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Fijany AJ, Chaker SC, Egozi HP, Hung YC, Hill BJ, Bhandari L, Thayer WP, Lineaweaver WC. Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival. Ann Plast Surg 2024; 92:667-676. [PMID: 38725110 DOI: 10.1097/sap.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
INTRODUCTION A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates. METHODS The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval. RESULTS Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05). DISCUSSION Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.
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Affiliation(s)
- Arman J Fijany
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Chen Z, Li M, Huang S, Wu G, Zhang Z. Is Prolonged Use of Antibiotic Prophylaxis and Postoperative Antithrombotic and Antispasmodic Treatments Necessary After Digit Replantation or Revascularization? Clin Orthop Relat Res 2023; 481:1583-1594. [PMID: 36795073 PMCID: PMC10344486 DOI: 10.1097/corr.0000000000002578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Ensuring the patency of repaired vessels is pivotal in improving the success rate of digit replantation. There is no consensus on how to best approach postoperative treatment for digit replantation. The influence of postoperative treatment on the risk of failure of revascularization or replantation remains unclear. QUESTIONS/PURPOSES (1) Is there an increased risk of postoperative infection with early discontinuation of antibiotic prophylaxis? (2) How are anxiety and depression affected by a treatment protocol consisting of prolonged antibiotic prophylaxis and administration of antithrombotic and antispasmodic drugs and by the failure of a revascularization or replantation procedure? (3) Are there differences in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins? (4) What factors are associated with failure of revascularization or replantation? METHODS This retrospective study was conducted between July 1, 2018, and March 31, 2022. Initially, 1045 patients were identified. One hundred two patients chose revision of amputation. In all, 556 were excluded because of contraindications. We included all patients in whom the anatomic structures of the amputated part of the digit were well preserved, and those with an ischemia time for the amputated part that did not exceed 6 hours. Patients in good health without any other serious associated injuries or systemic diseases and those without a history of smoking were eligible for inclusion. The patients underwent procedures that were performed or supervised by one of four study surgeons. Patients were treated with antibiotic prophylaxis (1 week); patients treated with antithrombotic and antispasmodic drugs were categorized into the prolonged antibiotic prophylaxis group. The remaining patients treated with antibiotic prophylaxis for less than 48 hours and no antithrombotic and no antispasmodic drugs were categorized into the nonprolonged antibiotic prophylaxis group. Postoperative follow-up was for a minimum of 1 month. Based on the inclusion criteria, 387 participants with 465 digits were selected for an analysis of postoperative infection. Twenty-five participants with a postoperative infection (six digits) and other complications (19 digits) were excluded from the next stage of the study, in which we assessed factors associated with the risk of failure of revascularization or replantation. A total of 362 participants with 440 digits were examined, including the postoperative survival rate, variation in Hospital Anxiety and Depression Scale scores, the association between the survival rate and Hospital Anxiety and Depression Scale scores, and the survival rate based on the number of anastomosed vessels. Postoperative infection was defined as swelling, erythema, pain, purulent discharge, or a positive bacterial culture result. Patients were followed for 1 month. The differences in anxiety and depression scores between the two treatment groups and the differences in anxiety and depression scores based on failure of revascularization or replantation were determined. The difference in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins was assessed. Except for statistically significant variables (injury type and procedure), we thought that the number of arteries, number of veins, Tamai level, treatment protocol, and surgeons would be important. A multivariable logistic regression analysis was used to perform an adjusted analysis of risk factors such as postoperative protocol, injury type, procedure, number of arteries, number of veins, Tamai level, and surgeon. RESULTS Postoperative infection did not appear to increase without prolonged use of antibiotic prophylaxis beyond 48 hours (1% [3 of 327] versus 2% [3 of 138]; OR 2.4 [95% confidence interval (CI) 0.5 to 12.0]; p = 0.37). Intervention with antithrombotic and antispasmodic therapy increased the Hospital Anxiety and Depression Scale scores for anxiety (11.2 ± 3.0 versus 6.7 ± 2.9, mean difference 4.5 [95% CI 4.0 to 5.2]; p < 0.01) and depression (7.9 ± 3.2 versus 5.2 ± 2.7, mean difference 2.7 [95% CI 2.1 to 3.4]; p < 0.01). In the analysis based on the failure of revascularization or replantation, the Hospital Anxiety and Depression Scale scores for anxiety (11.4 ± 4.4 versus 9.7 ± 3.5, mean difference 1.7 [95% CI 0.6 to 2.8]; p < 0.01) and depression (8.5 ± 4.6 versus 7.0 ± 3.1, mean difference 1.5 [95% CI 0.5 to 2.5]; p < 0.01) were higher in the failed revascularization or replantation group than in the successful revascularization or replantation group. There was no increase in the artery-related risk of failure (one versus two anastomosed arteries: 91% versus 89%, OR 1.3 [95% CI 0.6 to 2.6]; p = 0.53). For patients with anastomosed veins, a similar outcome was observed for the two vein-related risk of failure (two versus one anastomosed vein: 90% versus 89%, OR 1.0 [95% CI 0.2 to 3.8]; p = 0.95) and three vein-related risk of failure (three versus one vein anastomosed: 96% versus 89%, OR 0.4 [95% CI 0.1 to 2.4]; p = 0.29). Factors associated with failure of revascularization or replantation included the mechanism of injury (crush: OR 4.2 [95% CI 1.6 to 11.2]; p < 0.01, avulsion: OR 10.2 [95% CI 3.4 to 30.7]; p < 0.01). Revascularization had a lower risk of failure than replantation (OR 0.4 [95% CI 0.2 to 1.0]; p = 0.04). Treatment with a protocol of prolonged antibiotics, antithrombotics, and antispasmodics was not associated with a lower risk of failure (OR 1.2 [95% CI 0.6 to 2.3]; p = 0.63). CONCLUSION With proper wound debridement and patency of repaired vessels, prolonged use of antibiotic prophylaxis and regular antithrombotic and antispasmodic treatment may not be necessary for successful digit replantation. However, it may be associated with higher Hospital Anxiety and Depression Scale scores. Postoperative mental status is associated with digit survival. Well-repaired vessels, instead of the number of anastomosed vessels, could be critical to survival and decrease the influence of risk factors. Further research on consensus guidelines that compare postoperative treatment and the surgeon's level of expertise after digit replantation should be conducted at multiple institutions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Zhiying Chen
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Muwei Li
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Shaogeng Huang
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Gong Wu
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
| | - Zhe Zhang
- Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China
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Lin ICF, Yoon AP, Kong L, Wang L, Chung KC. Association Between Daytime vs Overnight Digit Replantation and Surgical Outcomes. JAMA Netw Open 2022; 5:e2229526. [PMID: 36048443 PMCID: PMC9437749 DOI: 10.1001/jamanetworkopen.2022.29526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown. OBJECTIVE To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation. DESIGN, SETTING, AND PARTICIPANTS This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein. EXPOSURES Daytime or overnight digit replantation. MAIN OUTCOMES AND MEASURES Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery. RESULTS A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (β, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (β, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time. CONCLUSIONS AND RELEVANCE In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.
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Affiliation(s)
- I-Chun F. Lin
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Alfred P. Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Lingxuan Kong
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor
| | - Lu Wang
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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SAITO T, UEHARA T, NAKAHARA R, SHIMAMURA Y, NAKAO A, OZAKI T. Risk Factors for Infection Following Operative Treatment of Traumatic Upper Extremity Amputation Injury. J Hand Surg Asian Pac Vol 2022; 27:691-697. [DOI: 10.1142/s2424835522500709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Identification of the risk factors for surgical site infection (SSI) can be a straightforward and cost-effective measure to reduce or prevent the occurrence of SSI. However, there are no studies that revealed risk factors for SSI for traumatic upper extremity amputation. The aim of this study is to investigate the risk factors that promote SSI after surgery for traumatic upper extremity amputation using a large nationwide database. Methods: We used data from the Japan Trauma Data Bank. Diagnoses were defined using the Abbreviated Injury Scale code. We applied multivariate logistic regression to evaluate the infection risk factor. We chose age, sex, vital signs, cause and type of trauma, concomitant injury, diabetes, amputation level, Glasgow coma scale, Injury Severity Score (ISS) and blood transfusion within 24 hours following hospital arrival as confounders. Receiver operating characteristic (ROC) curve analysis was adopted to identify thresholds for change in infection risk. We also applied propensity score (PS) matching to adjust for confounding factors that may affect the outcome. Results: A total of 1,150 patients (967 males, 183 females) had traumatic upper extremity amputation. The mean patient age was 46.5 years. A total of 21 patients (1.8%) suffered from SSI. ISS, blood transfusion, systolic blood pressure (BP) and the upper extremity amputation except for finger were identified as the independent significant risk factors for SSI occurrence by the multivariate analysis (p < 0.05, p < 0.005, p < 0.05 and p < 0.005, respectively). ROC modelling revealed that patients with ISS of over 9 or systolic BP of over 160 had a risk for SSI. After PS matching, the patients with blood transfusion or systolic BP of over 160 had a significantly higher risk of infection (OR 9.0; p = 0.01 and OR 7.0; p = 0.03, respectively). Conclusions: In treating patients with these risk factors, we must be especially careful in performing thorough debridement and wound care. Level of Evidence: Level II (Therapeutic)
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Affiliation(s)
- Taichi SAITO
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takenori UEHARA
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Ryuichi NAKAHARA
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasunori SHIMAMURA
- Department of Sports Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Atsunori NAKAO
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Toshifumi OZAKI
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Ishiura R, Shiraishi M, Okada Y, Mitsui K, Hansini Banda C, Danno K, Narushima M. Treatment of cold intolerance following finger pulp amputations: a case comparison between immediate finger replantation and delayed pulp and digital arterial arch reconstruction with flow-through free hypothenar flap. Case Reports Plast Surg Hand Surg 2022; 9:33-36. [PMID: 34993273 PMCID: PMC8725866 DOI: 10.1080/23320885.2021.2020656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a unique case of cold intolerance following identical fingertip amputations of two fingers on the same hand. The index finger was replanted and the middle finger was reconstructed with a free flow-through hypothenar perforator flap to anatomically restore the digital arterial arch circulation and successfully treat cold intolerance.
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Affiliation(s)
- Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
| | - Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
| | - Yoshimoto Okada
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
| | | | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Japan
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Harbour PW, Malphrus E, Zimmerman RM, Giladi AM. Delayed Digit Replantation: What is the Evidence? J Hand Surg Am 2021; 46:908-916. [PMID: 34376294 DOI: 10.1016/j.jhsa.2021.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/24/2021] [Accepted: 07/02/2021] [Indexed: 02/02/2023]
Abstract
A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of "delayed" replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.
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Affiliation(s)
- Patrick W Harbour
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Elizabeth Malphrus
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA
| | - Ryan M Zimmerman
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
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Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
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Letter to the Editor Regarding Errors in 2006 Review Titled "A Meta-Analysis of Success Rates for Digit Replantation". Tech Hand Up Extrem Surg 2021; 25:59. [PMID: 33617172 DOI: 10.1097/bth.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heineman J, Bueno EM, Kiwanuka H, Carty MJ, Sampson CE, Pribaz JJ, Pomahac B, Talbot SG. All hands on deck: Hand replantation versus transplantation. SAGE Open Med 2020; 8:2050312120926351. [PMID: 32537157 PMCID: PMC7268554 DOI: 10.1177/2050312120926351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 01/07/2023] Open
Abstract
Objectives: Our hands play a remarkable role in our activities of daily living and the
make-up of our identities. In the United States, an estimated 41,000
individuals live with upper limb loss. Our expanding experience in limb
transplantation—including operative techniques, rehabilitation, and expected
outcomes—has often been based on our past experience with replantation.
Here, we undertake a systematic review of replantation with transplantation
in an attempt to better understand the determinants of outcome for each and
to provide a summary of the data to this point. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses
guidelines, we conducted PubMed searches from 1964 to 2013 for articles in
English. In total, 53 primary and secondary source articles were found to
involve surgical repair (either replantation or transplantation) for
complete amputations at the wrist and forearm levels. All were read and
analyzed. Results: Hand replantations and transplantations were compared with respect to
pre-operative considerations, surgical techniques, post-operative
considerations and outcomes, including motor, sensation, cosmesis, patient
satisfaction/quality of life, adverse events/side effects, financial costs,
and overall function. While comparison of data is limited by heterogeneity,
these data support our belief that good outcomes depend on patient
expectations and commitment. Conclusion: When possible, hand replantation remains the primary option after acute
amputation. However, when replantation fails or is not possible, hand
transplantation appears to provide at least equal outcomes. Patient
commitment, realistic expectations, and physician competence must coincide
to achieve the best possible outcomes for both hand replantation and
transplantation.
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Affiliation(s)
- John Heineman
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ericka M Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew J Carty
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Christian E Sampson
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian J Pribaz
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Simon G Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Woo SH. Practical Tips to Improve Efficiency and Success in Upper Limb Replantation. Plast Reconstr Surg 2020; 144:878e-911e. [PMID: 31688770 DOI: 10.1097/prs.0000000000006134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVES After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation. SUMMARY This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.
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Affiliation(s)
- Sang Hyun Woo
- From the W Institute for Hand and Reconstructive Microsurgery and the Department of Plastic and Reconstructive Surgery, W General Hospital
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Miles O, Grinsell D. Proximal interphalangeal joint arthroplasty post digital replant: a case report. ANZ J Surg 2019; 90:1798-1799. [PMID: 31886599 DOI: 10.1111/ans.15679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Oliver Miles
- Department of Plastic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Damien Grinsell
- Department of Plastic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Kempny T, Knoz M, Lipovy B, Priol A, Holoubek J. The use of a Gore-Tex prosthesis to stabilise venous drainage in an amputated distal forearm replantation. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01542-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kamarul T, Mansor A, Robson N, Albusaidi SH, Suhaeb AM, Samsudin EZ. Replantation and revascularization of amputated upper limb appendages outcome and predicting the factors influencing the success rates of these procedures in a tertiary hospital: An 8-year retrospective, cross-sectional study. J Orthop Surg (Hong Kong) 2019; 26:2309499017749983. [PMID: 29320962 DOI: 10.1177/2309499017749983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Worldwide advances in microsurgery have made salvaging of amputated hand via replantation and revascularization common procedures. The present study examines the outcome of these procedures in a tertiary hospital in Malaysia. METHODS Patients with hand amputation who underwent replantation or revascularization from 2005 to 2012 were identified and reviewed for patient characteristics, amputation characteristics and survival rates. Successfully treated patients were interviewed to assess the functional outcome using Quick Disability of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Statistical analysis was performed to evaluate outcome and elicit predictive factors. RESULTS Fifty-five patients were enrolled: 37 (67.3%) underwent replantation and 18 (32.7%) underwent revascularization. The overall success rate of 78% ( n = 43) was within the range of previously reported data (61.6% to 96.0%). Ischaemic time <6 h provided significantly better survival rates ( p < 0.05). Functional outcomes were successfully assessed in 34 patients (79%), at a mean follow-up of 40 months (range 11-93 months). The overall Quick-DASH and MHQ scores were 42.82 ± 23.69 and 60.94 ± 12.82, respectively. No previous reports of functional outcome were available for comparison. Both Quick-DASH ( p = 0.001) and MHQ scores ( p < 0.001) were significantly higher for finger injuries, followed by thumb, wrist and palm injuries. CONCLUSION Ischaemic time and level of injury are important predictors of success rate of replantation and revascularization of amputated upper limb appendages.
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Affiliation(s)
- Tunku Kamarul
- 1 National Orthopaedic Centre of Excellence for Research and Learning, Department of Orthopaedics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.,2 Clinical Investigation Centre, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azura Mansor
- 1 National Orthopaedic Centre of Excellence for Research and Learning, Department of Orthopaedics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Noorzurani Robson
- 3 Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Salim Hh Albusaidi
- 1 National Orthopaedic Centre of Excellence for Research and Learning, Department of Orthopaedics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Abdulrazzaq M Suhaeb
- 1 National Orthopaedic Centre of Excellence for Research and Learning, Department of Orthopaedics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Ely Z Samsudin
- 2 Clinical Investigation Centre, University Malaya Medical Centre, Kuala Lumpur, Malaysia
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Satria O, Abubakar I, Mahendra Karda IW. Replantation at the level of the wrist joint: A case report. J Clin Orthop Trauma 2019; 10:873-878. [PMID: 31528060 PMCID: PMC6739268 DOI: 10.1016/j.jcot.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/09/2019] [Indexed: 11/27/2022] Open
Abstract
Upper extremities amputations are devastating injuries that have a major impact on patients' quality of life. Replantation after traumatic amputation is often performed to obtain limb recovery. Following the high survival rate of replantation of post-traumatic hand amputation, recent emphasis has now shifted to functional recovery rather than survival only. Wrist replantation remains a challenging procedure for orthopaedic and hand surgeon. We reported a case of a 25-year-old male with traumatic amputation of the right hand.
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Affiliation(s)
| | - Irsan Abubakar
- Department of Orthopaedics & Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
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15
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Abstract
Secondary surgery following digital replantation and revascularization is common and is often performed to improve range of motion, tendon gliding, sensibility, and/or contour. In this article, the authors present the most common secondary procedures performed after digital replantation or revascularization and discuss current techniques. The importance of patient selection and postoperative compliance with ongoing hand therapy is paramount to achieving good outcomes.
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16
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Shaterian A, Sayadi LR, Anderson A, Ng WKY, Evans GRD, Leis A. Characteristics of Secondary Procedures following Digit and Hand Replantation. J Hand Microsurg 2019; 11:127-133. [PMID: 31814663 DOI: 10.1055/s-0039-1681981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022] Open
Abstract
Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.
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Affiliation(s)
- Ashkaun Shaterian
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Lohrasb Ross Sayadi
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Amanda Anderson
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Wendy K Y Ng
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Gregory R D Evans
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
| | - Amber Leis
- Department of Plastic Surgery, University of California, Irvine, Orange, California, United States
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17
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Stjernbrandt A, Carlsson D, Pettersson H, Liljelind I, Nilsson T, Wahlström J. Cold sensitivity and associated factors: a nested case-control study performed in Northern Sweden. Int Arch Occup Environ Health 2018; 91:785-797. [PMID: 29808434 PMCID: PMC6132661 DOI: 10.1007/s00420-018-1327-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/22/2018] [Indexed: 12/01/2022]
Abstract
Purpose To identify factors associated with the reporting of cold sensitivity, by comparing cases to controls with regard to anthropometry, previous illnesses and injuries, as well as external exposures such as hand–arm vibration (HAV) and ambient cold. Methods Through a questionnaire responded to by the general population, ages 18–70, living in Northern Sweden (N = 12,627), cold sensitivity cases (N = 502) and matched controls (N = 1004) were identified, and asked to respond to a second questionnaire focusing on different aspects of cold sensitivity as well as individual and external exposure factors suggested to be related to the condition. Conditional logistic regression analyses were performed to determine statistical significance. Results In total, 997 out of 1506 study subjects answered the second questionnaire, yielding a response rate of 81.7%. In the multiple conditional logistic regression model, identified associated factors among cold sensitive cases were: frostbite affecting the hands (OR 10.3, 95% CI 5.5–19.3); rheumatic disease (OR 3.1, 95% CI 1.7–5.7); upper extremity nerve injury (OR 2.0, 95% CI 1.3–3.0); migraines (OR 2.4, 95% CI 1.3–4.3); and vascular disease (OR 1.9, 95% CI 1.2–2.9). A body mass index ≥ 25 was inversely related to reporting of cold sensitivity (0.4, 95% CI 0.3–0.6). Conclusions Cold sensitivity was associated with both individual and external exposure factors. Being overweight was associated with a lower occurrence of cold sensitivity; and among the acquired conditions, both cold injuries, rheumatic diseases, nerve injuries, migraines and vascular diseases were associated with the reporting of cold sensitivity.
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Affiliation(s)
- Albin Stjernbrandt
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden. .,Occupational and Environmental Medicine, University Hospital of Umeå, 901 85, Umeå, Sweden.
| | - Daniel Carlsson
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Hans Pettersson
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Ingrid Liljelind
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Tohr Nilsson
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Jens Wahlström
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, 901 87, Umeå, Sweden
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Lafosse T, Jehanno P, Fitoussi F. Complications and Pitfalls after Finger Replantation in Young Children. J Hand Microsurg 2018; 10:74-78. [PMID: 30154619 DOI: 10.1055/s-0038-1626684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/07/2017] [Indexed: 10/17/2022] Open
Abstract
Study Design This is a retrospective cohort study. Objective The authors report surgical outcome in a series of very young children who underwent finger replantation after traumatic amputation. Methods During a 10-year period, 65 children were treated with replantation for finger amputation in two institutions. This study focused on replantation of 15 fingers in 13 young patients under 6 years of age (mean age: 2.9 years; range: 1.1-5.7 years). Early postoperative complications were categorized into major or minor. At the time of assessment, the authors evaluated everyday life activities, pain and cold tolerance, total active range of motion (TAM) in patients with successful replantation, and growth disturbance. Results The overall success rate for children younger than 6 years was 47% (7 out of 15), and the authors had 67% of major complications, mainly in patients with crush injuries. There was venous ischemia in 13 (86%) fingers treated with controlled bleeding. The hemoglobin level decreased more than 2 g/dL in six patients, and blood transfusion was necessary in two patients. At the last follow-up, patients with successful replantation had a mean TAM of 72%. Conclusion Despite numerous complications mainly in relation with venous congestion, the functional outcome is satisfactory after successful replantation in young children, which should always be attempted. Level of Evidence/Type of Study Level III, case series, therapeutic study.
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Affiliation(s)
- Thibault Lafosse
- Department of Pediatric Orthopedic and Reconstructive Surgery, Trousseau Hospital, Paris, France
| | - Pascal Jehanno
- Department of Pediatric Orthopedic Surgery, Robert Debre Hospital, Paris, France
| | - Frank Fitoussi
- Department of Pediatric Orthopedic and Reconstructive Surgery, Trousseau Hospital, Paris, France
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19
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Zhao G, Mi J, Rui Y, Pan X, Yao Q, Qiu Y. Correlation of volumetric flow rate and skin blood flow with cold intolerance in digital replantation. Medicine (Baltimore) 2017; 96:e9477. [PMID: 29390590 PMCID: PMC5758292 DOI: 10.1097/md.0000000000009477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cold intolerance is a common complication of digital replantation. The exact etiology is unclear, but it is considered to be multifactorial, including nonsurgical characteristics, vascular, and neurologic conditions. Blood flow may play a significant role in cold intolerance. This study was designed to evaluate the correlation of digital blood flow, including volumetric flow rate (VFR) and skin blood flow (SkBF), with cold intolerance in replanted fingers.A retrospective study was conducted among patients who underwent digital replantation between 2010 and 2013. Patients were selected into study cohort based on the inclusion criteria. Surgical data was collected on each patient, including age, sex, injury mechanism, amputation level, ischemia time, number of arteries repaired, and whether or not vascular crisis occurred. Patients were included as study cohort with both nerves repaired and without chronic disease. Cold intolerance was defined as a Cold Intolerance Symptom Severity (CISS) score over 30. The arterial flow velocity and caliber were measured by Color Doppler Ultrasound and the digital VFR was calculated. The SkBF was measured by Laser Speckle Imager. Both VFR and SkBF were calculated as a percentage of the contralateral fingers. Comparative study of surgical data and blood flow was performed between the patient with and without cold intolerance. Correlation between VFR and SkBF was also analyzed.A total of 93 patients met inclusion criteria for the study. Approximately, 42 patients were identified as having cold intolerance. Fingers that survived vascular crisis had a higher incidence of cold intolerance with a lower VFR and SkBF. The VFR was higher in 2-artery replantation, but the SkBF and incidence of cold intolerance did not differ significantly. No differences were found in age, sex, injury mechanism, amputation level, or ischemia time. Furthermore, no correlation was found between VFR and SkBF.Cold intolerance of digital replantation is associated with decreased SkBF and VFR in the replanted fingers, which survived vascular crisis. Further work will be focused on how vascular crisis cause the decreasing of SkBF and VFR and the increasing chance of cold intolerance.
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Affiliation(s)
- Gang Zhao
- Department of Medicine, Soochow University, Suzhou
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Jingyi Mi
- Department of Medicine, Soochow University, Suzhou
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Yongjun Rui
- Department of Medicine, Soochow University, Suzhou
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Xiaoyun Pan
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Qun Yao
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Yang Qiu
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
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20
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Nolte MT, Shauver MJ, Chung KC, Giladi AM. Effect of Policy Change on the Use of Long-Distance Transport and Follow-Up Care for Patients With Traumatic Finger Amputations. J Hand Surg Am 2017; 42:610-617.e2. [PMID: 28499510 PMCID: PMC5545056 DOI: 10.1016/j.jhsa.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE In January 2006, the American College of Emergency Physicians released updated guidelines for air transfer. Digit amputation and near-amputation were no longer an indication for this costly service. We analyzed the effect of this update on the use of air transport and associated care outcomes for finger amputation patients and examined factors involved in providing follow-up care for these patients. METHODS A retrospective chart review identified all patients treated for traumatic finger amputation between 1995 and 2012 at a major hand trauma referral center. Analysis of available outcome measures was conducted using multiple logistic and linear regression models. Analysis of factors affecting frequency of return visits was performed via negative binomial regression. RESULTS We identified 724 patients with isolated traumatic finger amputations. A total of 267 patients (37%) were transferred from an outside hospital. Patients injured after 2006 were less likely to be transferred via air, with a decrease from 29.5% pre-2006 to 14.9% post-2006. There was no difference in likelihood of replantation success, length of hospital stay, or number of return visits pre- versus post-2006. Patients transferred via helicopter after 2006 were more likely to be younger than 20 years of age and injured in a winter month. Following successful replantation, work-relatedness was associated with a higher number of return visits, whereas increasing age and transfer from farther than 100 miles away were associated with fewer. CONCLUSIONS After the American College of Emergency Physicians policy update, decreased use of emergency air transport to a hand trauma referral center for patients with traumatic finger amputations did not adversely affect care delivery and outcomes. These changes may be successfully implemented on a center-by-center basis to reduce costs without detriment to patient care; however, coordination of follow-up care for long-distance transport patients may require special focus when designing policy around referral centers. TYPE PF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Melissa J. Shauver
- Clinical Research Coordinator, Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Aviram M. Giladi
- Resident, Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Wilkens SC, Claessen FMAP, Ogink PT, Moradi A, Ring D. Reoperation After Combined Injury of the Index Finger: Repair Versus Immediate Amputation. J Hand Surg Am 2016; 41:436-40.e4. [PMID: 26794123 DOI: 10.1016/j.jhsa.2015.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify factors associated with unplanned reoperation of severely injured index fingers and to address the number of amputations after initial repair. METHODS In this retrospective study, we included all patients older than 18 years of age who had repair or immediate amputation for combined index finger injury at 2 level I trauma centers and 1 community hospital tied to a level I trauma center between January 2004 and February 2014. Twelve patients were excluded because of inadequate follow-up. Bivariate and multivariable analyses sought factors associated with unplanned reoperation after repair and immediate amputation. RESULTS Among 114 patients with combined injury, 75 were treated with repair and 39 with immediate amputation. A total of 41 patients had an unplanned reoperation, 33 after repair (44%) and 8 after immediate amputation (21%). In multivariable analysis, patients who had a reoperation for fingers other than the index finger were at risk for unplanned reoperation after repair. Women were more likely to have an unplanned reoperation than men, and patients who had a ray amputation were at risk for unplanned reoperation after immediate amputation. Six patients (18%) had amputation after initial repair. CONCLUSIONS Surgeons may counsel patients that they are twice as likely to have an unplanned reoperation after a repair for combined injury of the index finger compared with an immediate amputation. Unplanned reoperations were more common among patients with injuries involving multiple fingers. Effective shared decision making is particularly important in this setting given that 1 in 5 repaired index fingers were eventually amputated. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Suzanne C Wilkens
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Femke M A P Claessen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Paul T Ogink
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - Ali Moradi
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
| | - David Ring
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA.
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Sun YC, Chen QZ, Chen J, Qian ZW, Kong J, Gong YP. Prevalence, characteristics and natural history of cold intolerance after the reverse digital artery flap. J Hand Surg Eur Vol 2016. [PMID: 26221010 DOI: 10.1177/1753193415596438] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This retrospective study was designed to investigate the prevalence, characteristics and natural history of cold intolerance after the use of the reverse digital artery flap. A total of 123 patients were treated between 2010 and 2013. After excluding patients who were lost to follow-up, 87 patients were studied. The mean follow-up time was 34 months (range 14-61). Cold intolerance occurred in 60% (52) of patients after the reverse digital artery flap procedure. The condition improved in only 15% (8) of the patients. Significant differences were observed in the age and the specific digit involved between the groups with and without cold intolerance. There was a lower incidence in younger patients, and the ring finger group showed a lower incidence than in other fingers. Furthermore, the Cold Intolerance Symptom Severity score was positively correlated with the temperature at which cold intolerance was triggered. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Y C Sun
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Q Z Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - J Chen
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Z W Qian
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - J Kong
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Y P Gong
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
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Ma Z, Guo F, Qi J, Xiang W, Zhang J. Effects of non-surgical factors on digital replantation survival rate: a meta-analysis. J Hand Surg Eur Vol 2016; 41:157-63. [PMID: 26272821 DOI: 10.1177/1753193415594572] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 03/26/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study aimed to evaluate the risk factors affecting survival rate of digital replantation by a meta-analysis. A computer retrieval of MEDLINE, OVID, EMBASE, and CNKI databases was conducted to identify citations for digital replantation with digit or finger or thumb or digital or fingertip and replantation as keywords. RevMan 5.2 software was used to calculate the pooled odds ratios. In total, there were 4678 amputated digits in 2641 patients. Gender and ischemia time had no significant influence on the survival rate of amputation replantation (P > 0.05). Age, injured hand, injury type, zone, and the method of preservation the amputated digit significantly influence the survival rate of digital replantation (P < 0.05). Children, right hand, crush, or avulsion and little finger are the risk factors that adversely affect the outcome. THE LEVEL OF EVIDENCE Level 5*.
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Affiliation(s)
- Z Ma
- Department of Orthopedics, Huazhong University of Science and Technology, Wuhan, China
| | - F Guo
- Department of Orthopedics, Huazhong University of Science and Technology, Wuhan, China
| | - J Qi
- Department of Orthopedics, Huazhong University of Science and Technology, Wuhan, China
| | - W Xiang
- Department of Orthopedics, Huazhong University of Science and Technology, Wuhan, China
| | - J Zhang
- Department of Orthopedics, Huazhong University of Science and Technology, Wuhan, China
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Abstract
There are many options in the management of fingertip or finger amputations. Injudicious revision amputation may cause complications. These complications can be prevented by tension-free closure of the amputation stump or primary coverage with appropriate flap. Replantation is the best way to keep the original length and maintain digital function. Patent vein repair or venous drainage with bleeding until neovascularization to the replanted part is the key to successful replantation. Prevention and management of complications in replantation and revision amputation increase patients' satisfaction and decrease costs. Research is needed to define new indications of replantation for digital amputation.
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Delayed and suspended replantation for complete amputation of digits and hands. J Hand Surg Am 2015; 40:883-9. [PMID: 25746146 DOI: 10.1016/j.jhsa.2015.01.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 01/08/2015] [Accepted: 01/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the clinical outcome for delayed or suspended replantation of complete amputations of digits or hands, or both. METHODS We analyzed 20 cases involving 28 digital and 4 hand amputations that underwent delayed or suspended replantation. In 15 cases of single-digit amputation, patients underwent delayed replantation the morning following amputation. With amputation of multiple digits, bilateral digits, or the hand, the important digits or dominant hand underwent immediate replantation, and we suspended the surgeries for the residual digits or non-dominant hand, or both, until the next morning. We then evaluated the mean warm and cold ischemic time for the operations, graft survival rates, and clinical outcomes. The mean follow-up period was 26 months. We evaluated the clinical results using the criteria of Chen. RESULTS The mean warm and cold ischemic times in 15 cases of delayed replantation were 2 hours 4 minutes and 7 hours 21 minutes, respectively. In 8 cases of suspended replantation, the mean warm and cold ischemic times in the first operation were 5 hours 54 minutes and 2 hours 36 minutes, respectively. In the second operation, the cold ischemic time averaged 15 hours 48 minutes. In this series, 24 of 28 digits and all 4 hands survived. Total survival incidence in both delayed and suspended replantation was 88%, not statistically different from the overall survival incidence in 711 cases of immediate replantation during the same period (84%). In delayed replantation, we observed an excellent result with 6 digits and a good result with another 6 digits. In suspended cases, we observed a good result with one multiple-digit and one hand procedure and we obtained a fair result in 3 multiple-digit and 2 hand replantation procedures. CONCLUSIONS Delayed and suspended replantations demonstrate results comparable to immediate replantation regarding graft survival and clinical outcome. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Yu H, Wei L, Liang B, Hou S, Wang J, Yang Y. Nonsurgical factors of digital replantation and survival rate: A metaanalysis. Indian J Orthop 2015; 49:265-71. [PMID: 26015624 PMCID: PMC4443406 DOI: 10.4103/0019-5413.156185] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The aim of this metaanalysis was to evaluate the association between nonsurgical factors and survival rate of digital replantation. A computer search of MEDLINE, OVID, EMBASE and CNKI databases was conducted to identify literatures for digital replantation, with the keywords of "digit," "finger" and "replantation" from their inception to June 10, 2014. Based on the inclusion and exclusion criteria, data were extracted independently by two authors using piloted forms. Review Manager 5.2 software was used for data analysis. The effect of some nonsurgical factors (gender, age, amputated finger, injury mechanisms, ischemia time and the way of preservation) on the survival rate of digital replantation was assessed. The metaanalysis result suggested that gender and ischemia time had no significant influence on the survival rate of amputation replantation. However, the survival rate of digital replantation of adults was significantly higher than that of children. The guillotine injury of a finger was easier to replant successfully than the crush and avulsion. The little finger was more difficult for replantation than thumb. Survival rate of fingers stored in low temperature was higher than that in common temperature. The present metaanalysis suggested that age, injury mechanism, amputated finger and the way of preservation were significantly associated with the survival rate of digital replantation.
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Affiliation(s)
- Huawei Yu
- Department of Clinical Laboratories, The 401th Hospital of People's Liberation Army, Qingdao 266071, China
| | - Li Wei
- Department of Cardiology, The 401th Hospital of People's Liberation Army, Qingdao 266071, China,Address for correspondence: Dr. Li Wei, Department of Cardiology, The 401th Hospital of People's Liberation Army, NO. 22 Minjiang Road, Qingdao 266071, China. E-mail:
| | - Bing Liang
- Department of Clinical Laboratories, The 401th Hospital of People's Liberation Army, Qingdao 266071, China
| | - Shujian Hou
- Department of Hand Surgery, The 401th Hospital of People's Liberation Army, Qingdao 266071, China
| | - Jinle Wang
- Department of Clinical Laboratories, The 401th Hospital of People's Liberation Army, Qingdao 266071, China
| | - Yinrong Yang
- Department of Clinical Laboratories, The 401th Hospital of People's Liberation Army, Qingdao 266071, China
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Thirty-Year Follow-up of Total Hand Replantation: A Case Report. Ann Plast Surg 2014; 76:521-3. [PMID: 25046672 DOI: 10.1097/sap.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The loss of a limb is a devastating yet relatively common injury with a vast panoply of effects. Beyond the obvious potential for the loss of livelihood are profound social, psychological, and aesthetic consequences. Thus, despite significant improvements in functional prostheses and rehabilitation for traumatic hand amputations, the option for replantation should always be carefully considered. We present a case of a total hand replantation at the level of the wrist performed 30 years ago, which to our knowledge exceeds the longest reported follow-up by 11 years. The excellent outcome observed in this patient demonstrates the importance of presurgical planning and analysis of the amputated segment, the utility of therapy, and the durable functionality of extremity replantation over an extended period.
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Economic analysis of revision amputation and replantation treatment of finger amputation injuries. Plast Reconstr Surg 2014; 133:827-840. [PMID: 24352209 DOI: 10.1097/prs.0000000000000019] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios. METHODS The study was conducted from the societal perspective. Decision tree models were created for the reference case (two-finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A Web-based time trade-off survey was created to determine quality-adjusted life-years for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and quality-adjusted life-years for revision amputation and replantation were calculated for each decision tree. An incremental cost-effectiveness ratio was calculated if a treatment was more costly but more effective. RESULTS The authors had a 64 percent response rate (n = 437). Replantation treatment had greater costs and quality-adjusted life-years compared with revision amputation in all injury scenarios. Replantation of single-digit injuries had the highest incremental cost-effectiveness ratio ($136,400 per quality-adjusted life-year gained). Replantation of three- and four-digit amputation injuries had relatively low cost-to-benefit ratios ($27,100 and $23,800 per quality-adjusted life-year, respectively). Replantation for distal thumb amputation had a relatively low incremental cost-effectiveness ratio ($26,300 per quality-adjusted life-year) compared with replantation of nonthumb distal amputations ($60,200 per quality-adjusted life-year). CONCLUSIONS The relative cost per quality-adjusted life-year gained with replantation treatment varied greatly among the injury scenarios. Situations in which indications for replantation are debated had higher cost per quality-adjusted life-year gained. This study highlights variability in value for replantation among different injury scenarios.
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Abstract
BACKGROUND Upper extremity replantation is a procedure that has revolutionized hand surgery. Since its introduction, a rapid evolution has occurred with a shifting focus from implant survival to optimization of functional outcomes and surgical efficiency. In this review, the current concepts surrounding the indications for replantation, variations in surgical technique, the factors affecting outcomes, and future directions of the specialty are analyzed. METHODS A literature review was performed of all recent articles pertaining to digit, hand, and upper extremity replantation surgery. Particular emphasis was placed on comparative studies and recent meta-analyses. RESULTS The indications and contraindications for replantation surgery are largely unchanged, with mechanism of injury remaining one of the most important determinants of implant survival. With advances in surgical technique, improved outcomes have been observed with avulsion injuries. Distal tip replantations appear to be more common with improved microsurgical techniques, and for these distal injuries, digital nerve and vein repair may not be necessary. Cold ischemia time for a digit amputation should not preclude transfer to a replantation facility or significantly affect the decision to perform a replantation. However, transferring physicians should thoroughly review the options with patients to prevent unnecessary transfers, which is an area where telemedicine may be useful. CONCLUSION This review provides an update on the current concepts of the practice of replantation and the treatment and management of patients with upper extremity amputations.
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Carlsson IK, Dahlin LB. Self-reported cold sensitivity in patients with traumatic hand injuries or hand-arm vibration syndrome - an eight year follow up. BMC Musculoskelet Disord 2014; 15:83. [PMID: 24629077 PMCID: PMC3995581 DOI: 10.1186/1471-2474-15-83] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 02/28/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Cold sensitivity is a common complaint following hand injuries. Our aim was to investigate long-term self-reported cold sensitivity, and its predictors and the importance of sense of coherence (SOC), 8 years after a hand injury as well as in patients treated for Hand Arm Vibration Syndrome (HAVS) during the same time period. METHODS Responses to the Cold Intolerance Symptom Severity (CISS) questionnaire and the Sense of Coherence (SOC) questionnaire were investigated in hand injured patients (n = 64) and in patients with HAVS (n = 26). The Mann-Whitney U-Test was used to identify significant differences between subgroups. When analysing predictors for cold sensitivity severity, the Spearman rank correlation (rS coefficient) were used for quantitative predictive variables, Mann-Whitney U-Test for dichotomous variables and Kruskal-Wallis Test for multiple categorical data. The Wilcoxon's signed rank test was used to investigate longitudinal changes in outcome. RESULTS There was a significant change in total CISS score for patients with traumatic hand injury, indicating fewer problems with cold sensitivity over time. Symptoms, such as stiffness, weakness and skin colour change on cold exposure, caused fewer problems, but perceived pain/aching and numbness remained unchanged as well as time needed for relief of symptoms on return to a warm environment. The negative impact of cold sensitivity on daily activities and at work was reduced, but problems when engaged in hobbies or when being exposed to cold wintry weather remained unchanged. None of the investigated predictors related to the hand injury were significantly associated with a change in cold sensitivity at the 8-year follow up. In contrast, no significant change in cold sensitivity was noted in the patients with HAVS for any of the situations included in the CISS questionnaire. A lower sense of coherence score correlated significantly with worse cold sensitivity (CISS score) in both patient groups. CONCLUSIONS The negative impact of cold sensitivity on daily life was reduced for patients with traumatic hand injury, but did not change over time in patients with HAVS. A low SOC is associated with worse cold sensitivity in such groups of patients. Information about relieving strategies should be provided for patients with cold sensitivity.
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Affiliation(s)
- Ingela K Carlsson
- Department of Hand Surgery, Skane University Hospital, Lund University, Malmö, SE-205 02, Sweden.
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Mahajan RK, Mittal S. Functional outcome of patients undergoing replantation of hand at wrist level-7 year experience. Indian J Plast Surg 2014; 46:555-60. [PMID: 24459349 PMCID: PMC3897104 DOI: 10.4103/0970-0358.122018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Replantation is defined as reattachment of amputated limb using neurovascular and musculoskeletal structures in order to obtain recovery of limb. Re-vascularisation involves all the above steps in case of limb injuries that result in a near total amputation. Aim and Objective: To study the functional outcome of patients undergoing replantation of hand at wrist level. Material and Methods: This is a retrospective study of patients who underwent replantation of total amputation of hand at wrist level within a period of Jan 2003-June 2010. We evaluated post operative functional outcome compared to uninjured hand taking into consideration: 1. The patient's overall satisfaction with the hand. 2. Recovery of flexor and extensor function of thumb and fingers. 3. Recovery of thumb opposition. 4. Recovery of sensations in the median and ulnar nerve distribution. 5. Ability of surviving hand to perform daily tasks. Results: There were total seventeen patients and age range was two years to 55 years. Out of 17 patients,16 were males. All the replantations were successful except for one. Summary: The results showed that, although the replanted hands were never functionally as good as the contralateral hand the patients were able to perform most of the daily activities.
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Affiliation(s)
- Ravi Kumar Mahajan
- Department of Plastic Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Seema Mittal
- Department of Plastic Surgery, Amandeep Hospital, Amritsar, Punjab, India
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Management of major limb injuries. ScientificWorldJournal 2014; 2014:640430. [PMID: 24511296 PMCID: PMC3913364 DOI: 10.1155/2014/640430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/02/2013] [Indexed: 12/16/2022] Open
Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Smits ES, Selles RW, Huygen FJP, Duraku LS, Hovius SER, Walbeehm ET. Disordered conditioned pain modulation system in patients with posttraumatic cold intolerance. J Plast Reconstr Aesthet Surg 2013; 67:68-73. [PMID: 24268692 DOI: 10.1016/j.bjps.2013.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 05/10/2013] [Accepted: 09/03/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Conditioned pain modulation (CPM) is a phenomenon of 'pain inhibiting pain' that is important for understanding idiopathic pain syndromes. Because the pathophysiology of posttraumatic cold intolerance is still unknown but it could involve similar mechanisms as idiopathic pain syndromes, we evaluated the functioning of the CPM system in patients with posttraumatic cold intolerance compared to healthy controls. METHODS Fourteen healthy controls and 24 patients diagnosed with cold intolerance using the Cold Intolerance Symptom Severity questionnaire were included in the study. Of the 24 patients with cold intolerance, 11 had a nerve lesion and 13 an amputation of one or more digits. To quantify the CPM, pain threshold for mechanical pressure was measured at the affected region as a baseline measure. Then, the contralateral hand received a cold stimulus of ice water to evoke the noxious conditioning. After the cold stimulus, the pain threshold for mechanical pressure was determined again. RESULTS The absolute and relative changes in algometer pressure (CPM effect) between pre- and post-conditioning were significantly smaller in the cold intolerance group compared to the control group (absolute p = 0.019, relative p = 0.004). The CPM effect was significantly different between the control group and the subgroups of nerve lesion (p = 0.003) and amputation patients (p = 0.011). CONCLUSIONS In this study, we found a CPM effect after a cold stimulus in both controls and patients. A significant weaker CPM effect compared to the controls was found, as in other chronic pain conditions. The CPM system within patients with cold intolerance is altered.
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Affiliation(s)
- E S Smits
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - R W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands; Department of Rehabilitation Medicine and Physical Therapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - F J P Huygen
- Pain Treatment Centre, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - L S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - S E R Hovius
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E T Walbeehm
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Klocker J, Peter T, Pellegrini L, Mattesich M, Loescher W, Sieb M, Klein-Weigel P, Fraedrich G. Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries. J Vasc Surg 2012; 56:410-4. [PMID: 22560312 DOI: 10.1016/j.jvs.2012.01.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 01/24/2012] [Accepted: 01/30/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this report was to present abnormal posttraumatic cold intolerance in patients that previously underwent repair of arterial injuries after civilian upper limb trauma in our institution. METHODS All patients who underwent repair of arterial lesions after upper limb trauma since 1990 were reviewed, and clinical follow-up studies were performed. Patients were asked to complete the cold intolerance symptom severity (CISS) questionnaire to evaluate presence and severity of self-reported cold sensitivity, and the disabilities of arm, shoulder, and hand (DASH) questionnaire to analyze functional disability. Abnormal cold intolerance was defined as a CISS score over 30. Further analysis included evaluation of epidemiologic, clinical, and perioperative data for factors predisposing to abnormal cold intolerance. RESULTS A total of 87 patients with previous repair of upper limb arterial injuries were eligible to answer the CISS and DASH questionnaires, and 56 patients (64%; 43 men; median age: 31.9 years) completed both. In our cohort, blunt trauma was the predominant cause of injury (n = 50; 89%). Accompanying lesions of nerves (n = 22; 39%) and/or orthopedic injuries (n = 36; 64%) were present in 48 patients (86%). After a median follow-up period of 5.5 years (range, 0.5-19.7), 23 patients (41% of 56) reported on abnormal cold intolerance. Patients with cold intolerance had worse functional results (as measured by the DASH questionnaire; mean ± SD, 42.7 ± 29.7 vs 11.5 ± 23.9; P < .001) when compared with patients without. Cold intolerance was more frequently seen in patients with previous nerve lesion (P = .027) and in proximal injuries (subclavian or axillary vs brachial or forearm arteries: P = .006), but was not correlated to gender, age, involvement of the dominant or nondominant arm, and the presence of ischemia, bone injury, or an isolated vascular injury. CONCLUSIONS Abnormal cold intolerance is frequently seen in patients with a history of arterial repair in upper limb trauma. It is associated with significant functional impairment. Concomitant nerve injury and involvement of the subclavian or axillary artery are the major predisposing factors for development of cold intolerance after upper limb trauma.
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Affiliation(s)
- Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
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Successful thumb reconstruction after tumor resection by immediate toe transfer in a 67-year-old patient: case report and literature review. ACTA ACUST UNITED AC 2012; 31:97-100. [PMID: 22484246 DOI: 10.1016/j.main.2012.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 12/13/2011] [Accepted: 01/15/2012] [Indexed: 11/22/2022]
Abstract
Age is a limiting factor for microsurgery. We report the case of a 67-year-old patient with a malignant tumor on the right thumb, treated by amputation and immediate reconstruction by partial transfer of the hallux, with an excellent result, but venous swelling at the fourth day that required a controlled bleeding for 3 days. In the light of this observation, we think that there is no age limit for reconstruction of a thumb by toe transfer, either cosmetically or functionally.
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Landin L, Bonastre J, Casado-Sanchez C, Diez J, Ninkovic M, Lanzetta M, del Bene M, Schneeberger S, Hautz T, Lovic A, Leyva F, García-de-Lorenzo A, Casado-Perez C. Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review. Transpl Int 2012; 25:424-32. [PMID: 22332605 DOI: 10.1111/j.1432-2277.2012.01433.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English, French, or German were reviewed systematically, with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty-eight patients were reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (±19.04) points on the DASH score after HAT (P = 0.005). Lower DASH scores (P = 0.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow-up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty-two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.
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Affiliation(s)
- Luis Landin
- Division of Plastic and Reconstructive Surgery, University Hospital La Paz, Madrid, Spain.
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Abstract
BACKGROUND The aim of this study was to conduct a systematic review of the English literature on replantation of distal digital amputations to provide the best evidence of survival rates and functional outcomes. METHODS A MEDLINE search using "digit," "finger," "thumb," and "replantation" as keywords and limited to humans and English-language articles identified 1297 studies. Studies were included in the review if they (1) present primary data, (2) report five or more single or multiple distal replantations, and (3) present survival rates. Additional data extracted from the studies meeting the inclusion criteria included demographic information, nature and level of amputation, venous outflow technique, nerve repair, recovery of sensibility, range of motion, return to work, and complications. RESULTS Thirty studies representing 2273 distal replantations met the inclusion criteria. The mean survival rate was 86 percent. There was no difference in survival between zone I and zone II replantations (Tamai classification). There was a significant difference in survival between replantation of clean-cut versus the more crushed amputations (crush-cut and crush-avulsion). The repair of a vein improved survival in both zone I and zone II replantation. The mean two-point discrimination was 7 mm (n = 220), and 98 percent returned to work (n = 98). Complications included pulp atrophy in 14 percent of patients (n = 639) and nail deformity in 23 percent (n = 653). CONCLUSIONS The common perception that distal replantation is associated with little functional gain is not based on scientific evidence. This systematic review showed a high success rate and good functional outcomes following distal digital replantation. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Lerman OZ, Haddock N, Elliott RM, Foroohar A, Levin LS. Microsurgery of the upper extremity. J Hand Surg Am 2011; 36:1092-103; quiz 1103. [PMID: 21636025 DOI: 10.1016/j.jhsa.2011.03.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 03/31/2011] [Indexed: 02/02/2023]
Abstract
In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.
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Affiliation(s)
- Oren Z Lerman
- Division of Plastic Surgery, Lenox Hill Hospital, and the Department of Plastic Surgery, NYU Langone Medical Center, New York, NY, USA
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Lied L, Lydersen S, Finsen V. Cold Intolerance after Flexor Tendon Injury. Disposing Factors and Long Term Prognosis. Scand J Surg 2010; 99:187-90. [DOI: 10.1177/145749691009900315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: Cold intolerance after hand injuries is often debilitating. We wished to determine what factors make it more likely to occur and whether it improves or worsens with time. Patients and Methods: We retrospectively studied 103 patients who had sustained a simple cut leading to a flexor tendon injury in the finger between 3 months and 20 years earlier. A total of 48 had also injured a digital nerve. At review patients indicated on a VAS scale their discomfort during the first winter after injury and the last winter before review and also gave a VAS evaluation of pain in the hand after keeping it in a bath of water at 1–4 degrees centigrade for 60 seconds. Results: Cold sensitivity during the first winter after injury was reported by 66% patients. Its development was unrelated to the age at injury. The proportions of smokers, injury of more than one finger, and re-operation or with postoperative complications were significantly higher among patients with cold sensitivity. At review 49% indicated that they had improved, 41% that cold sensitivity was unchanged and 10% that they were worse. Conclusions: Standardized immersion in cold water showed that on average cold sensitivity was slightly worse with time.
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Affiliation(s)
- L. Lied
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - S. Lydersen
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, NTNU, Trondheim, Norway
| | - V. Finsen
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
- Department of Neuroscience, NTNU, Trondheim, Norway
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Carlsson IK, Nilsson JA, Dahlin LB. Cut-off value for self-reported abnormal cold sensitivity and predictors for abnormality and severity in hand injuries. J Hand Surg Eur Vol 2010; 35:409-16. [PMID: 20031998 DOI: 10.1177/1753193409354184] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Our aim was to identify a cut-off value for self-reported, abnormal cold sensitivity and to identify cold sensitivity predictors after hand injuries. The Cold Intolerance Symptom Severity (CISS) questionnaire and a VAS question concerning discomfort on exposure to cold were investigated in 94 normal people and 88 patients. A CISS score >50 was defined as abnormal cold sensitivity. Multiple injured digits, an increased number of injured vessels, complete nerve injury and replantation were variables associated with high VAS scores. Factors linked to both abnormality and worse CISS or VAS scores were: the presence of bone injury; a larger number of repaired vessels; the use of vascular grafts and a high Hand Injury Severity Score (HISS). The causes of abnormality and severity suggest a multifactorial aetiology with bony, vascular and neural components. A cut-off for abnormality is useful for descriptive, comparative and assessment purposes.
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Affiliation(s)
- I K Carlsson
- Department of Hand Surgery and Department of Orthopaedics, Malmö University Hospital, Lund University, Sweden.
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Replantation versus revision of amputated fingers in patients air-transported to a level 1 trauma center. J Hand Surg Am 2010; 35:936-40. [PMID: 20488629 DOI: 10.1016/j.jhsa.2010.02.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 02/24/2010] [Accepted: 02/26/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the rate of replantation versus revision of amputated fingers in patients air-transported to a tertiary care hand trauma center. METHODS We included 40 consecutive subjects (70 digits) who were transported via air after digit(s) amputation distal to the metacarpophalangeal joint. The primary outcome measure was type of surgery (attempted replantation vs revision of the amputation). Data were collected prospectively. RESULTS We identified 3 groups of patients. In group 1 (15 patients, 23 digits), replantation of one or more digits was attempted. In group 2 (6 patients, 8 digits), replantation was not elected. In group 3 (19 patients, 39 digits), no digits were suitable for replantation. The mean age was 36.2 years (range, 5-69 years) and mean time of transport was 5.15 hours (range, 1-24 hours). Mechanisms of finger injury were crush (n = 34), followed by clean cut (n = 15), avulsion/crush (n = 15), and gunshot (n = 6). No significant differences were found between groups for age or time elapsed from injury to hospital arrival. Most patients (n = 25; 65%) transported via air did not undergo replantation surgery. Injury characteristics (n = 18 patients, 72%) were the main reason not to replant. The most common reason for the refusal of replantation was inability to return to work immediately. The most common reasons for surgeon's decision to not to replant were single digit amputations proximal to flexor digitorum superficialis attachment (7 patients), and crush/avulsion type injuries (7 patients), followed by health status and age (5 patients). CONCLUSIONS This study shows that a considerable portion of patients transported via air do not undergo replantation surgery. Further studies are needed to establish whether this is an overused service.
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Carlsson IK, Rosén B, Dahlin LB. Self-reported cold sensitivity in normal subjects and in patients with traumatic hand injuries or hand-arm vibration syndrome. BMC Musculoskelet Disord 2010; 11:89. [PMID: 20462418 PMCID: PMC2881018 DOI: 10.1186/1471-2474-11-89] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 05/12/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cold sensitivity is a common and disabling complaint following hand injuries. The main purpose of this study was to describe self-reported consequences of cold sensitivity and the association with disability and health-related quality of life in patients with hand injuries or hand-arm vibration syndrome (HAVS) and in normal subjects. METHODS Responses to the Cold Intolerance Symptom Severity (CISS) questionnaire, Potential Work Exposure Scale (PWES), Disability of the Arm, Shoulder and Hand (DASH) and Short-Form 36 questionnaire (SF-36) were investigated in normal subjects (n = 94), hand injured patients (amputation and nerve injuries, n = 88) and patients with HAVS (n = 30). The results are presented as median (range), percent and mean deviation from norms. The Kruskal Wallis Test or Mann-Whitney U-Test were used to identify significant differences between multiple groups or subgroups. The Spearman rank correlation was used to study the relationship between cold sensitivity and disability. RESULTS Abnormal cold sensitivity (CISS score > 50) was seen in 75% and 45% of patients with HAVS and a traumatic hand injury, respectively. Patients were significantly more exposed to cold in their work environment than the normal population, with a consequently negative effect on work ability due to cold sensitivity. Patients with abnormal cold sensitivity were more seriously disabled and had a poorer health-related quality of life than patients with normal cold sensitivity [higher DASH scores and e.g. significantly larger mean deviation from norms in the subscales Role Physical and Bodily Pain (SF-36)]. CONCLUSION Severe and abnormal cold sensitivity may have a profound impact on work capacity, leisure, disability and health-related quality of life. It is frequently seen in patients with traumatic hand injuries and particularly apparent in patients with HAVS.
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Affiliation(s)
- Ingela K Carlsson
- Department of Hand Surgery, Skåne University Hospital, Lund University, SE-205 02 Malmö, Sweden.
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Carlsson I, Cederlund R, Holmberg J, Lundborg G. Behavioural treatment of post‐traumatic and vibration‐induced digital cold sensitivity. ACTA ACUST UNITED AC 2009; 37:371-8. [PMID: 15328778 DOI: 10.1080/02844310310013055] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cold sensitivity is a common problem after all types of hand injuries. The aim of the present study was to assess possible effects of treatment by Pavlovian conditioning, a behavioural treatment method for digital cold sensitivity where whole body cold exposure becomes associated with warm hands. Eighteen hand-injured patients and nine patients with vibration-induced problems in their hands completed the treatment. Questionnaires and questions, assessment of perception of touch/pressure and skin temperatures after cold provocation, was made before and after the completed period of treatment and after 6 and 12 months. The results indicated subjective improvement in the hand-injured group in contrast to a lack of response in the vibration group. An increased digital skin temperature after treatment was noted for the vibration-exposed group only, which however did not persist at 6 and 12 months' follow-up.
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Affiliation(s)
- Ingela Carlsson
- Department of Hand Surgery, Malmö University Hospital, Malmö, Sweden.
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Carlsson I, Cederlund R, Höglund P, Lundborg G, Rosén B. Hand injuries and cold sensitivity: Reliability and validity of cold sensitivity questionnaires. Disabil Rehabil 2009; 30:1920-8. [DOI: 10.1080/09638280701679705] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Rosson GD, Buncke GM, Buncke HJ. Great toe transplant versus thumb replant for isolated thumb amputation: critical analysis of functional outcome. Microsurgery 2009; 28:598-605. [PMID: 18846572 DOI: 10.1002/micr.20549] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Thumb replantation following thumb amputation is the standard of care. When replantation is impossible, microneurovascular great toe transplantation is a well-established option. METHODS A retrospective review was conducted to evaluate functional outcome following isolated thumb replantation or great toe transplantation for thumb reconstruction. From 1974 to 1993, 384 thumb amputations were treated and 110 great toe-to-thumb transplantations were performed. RESULTS Ninety-one patients with isolated thumb amputation had an 85% survival rate. Failed replants usually resulted from crushing or avulsing injuries. Function of replanted thumbs was better in sharp compared with crush/avulsion injuries. Forty-three isolated thumb reconstructions had a 93% success rate. Function was comparable with thumb replants from sharp injuries. Interphalangeal motion was significantly better in great toe transplants than in replanted thumbs of the crush/avulsion type. CONCLUSIONS Amputated thumbs should be replanted. When replantation is not possible or unsuccessful, a transplanted great toe functions as well as, or better than, a replanted thumb.
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Affiliation(s)
- Gedge D Rosson
- Division of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Woo SH, Lee YK, Lee HH, Park JK, Kim JY, Dhawan V. Hand replantation with proximal row carpectomy. Hand (N Y) 2009; 4:55-61. [PMID: 18855073 PMCID: PMC2654953 DOI: 10.1007/s11552-008-9141-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 09/24/2008] [Indexed: 11/28/2022]
Abstract
The purpose of this study is to present our operative technique and postoperative results of the hand replantation with proximal row carpectomy in cases of complete amputation at the level of wrist joint. From May 2003 to April 2005, five patients suffered from complete amputation of the hand due to industrial trauma. Amputation level was radiocarpal joint in three cases and midcarpal joint in two cases. Three cases represented guillotine type and two cases with local crush type injuries. All were men and the mean age was 26.6 years. The mean follow-up period was 26.8 months. At the time of replantation, the wrist joint was stabilized with transarticular fixation using three to four Kirschner's wires after performing proximal row carpectomy. Postoperatively, functional results such as muscle strength, range of motion of the wrist and fingers, and sensory recovery were assessed according to Chen's criteria. Joint width and arthritic changes of the radio-capitate joint were evaluated with radiologic tools. According to Chen's criteria, the overall results in five cases were classified as grade II. Intrinsic muscle power of hands was found to be grade 4. The mean grip and pinch powers were 41% and 45%, respectively, compared to contralateral hand. The mean arc of flexion-extension of wrist was 53 degrees . Total mean active motion of fingers was 215 degrees. Static two-point discrimination of fingertip ranged from 8 to 13 mm. On the follow-up, computerized tomography showed well-preserved radio-capitate joint space without any arthritic changes. While performing hand replantation after amputation at the radiocarpal or midcarpal level, proximal row carpectomy is a useful procedure to preserve joint motion of the wrist in selected cases.
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Affiliation(s)
- Sang-Hyun Woo
- Woo & Lee's Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101-6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902, South Korea.
| | - Young-Keun Lee
- Woo & Lee’s Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101–6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902 South Korea
| | - Hang-Ho Lee
- Woo & Lee’s Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101–6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902 South Korea
| | - Ji-Kang Park
- Woo & Lee’s Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101–6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902 South Korea
| | - Joo-Yong Kim
- Woo & Lee’s Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101–6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902 South Korea
| | - Vikas Dhawan
- Woo & Lee’s Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, 101–6 Gamsam-Dong, Dalseo-Gu, Daegu 704-902 South Korea
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Vaksvik T, Hetland K, Røkkum M, Holm I. Cold hypersensitivity 6 to 10 years after replantation or revascularisation of fingers: consequences for work and leisure activities. J Hand Surg Eur Vol 2009; 34:12-7. [PMID: 19091739 DOI: 10.1177/1753193408094440] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We investigated cold hypersensitivity and activity in 81 adults (male/female 76/5), 6 to 10 years after finger replantation/revascularisation (mean age at injury 43 (SD 15) years). Questionnaires included the McCabe Cold Sensitivity Severity Scale, Potential Work-Exposure Scale and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Eighty per cent of the respondents were cold hypersensitive; 20% were severely or extremely cold hypersensitive. Of the 74 patients employed at injury, 7% had changed work and 4% were not working due to cold hypersensitivity. The median score for cold exposure at work at follow-up was 153 (scale 0-300). The correlation between cold sensitivity and DASH work was low. One-third of the respondents experienced limitations in their leisure activities because of cold complaints. Long-term cold sensitivity was mild or moderate for most patients. Many cold hypersensitive patients managed to continue to work even under cold conditions and cold hypersensitivity was a greater problem in leisure activities.
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Affiliation(s)
- T Vaksvik
- Rikshospitalet University Hospital, Oslo, Norway.
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Graham B, Schofield M. Self-reported symptoms of cold intolerance in workers with injuries of the hand. Hand (N Y) 2008; 3:203-9. [PMID: 18780096 PMCID: PMC2525881 DOI: 10.1007/s11552-008-9116-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 05/20/2008] [Indexed: 11/27/2022]
Abstract
Cold intolerance is a well-recognized complication of crushing injuries and amputations in the hand. These symptoms are usually thought to resolve within 2 years of injury. The objectives of our study were to determine the prevalence and course over time of self-reported symptoms of cold intolerance in workers with hand injuries. Files from a large worker's compensation carrier were randomly selected from index years 2, 4, 6, and 10 after a claim was made. Cohorts comprising cases with diagnostic codes corresponding to traumatic hand injuries and codes referring to non-trauma diagnoses in the hand were assembled for each of the years under consideration. A questionnaire was mailed to a total of 7,088 asking questions related to the symptom of cold intolerance. Twenty-five percent of the surveys were returned. Over 90% of trauma patients from all 4 years reported symptoms of cold intolerance. The rate of cold intolerance in the non-trauma group was between 59% and 69%. Individuals reporting cold intolerance indicated worsening over time in 50% of cases and improvement in only 9%. The severity of injury did not appear to be a factor in the development of cold intolerance. Symptoms of cold intolerance are highly prevalent in workers with significant hand injuries. Workers with non-trauma hand conditions also report a substantial prevalence of this symptom. The development of cold intolerance is not related to injury severity. The symptoms remain either static or deteriorate slightly over time. Improvement is experienced by less than 10% of patients.
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Affiliation(s)
- Brent Graham
- Department of Surgery, University of Toronto, University Health Network, Toronto, ON, Canada.
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