The trend of treatment and conveyance system for upper extremity replantation in Japan: A nationwide population-based study from the Japan trauma data bank

Analyzing attempt and success factors for amputated digit replantation in Japan using the diagnosis procedure combination database

The number of amputated finger replantation has declined in the USA and Germany in recent years; however, there have been no reports on recent trends in Japan. We examined the current practices, attempts, and success factors of digit replantation in Japan. We hypothesized that the rates of digit replantation and success rates were consistently standardized in Japan. The diagnosis procedure combination database was used to analyze 14004 cases from April 2014 to March 2020, excluding multiple-digit amputations, thus focusing on 13484 patients. We evaluated replantation success rates and identified factors influencing replantation decisions using multiple logistic regression analysis. The key findings included a higher frequency of replantation in thumb cases and surgeries during overtime hours, on Sundays, and in educational institutions. Success rates were notably higher for thumb replantations and patients under 20 years of age. Patients over 65 years of age treated with urokinase showed higher failure rates, unrelated to regional or hospital case volumes. The number of amputated digit replantation surgeries in Japan was high during overtime hours, on Sundays, and in educational institutions. Region, hospital type, and hospital case volume were not associated with a low success rate across Japan.

Review of Replantation Services from a Level One Trauma Center in India

The aim of this article is to examine the elements that contribute to effective operation of a specialized replantation center and to provide readers with a general idea of the outcome of replantation services in India. A dedicated high-volume center coupled with a sound referral system is the backbone of replantation services in a country. A retrospective study was done on all patients who visited a level 1 trauma center in India from November 1, 2017, to December 31, 2018, for various amputations. The medical records and digital pictures of these patients were extracted from the records and analyzed. During the study period, 77 replants were performed on 63 patients at our center. Males were 68% of the study, mostly belonging to the 20 to 40 years age group (63%). Thirty-four percent of cases were smokers. Agricultural injuries (49%) were the most common cause of amputation. Finger replantation was the most common type of replantation (82%). The rate of successful replantation was highest for scalp (100%) followed by hand (71%) and thumb (67%). Setting up dedicated replantation services is essential, especially in highly populated areas. Manpower, resources, and a protocol-led approach help in achieving optimum results. A multidisciplinary team approach with round-the-clock availability plays a vital role in intraoperative decision-making and planning postoperative rehabilitation.

Relative efficacy of three different tendon repairs in complete flexor digitorum profundus laceration in Zone I: A randomized controlled study

Hand flexor tendon injuries are common and biomechanically challenging to achieve good functional outcomes. Several approaches using the Pennington-modified Kessler repair technique have been attempted, but high-level evidence is still lacking. Here, we evaluated the relative efficacy of three versions of the Pennington-modified Kessler technique in repairing complete flexor digitorum profundus (FDP) laceration in Zone 1. We conducted a 2-year, single-center, double-blind, randomized clinical trial involving 85 patients with 105 digits enrolled between June 1, 2017 and January 1, 2019. Eligible participants were 20-60 years of age and underwent tendon repair in the acute phase for complete FDP laceration distal to the insertion of the superficial flexor tendon. The digits were randomized 1:1:1 to three treatment groups: (1) Pennington-modified Kessler repair; (2) Pennington-modified Kessler repair followed by circumferential tendon suture; or (3) Pennington-modified Kessler repair followed by circumferential epitenon suture. The primary endpoint was total active range of motion (TAROM) at 2 years after the initial surgery. The secondary endpoint was the reoperation rate. Compared with group 1, both techniques for peripheral suture were associated with a decrease in TAROM at 2 years after surgery. The total reoperation rates of the three groups were 11.4%, 18.2%, and 17.6%, and we found no significant differences among the three groups possibly due to the limited sample size. Unexpectedly, among participants with complete FDP laceration in Zone I, both circumferential-tendon and circumferential-epitenon sutures caused worsening of TAROM after 2 years. No conclusions can be drawn regarding reoperation rates among the groups. Level of evidence: Therapeutic level I.

Ten-Year (2010-2019) Activity Report of the Replantation Service for Hand and Finger Amputations in Poland

Replantation of amputated hands is now considered a routine procedure in countries representing high standards of medical care. However, organization of care for patients with hand amputations is not uniform and varies from country to country, even in the European Union. This article presents organization of the Replantation Service for hand amputations in Poland, and ten-year activity report of the Service. Data to this report were obtained by mailing questionnaires to seven participating departments.A total of 974 patients, 871 men (89 %) and 103 women (11 %) at a mean age of 40 years with total or subtotal amputations or other severe upper limb-threatening injuries were admitted to the seven units participating in the Service. The most common injury was multidigital amputation - 353 (36 %), followed by the thumb - 282 (29 %), the metacarpal and wrist - 231 (24 %) and the forearm and arm - 108 (11 %) amputations. The most common operation was replantation of totally amputated hands/fingers - 368 cases (38 %), followed by revascularization of subtotal amputated hands/fingers - 344 (35 %). Primary reconstruction of a complex injury to the hand was performed in 135 patients (14 %). The rate of survival of the replanted/revascularized hands/fingers was a mean of 80 %. The report is supported by literature review about replantation services in other countries.

Nerve merging repair in the replantation of a severed limb with defects in multiple nerves: five cases and long-term follow-up

Background

Repairing all nerves is challenging in cases of upper arm avulsion combined with defects in multiple nerves because the donor area for autogenous nerve transplantation is limited and the outcomes of long-segment allogeneic nerve transplantation are poor. Based on the principle of magnified nerve regeneration, we present a method called nerve merging repair, the feasibility of which needs to be confirmed in clinical practice.

Methods

The nerve merging repair method relies on the use of fewer proximal nerves to innervate more distal nerves and depends mainly on whether the radial nerve (RN) can repair itself. In the case of defects in multiple nerves precluding RN self-repair, median-(median + radial) (M-(M + R)) repair is performed. If the RN can undergo self-repair, median-(median + ulnar) (M-(M + U)) or ulnar-(ulnar + median) (U-(U + M)) is used to repair the three nerves. Five cases were included in the study and involved the analysis of joint motor function, muscle strength and sensory recovery of the affected limb.

Results

The replanted limb survived in all 5 cases. Follow-up visits were conducted with the patients for 51–80 months, during which they experienced satisfactory recovery of skin sensation, elbow flexion and extension and partial recovery of hand muscle strength.

Conclusions

To a certain extent, treatment with the nerve merging repair method improved the sensory and motor function of the affected limb and limited the loss of function of the donor nerve area. This intervention provides a new approach for repairing long-segment defects in multiple nerves caused by avulsion amputation of the upper limb.

The Declining Number of Finger Replantations in Germany

INTRODUCTION

Data from the United States have shown that finger replantation numbers have declined significantly in recent years. It is unclear whether this is due to a decrease in amputation injuries or other reasons.

MATERIALS METHODS

Since 2005, all German hospitals have been required to produce structured quality reports. Based on these reports, we analyzed finger and hand replantation development and the incidence of amputation injuries between 2006 and 2018.

RESULTS

Replantations decreased by 30%, whereas amputation injuries increased slightly. In 2018, only 17 centers carried out more than 10 replantations. Most hospitals had replanted less than 4 times a year. The majority of residents participated in fewer than 1 replantation per year. Most specialists performed fewer than 1 replantation per year. The reasons for the decline in replantation remain speculative.

CONCLUSIONS

However, a reduction in amputation injuries was not observed. A change in medical indications, technical skills, and economic motivations needs to be considered. A further loss of specialized technical skills and experience with replantations might be a future consequence of this trend.

Contribution of revision amputation vs replantation for certain digits to functional outcomes after traumatic digit amputations: A comparative study based on multicenter prospective cohort

BACKGROUND

Traumatic digit amputations can result in significant impairment. Optimal surgical treatment is unclear for certain digits in various amputation patterns. Our aim was to compare the contribution of revision amputation vs replantation for each particular digit to functional outcomes.

MATERIALS AND METHODS

Prospective cohort study at three tertiary hospitals was conducted in China. Eligible participants were 3192 patients with traumatic digit amputations enrolled from January 1, 2014, to January 1, 2018. The primary outcome was Michigan Hand Outcomes Questionnaire (MHQ) scores 2 years after initial surgery. Secondary outcome was score on the Disabilities of the Arm, Shoulder, and Hand (DASH).

RESULTS

Of 3192 enrolled patients, 2890 completed the study. Main-effect linear regression showed that participants with replantation of thumb, index, long, and ring (proximal to the proximal interphalangeal [PIP] joint) fingers had significantly better MHQ scores compared to participants with the corresponding finger revision amputation. DASH results were comparable. Finger-finger interaction analyses conducted with multifactor dimensionality reduction (MDR) revealed that the small finger and ring finger had the smallest and greatest interactions with other fingers, respectively. After stratification by amputation level of thumb, index finger, or long finger, linear regression showed that replantation of the ring finger distal to the PIP joint resulted in better MHQ and DASH when the thumb or long finger was also traumatically amputated proximal to the IP/PIP joint.

CONCLUSIONS

Replantation of the thumb, index, long, and ring (proximal to PIP joint) fingers is preferable to revision amputation, regardless of amputation pattern. Replantation of the ring finger amputated distal to PIP was beneficial only when the thumb or long finger was amputated proximal to IP/PIP joint. Replantation or revision amputation of the small finger was indistinguishable in terms of functional outcome. Future investigations and clinical decisions should take into account the role of finger-finger interactions.

Three-year (2017-2019) activity report of the Replantation Service for hand amputations in Poland

This article summarises activity of the Replantation Service for hand amputations in Poland in years 2017-2019. Over this period a total of 551 cases of total and subtotal amputations as well as other complex injuries to the hand were referred to the referenced centres. Of these, 330 referrals were accepted and 221 rejected, for various reasons. Among these accepted, there were 165 total (50%) and 131 subtotal (40%) amputations; 34 patients (10%) had other severe hand injuries. Vast majority of the patients constituted young and middle-age males. The most common was amputation of several digits and thumbs - a total of 251 cases (76%), followed by transmetacarpal - 30 (9%), forearm - 23 (7%) and wrist - 20 (6%) amputations. Replantation of amputated extremity was performed in 138 patients (42%), revascularization in 98 (30%) and in 45 (14%) primary repair of the complex injuries. In 26 cases (8%), coverage of tissue defects was performed, and in 23 (7%) primary terminalization. Survival rate was of a mean of 65% for replantations and 85% for revascularizations. Comparing to the previously reported period 2013-2017, the number of treated patients was similar, but structure of injuries differed: number of digital amputations increased (of 22 cases), whereas number of proximal amputations (hand, forearm and arm) significantly dropped (of 50 cases). The importance of Replantation Service, an informal structure, in saving limbs of severely mutilated patients was emphasised.