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.     

Restoration of basic hand function by double transpositional digital replantation in five-digit amputations

In multiple digital amputations with severe crush injury, replantation of digits with a poor prognosis is often fruitless. Those digits with a favorable prognosis should be selectively replanted in positions that provide optimal functional outcome, regardless of their anatomic origins: this is the principle of transpositional replantation. The authors present a case of right-hand crush injury with amputation of all five digits. Basic hand function was restored by double transpositional digital replantations without additional reconstructive procedures. In properly selected cases, such procedures can preserve greater hand function and reduce the necessity for secondary operations. It is suggested that transpositional replantation should be considered when multiple digital amputations are encountered.     

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.     

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.     

Alternatives to thumb replantation in three cases of traumatic amputation of the thumb

Three cases of complete amputation of the thumb are reported in which the amputated distal parts were not suitable for replantation. In all cases there were either complete or incomplete amputations of other digits. Two different techniques were used for thumb reconstruction: 1) pollicization of a partially amputated digit with transposition microsurgery in case 1; and 2) replantation of a less important amputated digit to the thumb stump for cases 2 and 3. These microsurgical efforts successfully restored thumb function in all three patients.     

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.     

Replantation and revascularization vs. amputation in injured digits

Background

The purpose of this study was to analyze factors associated with the decision to replant or revascularize rather than amputate an injured digit as well as factors associated with successful replantation or revascularization.

Methods

We reviewed 315 complete and subtotal amputations at or proximal to the distal interphalangeal joint in 199 adult patients treated over 10 years. Ninety-three digits were replanted (30 %), 51 were revascularized (16 %), and 171 were amputated (54 %), including 5 attempted replantations. Bivariate and multivariable analyses sought factors associated with replantation vs. amputation, revascularization vs. amputation, and success of replantation or revascularization.

Results

Factors associated with replantation rather than amputation were injury to the left hand, thumb, middle digit, and ring digit, more than one digit affected, and surgeon. Factors associated with revascularization are surgeon and shorter ischemia time. Forty-five replantations (48 %) and 41 revascularizations (80 %) were successful. Successful replantation was associated with the side of injury (left side more likely to survive), zone of injury (distal interphalangeal and interphalangeal joint more likely to survive and proximal phalanx less likely to survive), and shorter ischemia time. Success of revascularization was associated with the mechanism of injury (saw and not crush injury), multiple digits involved, and the surgeon.

Conclusions

The decision to replant, revascularize, or amputate a nonviable digit and the success of replantation and revascularization are related to both injury factors, such as mechanism of injury, affected digit, and zone of injury, and the surgeon.     

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.     

Indications and surgical techniques for digit replantation

Finger amputations are devastating, life-changing injuries. They can occur from many different types of injury, but most often are caused by power tools or machinery in the workplace. Modern microvascular surgical techniques have enabled surgeons to successfully reattach fingers that have been amputated at almost level of injury. Patient outcome and digit viability have improved as surgeons have gained more experience with microvascular techniques, and have narrowed the operative indications for replantation. Currently, replantation is recommended for amputated thumbs, multiple digit amputations, and single digit amputations distal to the FDS insertion, as well as all amputations in children. Replantation surgery is technically demanding. Success relies on patient selection, meticulous operative technique, and postoperative monitoring. Most patients have successful outcomes with at least protective sensation and useful range of motion in the replanted digit. Though complications, including joint stiffness, tendon adhesions, malunion, and cold intolerance are not infrequent, patient satisfaction following replantation is high.     

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.     

Microvascular digit transposition following a two-digit amputation in an infant.

Multiple digit amputations in children demand special consideration to make subsequent hand function optimal. Replanted digits in children have a comparatively lower viability rate, but those that do survive usually go on to excellent function. In this case, an amputated thumb was severely mangled and not suitable for replantation. An amputated index finger was transposed to the thumb position. A six-month postoperative follow-up of the transposed digit confirmed satisfactory joint motion, restored sensibility, and unimpaired digit growth. The 11-month-old infant described is the youngest patient ever reported to have undergone a successful emergency microvascular digit transposition.     

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.     

Digital replantation including postoperative care

Digital replantation first became a reality in the 1960s with the advent of microsurgical techniques. Indications for replantation have evolved over the ensuing years and currently include 1) thumb amputations, 2) multiple digit amputations, and 3) amputations in children. Crush and avulsion injuries and amputations of a single digit proximal to the flexor digitorum superficialis insertion remain relative contraindications. Good communication between the replantation center microsurgeon and the referring physician is paramount to achieving appropriate and timely referrals and correct transport of amputated parts. Communication with patients is also important: possible candidates for replantation must be informed of the likely outcomes of replantation and revision amputation procedures, and the different postoperative regimens for each. For patients who choose revision amputation or whose replants do not survive, there are a variety of reconstructive options available, if necessary, such as toe-to-hand transfer. The techniques to perform such elective free tissue transfers have been perfected during the last 30 years largely from experience gained through digital replantation.     

Replantation of untidily amputated finger, hand, and arm: experience of 99 replantations in 66 cases

Three problems the authors think important in replantation of untidy amputations are discussed based on our 99 replantations with the success rate of 92.6% over a 4-year period. To restore circulation in this type of amputation, such techniques as transfer of blood vessels, use of a neurovascular island flap with neurovascular anastomoses at its distal margin, vein graft, and free split-skin graft directly on the anastomosed blood vessels are recommended. Recovery of tendon gliding when replanted proximally to the MP joint was reasonably good but not when replanted distally to it. Recovery of intrinsic muscles was generally poor. Protective sensation was usually regained, although occasionally accompanied by paresthesia. Amputation of single digit was found not to be an absolute indication for replantation except for the thumb. In multiple digital amputation, more important digits should be restored by amputated digits in better condition. Replantation for cosmetic improvement may be justified in such cases as unmarried young females. In infants, replantation is especially worthwhile because good functional recovery and good further growth can be expected.     

Distal phalanx replantation

Microsurgical replantation has been attempted in the distal phalanx of the digits. Twenty-three complete, single digit amputations are reviewed. The patients' ages ranged from 9 months to 48 years. Viability was 78%. Sensory recovery averaged 7 mm static two-point discrimination. Range of motion in the distal interphalangeal joint of the finger and the interphalangeal joint of the thumb averaged 64 and 51 degrees, respectively. Eight of the 17 successfully replanted digits had mild to moderate atrophy. Eighty-two percent of patients were able to use the replanted digit successfully in their daily work. We feel that distal digital replantation is rewarding. In successful cases, it always preserves acceptable function and good appearance at a price of an average of 2.3 months off work. © 1994 Wiley-Liss, Inc.     

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.     

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。     

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection,Outcomes, and Cost

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid’s Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.     

Replantation of the thumb, especially avulsion

In replantation for avulsion amputation of the thumb, high survival rate of replanted digits depends on good debridement, good arterial repair with vein grafts or neurovascular bundles, and good coverage, with loose closure of the wound. The functional success depends on liberal use of nerve and tendon grafts or transfer; subsequent procedures, such as tenolysis and opponensplasty; and backup procedures for cases with severe soft tissue avulsion or long ischemic periods. All thumb amputations should be explored in the operating room for evaluation of replantability. If it is still questionable, an experienced microsurgeon should be consulted to choose between replantation and an alternative reconstructive procedure.     

Recovery of sensation in replanted digits— time of recovery and degree of two-point discrimination

Even if good motor function returns in a replanted digit, if no useful sensation returns, the digit cannot be considered fully functional. In such cases sensory reconstruction with nerve grafts may be necessary, but it is difficult to determine the optimal time for such surgery. Therefore, we studied 37 replanted digits in which the palmar digital nerves had been severed bilaterally and anastomosed at the replantation procedure. Our findings indicate a correlation between the time at which sensation returned to the digits and the degree of two-point discrimination (2PD) that returned. In digits in which sensation returned less than four months after replantation, a 2PD of less than 15 mm returned in more than 50% of cases, but when more than four months passed before the return of sensation, a useful degree of 2PD seldom returned. We believe, therefore, that if the recovery of sensation in a replanted digit has not been satisfactory by four months after replantation, reconstructive surgery should be considered.