Late digital replantation failure: pathophysiology and risk factors

Complicated Replanted Finger, 34 Years after Revascularization

Merely a few reports of late failure (later than the 7th postoperative day) of a digital replantation can be found in the literature. Discussions of the factors that might cause a late failure are concise. To our knowledge, there are no reports of failure in literature as late as the case we are presenting. An 87-year-old white man was diagnosed with acute complications of a digital replantation, 34 years after initial surgery. Ultrasound examination and an arteriography demonstrated occlusion of the arterial anastomosis. The patient’s surgical file revealed scars of former replantation surgery of both the index and the middle finger. In the latter, 1 artery and 2 veins were anastomosed. Considering the age and comorbidities of the patient, revascularization of the finger was not performed. Local wound care and analgesic drugs were prescribed. After initial deterioration and ulceration, gradual improvement was noticed. Total wound healing occurred at 3 months after the initial consultation. Compared with free flap surgery in general, finger replantations are at a higher risk of late complications because digital neovascularization is directly correlated to the contact surface area. This contact surface is usually larger in other free flaps. Furthermore, diseases that deteriorate circulation most likely affect the short- and the long-term survival of a digital replantation. From this point of view, performing both volar digital arterial anastomoses, whenever possible, might reduce early as well as late failure in replantation surgery.

Finger avulsion injuries: a report of four cases

Injury that occurs to a finger wearing a ring though rare can have grave consequences. It is a preventable injury which has a peculiar mode of trauma that is usually occupational. Injury ranges from simple contusion to degloving of soft tissues to traumatic amputation. We hereby report our experience of four cases of finger avulsion injuries due to a ring and discuss their variable clinical presentation and individualized management.

Tendon function after replantation: prognostic factors and strategies to enhance total active motion

The purpose of this study was to determine the important prognostic factors for recovery of tendon function as measured by total active movement (TAM) in patients undergoing digital replantation. More important, the authors wanted to establish which factors may be manipulated to maximize motion. A retrospective review of 48 patients (103 digital rays) who underwent replantation was performed. Average TAM for all digits was 129 deg. Zone 1 and zone 5 injuries had better TAM than injuries in zones 2, 3, and 4, which had TAM values not significantly different from one another. Avulsion injuries fared significantly worse than other mechanisms of injury. TAM values were not affected by age, type of bone fixation, number of arteries repaired, or number of digits injured. Digits with both the profundus and the superficialis tendons repaired had significantly better TAM values relative to one-tendon fingers. Similarly, fingers treated with an "early" mobilization regime also exhibited better movement. Small numbers of injured digits in some groups may have limited our ability to detect significant differences.

Late salvage of a free TRAM flap

We present the case of a patient with arterial thrombosis of a free TRAM flap 11 days after surgery. Initial salvage involved thrombectomy through an arteriotomy using a Fogarty catheter. Subsequent return to the operating theatre was necessary because of further vascular compromise. Thrombectomy was combined with flap thrombolysis and anticoagulation, and the flap remained viable at 6 months. Although rates of successful salvage vary, the literature indicates that flaps are rarely saved if signs of compromise present later than 2 days postoperatively. This case demonstrates that aggressive salvage may be successful even in cases of 'late' vascular compromise.

Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts

Ring avulsion replantation is a technically challenging procedure with a very low success rate. Because the zone of arterial injury is more extensive than what it appears to be in such avulsion amputations, a technique was developed to debride the avulsed digital artery for a long distance, extending well into the digital pulp, thereby creating healthy arterial ends to be bridged by one or two segments of long venous grafts. Using this technical approach, 7 patients with complete amputations of ring avulsion injury (Urbaniak's class III) were operated. In all amputations the bone was disrupted at the distal interphalangeal level (except in 1 patient) and the soft tissues at the proximal phalanx level, with the proximal interphalangeal joint and the flexor digitorum superficialis tendons being intact. Results indicated that replantation was successful in all patients. However, 2 patients presented with unusually late arterial failure 28 and 30 days after surgery respectively. Although one of these cases was salvaged by reoperation, the other case (followed by conservative management) demonstrated partial distal necrosis. Therefore, the ultimate success rate in this series was 85% in the long term. At follow-up, sensibility was protective in all patients, with an average static two-point discrimination of 7.8 mm (range, 6-14 mm). The total active motion of the replanted digits was 194 deg on average (range, 155-205 deg) without loss of function of the proximal interphalangeal joint except in 2 patients who had late vascular problems. The authors conclude that microsurgical replantation of completely amputated ring avulsion injuries with an intact proximal interphalangeal joint and flexor digitorum superficialis tendon, is a worthwhile procedure that results in good functional and aesthetic results. Furthermore, using an aggressive approach for debridement of the avulsed digital artery, as described in this article, an experienced microsurgeon can replant successfully nearly all cases. However, one should be cautious in the follow-up of such patients, because late arterial failure may be encountered, as was observed in 2 patients in this series. The authors suggest immediate reoperation in such unusual circumstances.