The use of arteriovenous anastomosis for venous drainage during Tamai zone I fingertip replantation

PurposeThe purpose of this study was to evaluate outcomes for patients sustaining a distal fingertip amputation who underwent replantation witharteriovenous anastomosis for venous drainage over a one year period at our institution. This technique has been utilized when insufficient veins are identified in the amputated part for standard veno-venous anastomosis.MethodsA retrospective study was performed on patients presenting from 2013 to 2014. Guillotine, crush, and avulsion/degloving injuries were included if they underwent fingertip (Tamai Zone I) replantation with arterial anastomosis for vascular inflow and arteriovenous anastomosis for venous drainage. The cases were further classified as Ishikawa subzone I and subzone II.ResultsArteriovenous anastomosis for venous drainage during replantation was used in 45 digits in 35 patients. 41 of the 45 digits underwent successful replantation using this technique (91%). The mean active ROM in the DIP joint of the fingers and in the IP joint of thumbs was 65° and 57°, respectively. Sensory evaluation demonstrated a mean of 6.9 mm s2PD in digits where the digital nerves could be repaired. 11 replanted digits without nerve repair regained some sensory recovery with a mean of 9.6 mm s2PD. 91% of patients were highly satisfied with the appearance of the replanted digits based on Tamai criteria.ConclusionsArteriovenous anastomosis for venous outflow should be considered during zone I fingertip replantation if sufficient veins are not identified in the amputated part. This technique may allow for more routine and successful distal replantation.     

仅吻合动脉的指尖再植30例

目的探讨指尖再植的治疗经验．方法对30指指尖离断进行再植,吻合指端动脉弓以远一条动脉分支21指．吻合两条动脉弓分支6指,指端动脉弓以近吻合一条指动脉3指,均未吻合静脉。缝合神经28指．术后所有再植指均未给予指腹侧方切口放血或甲床放血治疗。结果成活28指,坏死2指．成活率为93．3％。术后随访6～36个月,7指指甲有不同程度畸形,5指指腹轻度萎缩,3指指腹软组织略变硬．1指创口有瘢痕痛。其中16指外形良好,感觉恢复正常,两点辨别觉为3-6mm,运动功能正常、结论对离断指内血管损伤程度的正确评估和高质量的血管吻合是指尖再植成活的关键,指尖再植静脉不易吻合．术后可根据再植指情况给予放血治疗。     

Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations

Background:The fingertip is the most frequently injured and amputated segment of the hand. There are controversies about defining clear indications for microsurgical replantation. Many classification systems have been proposed to solve this problem. No previous study has simultaneously correlated different classification systems with replant survival rate. The aim of the study is to compare the outcomes of fingertip replantations according to Tamai and Yamano classifications.Results:Of the 34 fingertips, 26 (76.4%) survived. Ten (66.6%) of 15 digits replanted in Tamai zone 1 and 16 (84.2%) of 19 digits replanted in Tamai zone 2 survived. There were no replantation failures in Yamano type 1 injuries (100%) and only two failed in Yamano type 2 (75%). Replantation was successful in 14 of 20 Yamano type 3 injuries, but six failed (70%). The percentage of success rates was the least in the hybridized groups of Tamai zone 1-Yamano type 2 and Tamai zone 1-Yamano type 3. Although clinically distinct, the survival rates between the groups were not statistically significantly different.Conclusions:The level and mechanism of injury play a decisive role in the success of fingertip replantation. Success rate increases in proximal fingertip amputations without crush injury.     

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.     

Digital replantation in children: a long-term follow-up study

This paper reports a series of 14 cases of digital replantation in children who had had a total of 17 digits traumatically amputated. All but two digits survived, for an overall success rate of 88%. The length of follow-up was between 3 and 14 years (average 8 years). Sensory recovery of all digits was satisfactory. The mean growth rate of replanted digits relative to contralateral digits was 86%. Twelve cases had an excellent result, and one case had a good result. Digital replantation in children is recommended when feasible.     

再植指晚期骨与关节畸形

目的　探讨断指再植后晚期骨与关节畸形的发生原因和矫治方法 ,并提出相应的预防措施。方法　 1990年 1月至 2 0 0 0年 5月 ,对 3 2 8个再植指进行长期随访 ,发现 85指晚期并发骨与关节畸形 ,对畸形发生的原因进行回顾性分析 ,并对其中 5 4指进行了各类修复和重建手术。结果　再植指晚期骨与关节畸形的发生原因包括 :内固定使用不当、骨与关节处理欠妥、肌腱粘连或修复不牢固、瘢痕挛缩、受伤机制的影响和小儿骨骺损伤等。 5 4指经功能重建术后 ,其功能评分较术前显著提高 (P <0 0 5 )。结论　断指再植后晚期并发骨与关节畸形的几率较高 ,在再植术中应用各种预防手段 ,可有效降低畸形的发生 ,从而提高再植指的功能。     

双手多指离断伤再植六例分析

探讨双手多指离断再植的手术方法。方法:总结对6例双手8至10指完全离断进行再植手术并获得成功的经验。结果;6例共离断53指,再植49指成活48指,术后随访2～6年,功能恢复达到优良。结论:合理的人员组合,精湛的显微外科技术和多数量的血管吻合是再植多指成活的关键因素。     

铡草机致多指、多节段指体离断的再植

目的 探讨铡草机所致不同类型断指的手术方法 和疗效.方法 单手指再植,应用传统方法 再植;多指、多节段再植应根据伤情、人员组成、再植的顺序等方面进行合理的规划后有序的进行再植;无再植条件的指体则进行残修、皮瓣修复或足趾再造.结果 36例患者离断79指、再植69指、成活63指,成活率91.3%.术后随访3月～2年,按中华医学会手外科分会断指再植功能评定试用标准评定：优44,良10,可6,差3,优良率85.7%.结论 铡草机所致的不同断指经严格掌握再植适应症、周密的手术计划与术中精细操作、术后精心护理和早期功能锻炼,再植指体存活率高,外观及功能良好.     

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。     

指尖再植27指报告

目的介绍指尖再植的手术要点。方法对２７指指尖离断进行再植。吻合指动脉末端分支１５指，末端指动脉弓分支１２指。吻合指静脉分支１４指，动静脉转流４指，未吻合９指。神经直接缝合２３指，抽出神经束植入指尖皮下４指。结果成活２４指，成活率为８８．９％。术后随访６～３６个月，除３指指甲有增厚卷曲畸形，５指指腹有不同程度萎缩外，１９指外形良好，感觉已恢复正常，两点辨别觉为５～７ｍｍ。结论熟悉指尖部动静脉的解剖和高质量的血管吻合技术是保证再植成功的关键。     

Arteriovenous shunt in digit replantation

From May 1958 to May 1987, 331 digits were replanted successfully with an overall survival rate of 86.2%. Complete success in replantation of amputated fingers requires an accurate anastomoses of both arteries and veins. However, anastomosis between arteries may not be possible in some patients. Since reports that a thumb amputated at the interphalangeal joint area could be successfully replanted by an arteriovenous shunt on the palmar side, we did arteriovenous shunts in four such cases. Two replantations were successful; necrosis developed in the other two patients.     

Present status of replantation in Japan

We conducted a survey among 94 members of the Japanese Society of Reconstructive Microsurgery on the present status of replantation in Japan. The results indicate that 9,664 extremities were replanted (157 upper arms, 415 forearms, 471 hands, 8,320 digits, 33 thighs, 103 calves, 37 feet, and 128 toes); 8,227 replants survived, for a success rate of 85%. The survival rate was over 90% in 23 hospitals, and 7 of these hospitals replanted more than 100 limbs. Postoperative treatment consisted of continuous intravenous infusion of urokinase (120,000-240,000 U/day), heparin (10,000-20,000 U/day), and prostaglandin E₁ (80–120 μg/day) for 3–10 days. Fifty-six surgeons attempted replantation whenever the patient requested it. At Nara Medical University, continuous local intra-arterial infusion of anticoagulants and fibrinolytic agents has increased the survival rate of the replantation to 97%, compared with 88% when using intravenous infusion. © 1994 Wiley-Liss, Inc.     

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.     

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.     

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.     

软组织缺损断指再植的皮瓣移植

为解决伴有软组织缺损的断指进行再植，自１９８９年１月－１９９３年１２月，应用１２处１０５块带蒡及游离皮瓣移植修复软组织缺损进行再植８６例，共１１２指。再植成活率９６．４％，皮瓣成活率９８．１％。随访６－２４个月，按中野与玉井断指再植的功能评价：优良率达８５．９％。结果表明：利用不同皮瓣一期修复断指再植时皮肤、神经、血管、肌腱能最大限度恢复再术后的外形及功能。     

Cortical reorganization after digit-to-hand replantation

Functional recovery after digit-to-hand replantation depends on the interaction of various factors. In addition to peripheral mechanisms, cortical and subcortical reorganization of digit representation may play a substantial role in the recovery process. However, cortical processes during the first months after replantation are not well understood. In this 25-year-old man who had traumatically lost digits II to V (DII-V) on his right hand, the authors used magnetoencephalographic source imaging to document the recovery of somatosensory cortical responses after tactile stimulation at four sites on the replanted digits. Successful replantation of DIV and DV was accomplished at the original position of DIII and DIV with mixed innervation. Cortical evoked fields could be recorded starting from the 10th week after digit-to-hand replantation. Initially, signals from all sites showed decreased amplitudes and prolonged latencies. In the subsequent six recordings obtained between the 12th and 55th week postreplantation, a continuous increase in amplitude but only a slight recovery of latencies were observed. Components of the recorded somatosensory evoked fields were localized in the primary somatosensory cortex (SI). The localizations of the replanted DIV showed a gradual lateral-inferior shift in the somatosensory cortex over time, indicating cortical reorganization caused by altered peripheral input. The authors infer from this shift that the original cortical area of the missing finger (DII) was taken over by the replanted finger. From these data the authors conclude that magnetic source imaging might be a reliable noninvasive method to evaluate surgical nerve repair and that cortical reorganization of SI is involved in the regeneration process following peripheral nerve injury.     

Digital replantations distal to the distal interphalangeal joint

Microvascular replantations of digits distal to the distal interphalangeal (DIP) joint were reviewed in 33 digits of 29 patients. Twenty-five digits were completely amputated and eight were incompletely amputated. Ten of 33 replants failed and 23 digits survived. Even without venous reconstruction, good results were obtained in Zone I. Of eight completely amputated digits in Zone 1 in which venous reconstruction was not performed, seven digits survived. Of four completely amputated digits in Zone 2 without venous reconstruction, all became necrotic. In digits followed for six months or more after surgery, 11 of 13 replantations showed good functional recovery. Two digits that developed paresthesia after replantation were functionally useless. Seven digits without bilateral digital nerve reconstruction were reviewed six months or more after surgery. Sensory recovery was good in the digital phalanx; the factor impeding functional recovery was the development of paresthesia. Replanted digits distal to the DIP joint are thus satisfactory in both function and cosmesis, even if digital nerves have not been reconstructed. The replantation of such digits should be considered.     

多指离断再植的探讨

目的 探讨多指离断再植手术中各阶段处理方法，提高各种断指再植的成功率。方法 手指末节、指尖部的断指再植，吻合1条动脉及静脉或者吻合1条动态加拔指甲、小切口放血处理，手指中节断指再植吻合动，静脉比例为1：1，手指近节的距离断再植吻合动、静脉比列1：2或者2：2。如有血管缺损，行浅静脉移植桥接或者邻指动脉移植修复。临床再植58例，142指。结果 再植58例142指中成活129指，成活率90.8%。术后经3个月-3年随访到46例113指。按断指再植评定标准评定，其中优53指，良44指，可14指，差7指，总优良率85.8%.结论 多指离断再植手术时间长,技术要求高。术中高质量的血管吻合及对血管缺损的正确处理，术后血管危象的防治是提高多手指离断再植成功的关键。加强功能锻炼是再植手指功能恢复的重要环节。     

Nonarterialized Venous Replantation of Part of Amputated Thumb—A Case Report and Review of the Literature

Since the first successful replantation of a human thumb reported by Komatsu and Tamai in 1968, thousands of severed digits and body parts have been successfully salvaged. Restoration of anatomic form and function are the goals of replantation after traumatic tissue amputation. Regardless of anatomic location, methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. Numerous techniques to maximize tissue survival after revascularization have been described, including “pocket procedures” to salvage composite grafts, interposition vein grafts, and medicinal leeches to name a few. Artery-to-venous anastomoses have been performed with successful “arterialization” of the distal venous system in fingertip replantation. Although there is documented survival of free venous cutaneous flaps, to our knowledge this is the first report of a replanted composite body part (bone, tendon, soft tissues, and skin) utilizing exclusively multiple, microvascular, nonarterialized venous–venous anastomoses. We present a patient with an isolated band saw fillet amputation to the back of the thumb at the metacarpal–phalangeal joint region, resulting in a composite graft composed of bone, tendon, soft tissue, and skin. The hand wound provided no viable regional arterial inflow source, but there were multiple good caliber superficial veins present. The amputated tissues were replanted and revascularized by using only venous blood flow. The replanted part survival was 100% with excellent function of the digit. We conclude that a hand composite body part involving bone, tendon, soft tissues, and skin can survive replantation with a strict venous blood supply if sufficient good caliber, microvascular, venous–venous anastomoses are performed, granted that arterial inflow options are not available. This is an isolated case, yet introduces a new way of thinking regarding tissue replantation.