. In these circumstances the amputated digits that are in the best condition as regards undamaged tissue are used for replantation. The primary priority is an optimal functional outcome and the secondary priority the cosmetic outcome. Amputated long digits will always be used to substitute for a non-replantable thumb rather than to replace a long finger. We present 13 cases of successful transpositional digit or joint replantations in traumatic amputations of more than one digit.     

Transpositional microsurgery in multiple digital amputations

In 34 of the 62 patients treated for complete multiple digital amputations, the severed part was not replanted in its anatomical position, but in the place of the most useful stump. This procedure is defined as transpositional digital microsurgery and refers to the transposition and replantation of any digit to another stump which plays a more significant role in the function of the hand. Twenty-eight patients had transposition of a digit, while six patients underwent thumb transposition. All except six of the transposed digits survived, while all of the thumbs survived the surgical procedure. The cosmetic appearance of the hand with a transposed digit or thumb was acceptable to the patients. Two-point discrimination was assessed to be 10–14 mm for the transposed digits, and the functional ability of the transplanted digit was comparable to digits which were replanted in their anatomical position. In conclusion, transpositional digital microsurgery remains a useful alternative for the treatment of multiple digit amputations, particularly in patients with severely damaged non-replantable amputated parts. © 1994 Wiley-Liss, Inc.     

Finger replantation after 60 years of age. Apropos of 7 cases

The authors analysed retrospectively 7 cases of digital replantation in 7 men aged from 60 to 71 years, performed between 1985 and 1996. There were 2 amputations of the thumb, 1 of the index, 2 of the middle finger, 1 of the fourth and 1 of the fifth finger. 4 failures of replantation were noted. These 4 failures always concerned amputations of long digits by a circular saw with associated complex multidigital injuries of bad prognosis and in combination with a poor vascular status. We had 3 successful results: the 2 amputations of the thumb and the ring finger of the auricular. All these 3 patients recovered a good hand function. We found some common characteristics in this group of patients: excellent general condition, non smoker, good motivation and cooperation, injury of one digit, clear amputation (except the ring finger), correct conservation of the amputated part. The advanced patient's age does not represent a contraindication for digital replantation. The injury mechanism and the general condition of the patient represent major criteria of prognosis. In favourable circumstances, a good functional result can be expected.     

A complex reimplantation of digits: a case report.

In multiple finger amputations, microsurgical reconstruction should concentrate on the thumb, index, and middle fingers. The patient in the case report presented in this paper initially sustained an amputation of all of the digits on the left hand and an amputation of the right thumb. Both thumbs were amputated at the metacarpophalangeal joint. Initial replantation of the left thumb, index, and middle fingers and of the right thumb was carried out. The right thumb replantation failed and, after healing, the right great toe was transferred to the right hand. Subsequent to this, the patient developed useful function of all reconstructed digits. Twenty-one months after the first injury, both thumbs sustained new traumatic amputations 1.0 cm distal to the previous amputations. Both thumbs were replanted again successfully.     

Replantation and revascularization of hands: clinical analysis and functional results of 261 cases

During the past 4 years we performed 261 replantations and revascularizations on amputated digits and hands in 153 patients. The overall survival rate was 82%. Clean-cut proximal level amputations and hypothermically preserved amputation parts had the highest survival rate. A higher survival rate and more satisfactory results with accelerated return of sensory function correlated with repair of both digital arteries and two veins rather than only one. All patients experienced intolerance to cold, but this was more troublesome in patients with digital replantation in whom only a single artery was repaired. Digital sensibility and joint motion after replantation were better in these patients who had sharp amputations and on whom repairs were carried out in zone III. Return of intrinsic muscle function after hand replantation was poor; however, patient satisfaction with the procedures remained high.     

Effect of hyperbaric oxygen therapy as a monitoring technique for digital replantation survival.

There have been few clinical reports of successful replantation assisted with hyperbaric oxygen (HBO) therapy. In order to improve replant survival, the author has used HBO in ten digital replantations of crush, avulsion, and degloving amputations. Seven of ten replants survived and the other three failed. The failed three digits demonstrated remarkable color changes during HBO therapy. No color changes were observed in six of the seven surviving digits under HBO. The remaining digit showed a slight color difference between pre- and post-therapy. It appears that hyperbaric oxygen is potentially effective in distinguishing "uneventful" replants in which color does not change during HBO therapy, while hyperbaric oxygen could not salvage those "congestion to necrosis" replants in which the color became bright vermilion under hyperbaric oxygen therapy. The difference in digital color reaction to hyperbaric oxygen may be helpful in early decisions to employ salvaging procedures.     

Evolution and present status of orthopedic microsurgery in Greece

Replantation of complete or incomplete nonviable amputations of digits, hands, and major limbs along with a number of reconstructive microsurgical procedures reflect the work that has been done in the field of orthopedic microsurgery in Greece during the last ten years. The history of trauma microsurgery in Greece starts in the mid-1970s, when the first attempts were directed toward patients with complete or incomplete nonviable amputations of digits and hands. Few cases of major limb replantations without the aid of an operating microscope or other means of magnification have been reported for the years 1965-1975. The first successful digital replantation was performed in 1979 on a female patient with multiple digit amputations; only the little finger was successfully replanted. More than 310 replantations and revascularization procedures have been performed during the past decade, mainly in two major replantation centers, with an overall success rate of 85% for complete and 90% for incomplete nonviable amputations. Reconstructive microsurgical procedures are mainly related to free skin flaps, vascularized bone grafts, toe-to-thumb transfer, and peripheral nerve microsurgery.     

Sensory recovery following digital replantation

The recovery of sensibility following digital replantation is essential in the restoration of hand function. We reviewed 12 series of digital replantations between 1977 and 1989. Three hundred sixty-seven fingers and 87 thumbs were successfully replanted. Mean age was 32.5 years. Mean follow-up was 33.5 months. Mean static two-point discrimination (S2PD) was 9.3 mm in clean thumbs vs. 12.1 mm in crush/avulsion thumb replantations. Mean S2PD was 8 mm in clean finger vs. 15 mm in crush/avulsion finger replantations. Overall mean S2PD was 11 mm in thumb and 12 mm in finger replantations. Sixty-one percent of replanted thumbs and 54% of replanted fingers regained useful S2PD (less than 15 mm or greater than or equal to S3 +). Factors that influenced digital sensibility following replantation included patient's age, level and mechanism of injury, digital blood flow, cold intolerance, and postoperative sensory reeducation. Recovery of sensibility in the replanted digit is comparable to simple nerve repair and to nerve grafting techniques. Further emphasis should be on elucidating the mechanism of cold intolerance, which was a significant complaint for most replanted digits. The universal practice of postoperative sensory reeducation will continue to improve digital sensibility following replantation.     

甲中份以远指尖再植

目的探讨甲中份以远指尖离断再植的临床特点和预后。方法2001年8月～2005年8月,对16例1甲中份以远指尖离断采取只吻合动脉的方法再植,术后小切口放血。结果16例离断指尖中,成活14例,坏死2例,再植成功率为87．5%。对再植成功的12例随访3～12个月,成活指体饱满和指甲外形满意,静态两点辨别觉为3～6mm。结论甲中份以远的指尖离断冉植是恢复手指外形和功能的最佳治疗方法,具有较高的成功率。但要求术者具有较高的小血管吻合技术,指尖损伤程度和较高的医疗费用也在考虑之中。     

Indications and selection for digital amputation and replantation

Even though replantation surgery has now become a routine procedure, it remains delicate and demanding surgery, requiring adequate training and expertise in microsurgical techniques. Well-defined selection criteria for replantation procedures have evolved over the past few years, including definitive guidelines for thumb, single digit, multiple digit and mid-palm amputations. For more complex cases, other techniques, including transpositional microsurgery and various secondary reconstructive procedures, such as toe-to-hand transfer, are now available. Although replantation procedures have been simplified, a second surgical team can save valuable surgical time by debriding and identifying the vessels in the amputated part, harvesting microvenous grafts, and performing bone fixation or tendon repair among other things, while the chief surgeon focuses on revascularization. Overall, the most significant guideline underlining the philosophy of digital replantation today reflects the aim of not only ensuring the survival of a digit, but its functional use as well. Experience dictates that this can be achieved only if the basic principles and indications of replantation surgery are adhered to.     

Lower leg replantation in children: railroad amputation

Replantation in the lower leg, although technically feasible, still remains a complicated clinical issue in terms of the decision-making process. In children, a limb salvage or replant procedure would seem preferable; however, in crush amputations from railroad injury, a very severe trauma, difficulties in treatment should be thoroughly weighed against prosthetic possibilities: for example, only a fair or good functional outcome would justify an attempt to replant a severed shin. Unfortunately, the outcome in most cases is unpredictable at the time of initial evaluation, and even during the replantation procedure itself. To facilitate prognosis, the authors determine four typical variants of replantation course and outcome, based on local patient conditions, although they stress that no clear indications for replantation vs. prosthesis can be derived from the variants listed. Rather, general guidelines for the surgeon's decision at a very early stage of treatment are presented. Choice of procedure and tactics cannot be determined once and for all, because the prognosis for functional outcome can change during the course of treatment. Among a few well-defined situations are clean amputations (replantation is indicated) and traumas with very extensive crushing of the whole lower leg (replantation is contraindicated). In the majority of cases, replantation is a worthwhile attempt, but this does not imply that a replanted extremity must be preserved at any cost. The surgeon must consider the possibility of re-amputation, in case of an unfavorable variant in the postoperative course. A successful case of replantation, involving two lower leg railroad amputations in a child, is presented.     

Temporary ectopic digital implantation: a clinical series of eight digits

This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted onto the foot, while in the second patient the four amputated digits were implanted onto the opposite forearm. After stump reconstruction, the digits were microsurgically transferred to the hand, restoring a functional pinch. One digit suffered a venous congestion and necrosis in the ectopic site caused by a haematoma and another experienced a no-reflow phenomenon. In conclusion, temporary ectopic implantation remains a procedure that can be used to salvage amputated digits.     

Secondary procedures following digital replantation and revascularisation.

In this retrospective study, 79 digits of 55 patients received 102 secondary procedures following replantation. We divided the procedures into two groups, occurring before or after 2 months following replantation. The procedures in the early group were mainly for soft tissue coverage (92%), and those in that late group were mainly for tendon (67%) to improve function. Factors associated with higher incidence of early secondary procedures included multiple-finger injury, avulsion or degloving injury and level of injury proximal to zone III in finger replantation (p<0.05). However, younger patients and those with proximal level replantation in fingers had more late secondary procedures (p<0.05). Flexor tenolysis procedure significantly improved the digital function after replantation (p<0.05).     

Nonmicrosurgical replantation using a subcutaneous pocket for salvage of the amputated fingertip

PURPOSE: The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. METHODS: Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. RESULTS: Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. CONCLUSIONS: The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.     

Toe-to-hand transfer from a cross-foot replantation in a traumatic four-extremity amputation

Treatment of mutilating hand injuries often requires multiple innovative procedures. This report describes a case of multi-limbed amputations from a train injury and the extraordinary microsurgical approaches for a two-hand reconstruction. The first stage of the procedure was a cross replantation of the left foot to the right leg. The second stage was a combined second and third toe transfer from the cross replantation of the left foot to the right hand, and a sensate fibular osteocutaneous flap transfer for left hand reconstruction. Satisfactory function was restored, including good protective sensation. These kinds of extraordinary microsurgical approaches are useful salvage procedures for hand reconstruction, when presented with a case of multi-limb amputation.     

手指多平面离断再植11例报告

目的 研究手指多平面离断再植的方法。方法 首先将手指远断段“无血再植”，再将已接好的手指断段与近端再植，最后备段一起通血同时灌注。当手指部分节段毁损部分健康时，则切取足趾节段嵌入代替毁损的手指节段。结果 本组11例24指成活23指，其中13指为两段离断，成活12指，2指为小指末节与中指中节毁损，分别取第二足趾末节与中节移植代替毁损的手指节段，均成活。结论 手指多平面离断，通过节段再植与移植可取得较满意效果。     

Solutions to challenging digital replantations

Replantation of amputated digits remains one of the most challenging areas in plastic and reconstructive surgery. Complicated cases of digital amputation, such as fingertip amputations, multidigital amputations, and so forth, pose an even greater challenge, requiring extraordinary solutions for successful replantation. The authors present their experience with complicated digital replantations at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Cases presented include fingertip replantation, replantation of a finger with impairment of arterial inflow, and two cases of multidigital amputations. In one case of multidigital amputation, heterodigital replantation was performed, and in the other case, a minute skin neurovascular free flap from a nonreplantable finger was used for the reconstruction of another injured finger. Presented cases demonstrate various tools that can be successfully used in the performance of challenging digital replantations.