HAND/PERIPHERAL NERVE Upper Extremity Replantation: Current Concepts Roni B. Prucz, M.D. Jeffrey B. Friedrich, M.D. Seattle, Wash.
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. (Plast. Reconstr. Surg. 133: 333, 2014.)
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raumatic hand amputations are devastating injuries with significant psychological and socioeconomic consequences. Since the advent of limb and digit replantation in the 1960s, thousands of procedures have been performed.1,2 Initially, all potentially viable amputated parts were replanted with a focus on improving replant survival. However, with advances in surgical methods and changes in the distribution of health care resources, the focus has shifted to maximizing function and surgical efficiency. Thus, although surgeons can now perform even the most technically demanding procedures, such as the replantation of digital tips in children,3 more recent work has focused on patient selection and minimization of surgical costs. At the same time, surgeons must balance these efforts with a popular cultural belief that any severed part can be replanted.4,5 With this understanding, current concepts in replantation surgery largely focus on preoperative From the Division of Plastic Surgery, University of Washington Received for publication February 4, 2013; accepted April 24, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000437254.93574.a8
identification of the patients and injuries most likely to have an excellent functional outcome and the most efficient techniques to deliver this result. This review examines the latest indications for replantation and expected outcomes and variations in venous and nerve repair, reviews special circumstances, and examines future directions in replantation surgery.
INDICATIONS AND CONTRAINDICATIONS FOR REPLANTATION The general indications and contraindications for replantation are summarized in Table 1. Patient age, mechanism and extent of injury, overall health, likely functional outcome, and the patient’s motivation are a few of the factors considered before replantation. Thumb replantation is usually attempted because of its important
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • February 2014 Table 1. Indications for and Contraindications to Upper Extremity Replantation Indications Amputation of the thumb Multiple-digit amputations Mid-palm/hand amputations Single finger amputations distal to the flexor digitorum superficialis insertion Any amputation in a child Contraindications Severe crush injuries Multilevel amputations Concomitant life-threatening injuries Single finger amputations proximal to the flexor digitorum superficialis insertion Patients unable to comply with rehabilitation program Prolonged normothermic ischemia time
biomechanical function and its utility in pinch and grip (Fig. 1). The thumb provides 40 to 50 percent of hand function, and even with limited range of motion, a successfully replanted thumb is more functional than any other reconstructive procedure or prosthetic device.4 Similarly, replantation of multiple digits is usually indicated because of the potential debilitating loss of hand function associated with these injuries (Figs. 2 and 3). In some cases, transpositional replantation may be required and many surgeons prioritize restoration of thumb and middle finger function to preserve at least rudimentary pinch and grip. Nonthumb single-digit replantation remains controversial,
Fig. 1. (Above) Preoperative and (below) postoperative views of thumb amputated at the level of the proximal phalanx with a band saw.
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Fig. 2. (Left) Preoperative view of four fingers amputated by a table saw. (Center) Immediate postoperative view of the four replanted digits. (Right) One-week postoperative image demonstrating nonviable index finger despite multiple therapeutic interventions.
Fig. 3. Long-term postoperative result following flexor and extensor tenolysis and prolonged hand therapy. Note the limited motion of the middle finger proximal interphalangeal joint.
as a replanted finger with limited function may negatively affect overall hand dexterity.5 Amputations distal to the insertion of the flexor digitorum superficialis are often attempted because digit function with preserved proximal interphalangeal joint motion is enhanced by the additional length, even if the distal interphalangeal joint is stiff or fused.6 Mid-palm amputations should generally be replanted, as any successful procedure will have superior function compared with a prosthetic device. However, these patients often have poor recovery of intrinsic muscle function and replantation is typically more successful if performed at the level of the palmar arch than at the level of the common digital arteries.7 Finally, replantation should be attempted for any injury in a child. Replantation is relatively contraindicated for severely crushed or mangled body parts,
amputations occurring at multiple levels, in patients with concomitant life-threatening injuries, patients with atherosclerosis, and in patients who are unlikely to comply with future rehabilitation (Figs. 4 and 5). Replantation of a single digit at the proximal phalanx or proximal interphalangeal joint is contraindicated because of the limited motion that is restored, although exceptions may be made for patients in manually demanding professions, such as musicians.
INJURY FACTORS AFFECTING REPLANTATION OUTCOMES Mechanism of Injury The type of injury is one of the most important determinants of survival rates and functional outcomes.5 A meta-analysis by Dec demonstrated
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Plastic and Reconstructive Surgery • February 2014 that sharply amputated fingers have the highest rates of survival (91.4 percent) compared with crush and avulsion injuries (68.4 and 66.3 percent, respectively).8 These differences in mechanism-dependent survival have been corroborated by other studies.9,10 Despite these data, the indications for ring avulsion injuries have expanded from only Urbaniak type II injuries (incomplete avulsion with damage of artery or vein) to include type III injuries (avulsion injury with complete degloving of both dorsal and palmar skin and blood supply) because of good outcomes with replantation of digits with a preserved proximal interphalangeal joint and flexor digitorum superficialis tendon.11–13 New studies have shown improvements in overall survival of ring avulsion injuries with advances in microsurgical technique, such as the use of vein grafts. Although only six patients with type III ring avulsion injuries were presented, all survived, with a mean total arc of motion of 195 degrees and mean two-point discrimination of 8.6 mm.11 All patients in the study were satisfied with the outcome and would choose replantation over amputation.11 Similarly, improved functional outcomes have been observed, challenging traditional notions that Urbaniak type III injuries are a contraindication for replantation. For example, although a recent meta-analysis of over 400 ring avulsion injuries demonstrated a mean survival rate for complete avulsions of 66 percent (thumb, 68 percent; other digits, 78 percent), it found better than expected functional outcomes with respect to finger total active arc of motion and two-point discrimination.13 Distal Amputations The insertion of the flexor digitorum superficialis is an important anatomical marker when deciding whether to attempt replantation. Studies have demonstrated that active range of motion is increased in patients with single-digit replantation distal to the flexor digitorum superficialis insertion, with an average of 82 degrees compared with 35 degrees with a more proximal amputation.6,14,15 Survival rates of distal phalangeal replantation are also good, with an overall rate of 86 percent and with no major difference observed for Tamai zone I or II injuries (Table 2).9 Additional studies support this finding, with survival rates of distal tip injuries (past the start of the nail plate) reported to be 85 percent.16 With respect to functional outcomes, use of the Ishikawa grading system allows for more detailed analysis (Table 2). Mean range of motion
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at the distal interphalangeal joint based on level of injury has been reported as 60 to 80 percent compared with the opposite side for subzone II injuries and subzone III injuries, but only 30 percent for subzone IV injuries because of bony fixation.17 Mean pinch strength and mean grip strength showed no significant difference based on Ishikawa level of injury.17 Thus, the question of whether to replant a distal tip injury versus revision amputation becomes an important one, especially with subzone IV injuries. Proposed advantages of replantation include preserved digital length, protective sensation, preservation of the nail, and conservation of joint motion. A recent study by Hattori et al. found no difference in grip strength when comparing distal tip replantation versus stump revision, but the replanted group demonstrated increased range of motion at the proximal interphalangeal joint, more frequent use of the replanted digits, and decreased pain.16 Paresthesias and cold intolerance were not significantly different between the two groups; however, it is important to note that the f ollow-up time in the amputation group was significantly shorter.16 Finally, Disabilities of the Arm, Shoulder and Hand scores were reportedly better for index and middle finger replantation versus amputation, likely because of preserved length and maintenance of tripod pinch, but separate Disabilities of the Arm, Shoulder and Hand scores for ring and small finger were not reported.16 Thus, with variable follow-up times, no separate reporting of functional outcomes per digit, and lack of information regarding subzone of injury, the results of this study are difficult to interpret. Based on this information, replantation should be favored for subzone I to III injuries. However, for subzone IV injuries, given the low likelihood of functional range of motion at the distal interphalangeal joint, revision amputation may be considered, especially in ring or small finger Table 2. Classification of Distal Fingertip Amputation According to Tamai* and Ishikawa† Anatomical Location Midpoint of nail to fingertip Base of nail to midpoint of nail Distal to midpoint between DIP and base of nail Proximal to midpoint between DIP and base of nail
Tamai
Ishikawa
Zone I
Subzone I Subzone II Subzone III
Zone II
Subzone IV
DIP, distal interphalangeal joint. *Tamai S. Twenty years’ experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg Am. 1982;7:549–556. †Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. A new classification of the amputation level for the distal part of the fingers. J Jpn Soc Microsurg. 1990;3:54–62.
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Fig. 4. Preoperative photographs and radiographs of the hand and four fingers amputated at multiple levels with a radial arm saw. The central amputation mass contained the thumb and was amputated through the carpus. The digits were amputated through the bases of the proximal phalanges. Some would consider this multiple level type injury to be a relative contraindication to replantation.
injuries in patients who desire a faster return to work (4 months versus 1 month), and those who are willing to accept a possibly painful stump.16 Hand Amputation Unless severely mangled or crushed, all palmand wrist-level hand amputations should be replanted. In a study of patients with transmetacarpal injuries, replantation had an 86 percent success rate, and all patients were overall satisfied with their surgical outcome and would choose replantation again if given the choice.7 Over half the patients in this study achieved nearly normal sensation,7 which is improved compared with prior studies.18 However, approximately 50 percent of patients did require secondary
procedures and all patients reported cold intolerance, although this improved in 50 percent of the patients.7 Relatively good results have been reported with wrist and proximal wrist level amputations.19,20 In a small series of complete amputations at the radiocarpal joint, Hoang found that patients regained 60 to 80 percent of contralateral wrist and finger range of motion, with all patients able to use the hand for pinch and grasp.19 However, intrinsic muscle function was limited, especially in cases of prolonged ischemia. A temporary vascular shunt should be considered if ischemia time exceeds 6 hours, and in these patients, arterial inflow should be reestablished before rigid internal fixation to allow accumulated toxins to
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Fig. 5. Postoperative results of replantation before tenolysis and corrective osteotomy of the small finger. Note malrotation of the small finger.
clear through transected veins.20 Fasciotomies of the hand, forearm, and arm may also be required. Ischemia Time Irreversible ischemic injury occurs in muscle tissue after 2 to 4 hours of warm ishemia and 6 to 8 hours of cold ischemia time, but digits lack muscle tissue and are thus less susceptible to ischemic damage (tolerating up to 6 to 12 hours of warm ischemia and 12 to 24 hours of cold ischemia time).21 Despite these well-established guidelines, successful digit replantation after 33 hours of warm and 94 hours of cold preservation, respectively, have been reported,22,23 as has successful hand replantation after 54 hours of cold ischemia.24 With more proximal amputations and in the setting of prolonged ischemia time, one can consider interosseous muscle stripping to prevent later necrosis or fibrosis. Dec’s meta-analysis of ischemia time for all digit replantations identified two studies and demonstrated an odds ratio for survival of 2.08 with ischemia times less than 12 hours (93.1 percent compared with 86.7 percent). However, these results are difficult to interpret because of variations in reported ischemia time and grouping, the lack of indication of whether warm or cold ischemia was used, and small sample size.8 A more recent study demonstrated that with cold preservation, ischemia time did not affect survival, but 33 hours was the longest time reported.10 Only one study analyzed ischemia times greater than 24 hours (31 amputations total), and no correlation
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between ischemia time and postoperative outcomes was identified.21 The digit replantation survival rate after 24 hours was 65 percent in this study. Based on available evidence, cold ischemia time should play little role in deciding whether to perform a replantation unless the amputated part contains significant muscle (i.e., forearm). Ischemia time should also not preclude transfer to a replantation facility, although more data are needed regarding the effect of prolonged ischemia on functional outcomes and survival.
PATIENT CHARACTERISTICS AFFECTING REPLANTATION OUTCOMES Age Children show better functional recovery than adults, and replantation should almost always be attempted in the pediatric population.25,26 In addition, replanted parts appear to demonstrate normal growth.27,28 However, comparing replantation success rates between children and adults is difficult because of variable reporting of age and the lower threshold for surgery in children. Although medical comorbidities, decreased nerve regeneration, and decreased range of motion make elderly patients less likely to undergo replantation,25,29–31 recent studies have not demonstrated higher perioperative morbidity, and the only age-related differences were higher rates of transfusion and increased need for support after discharge.32
Volume 133, Number 2 • Upper Extremity Replantation Age alone should not be a contraindication for replantation, with functional demand, American Society of Anesthesiologists score, and likelihood of successful rehabilitation being more important factors.32,33 Anticoagulation Replantation thrombosis is the most feared short-term postoperative complication. Most thrombosis occurs in the vein because of its relatively low flow state. A variety of antiplatelet and antithrombotic agents, including aspirin, intravenous heparin, intraluminal heparin, low-molecular-weight heparin, dextran, and prostaglandin derivatives have been used prophylactically to avoid this complication. Many of the principles regarding pharmacologic treatment of replanted digits and hands are extrapolated from the free flap surgery literature. Aspirin is the most commonly used agent. Although clinical studies have never shown aspirin to be effective in decreasing the rates of either venous or arterial thrombosis in microsurgery, few studies have shown increased rate of complications. In light of evidence for the use of aspirin in other circulatory problems such as cerebrovascular accidents, carotid stenosis, and myocardial infarctions, the use of aspirin is widespread.34 The safety profile is further enhanced by evidence that demonstrates low-dose aspirin, in combination with subcutaneous heparin or low-molecular-weight heparin for deep vein thrombosis prophylaxis, poses no increased risk.35 Several studies have shown no benefit of heparin over aspirin alone for the prevention of microvascular thrombosis.35,36 A recent study by Nikolis et al. evaluated the role of aspirin, aspirin with subcutaneous heparin, and aspirin with intravenous heparin infusion in replantation surgery.37 Local complication rates for hematoma, thrombosis, venous congestion, ischemia and/or partial necrosis, and infection were recorded. The use of intravenous heparin did not correlate with higher rates of successful replantation but was found to increase local complications three-fold.37 In addition, when the study analyzed two distinct time cohorts, no change in overall replantation survival was observed (95.4 percent versus 95.1 percent) despite a decrease in the use of intravenous heparin from 35.1 percent to 14.6 percent.37 Although the routine use of intravenous heparin following digital replantation and revascularization is not indicated,37 there are several instances where it may be warranted. These indications include clinical evidence of severely
atherosclerotic vessels, unresectable intimal damage (i.e., crush and avulsion injuries), intraoperative thrombus, or following successful thrombolysis.34,37 In addition, heparin irrigation should be used during the time of vessel anastomosis to reduce platelet aggregation and prevent arterial thrombus.10,34 Smoking Although smoking is known to impair microcirculation in a replanted digit,38 its effect on replantation survival is unclear. One study of ring avulsion injuries demonstrated that smoking history had no effect on replantation survival.39 Similarly, a study analyzing preoperative risk factors demonstrated that a history of smoking had no effect on survival, but did show that postoperative smoking negatively impacted surgical outcomes.10 These data contradict an older study of over 500 digit replantations that showed the digits of smokers were saved at a rate of 61.1 percent compared with 96.7 percent for nonsmokers.5 Thus, the data are inconclusive. In our practice, smoking history has minimal influence on the decision to perform replantation surgery unless it is clear the patient will continue to smoke postoperatively, but patients are warned that they may have a higher risk for complications and failure.
SURGICAL TECHNIQUE AFFECTING REPLANTATION OUTCOMES Replantation without Digital Vein Repair It has been previously shown that the number of venous anastomoses in a replant procedure correlates with survival, and anastomosis of two or more veins is generally superior to single-vein anastomosis.14 However, this dictum may not be applicable to Tamai zone I and II injuries (Table 2), and the available data are contradictory, espe eta-analysis by cially for zone I injuries.9,10,40 The m Sebastin and Chung found an overall survival rate of 87 percent for Tamai zone I and II injuries with vein repair (performed in 63 percent of replantations), leading to a statistically significant 10 percent increase in survival for both zones, which is similar to the survival rate of 87 percent published by Nazerani et al., where an artery or vein was used for outflow in all zone I and II replantations.9,41 The meta-analysis by Sebastin and Chung does not subdivide by the Ishikawa classification as did other studies that demonstrated similar survival rates with artery-alone and alternative methods of venous drainage including paronychial stab
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Plastic and Reconstructive Surgery • February 2014 incision, topical dripping of heparinized saline, venous drainage through the medullary cavity and shaving of the nail bed or skin over the pulp combined with heparin-soaked pledgets.10,42,43 These studies evaluated specific subzones of injury and found that venous repair may only be required in subzone IV and that replanted digits can survive with any method of venous drainage in subzone II (80 percent survival) and III (83 percent survival) injuries.17,43 In addition, the number of venous anastomoses (none, one, or two) was not found to be an independent predictor of replantation survival for distal injuries in a retrospective analysis of over 200 patients.10 Based on the available data, the lack of a suitable vein does not preclude replantation in our practice for subzone I to III injuries if alternative venous drainage methods are available. Utility of Vein Grafts Vein grafts provide a reliable method of creating tension-free anastomosis when bone shortening is limited or when the zone of injury is large. Several studies have demonstrated the reliability of vein grafts in microsurgical and replantation surgery, including distal fingertip amputations, and have shown that vein grafts do not increase the rate of thrombosis or decrease replant survival.44 However, determining when to use a vein graft is challenging, especially when it is difficult to assess the degree of vessel damage and the amount of resection that is necessary to obtain normal intima. Avulsion injuries are a subset of amputations where vein grafts may lead to increased replant survival. Intimal damage can extend beyond the level of vessel transection by as much as 4 cm and thus aggressive resection is warranted.11 In one study analyzing crush or avulsion injuries, primary venous anastomosis was more likely to fail compared with bleeding or perimedullary drainage, but vein grafting was found to have better outcomes compared with venous anastomosis alone.10 The poor outcomes seen in avulsion injuries may be attributable to shearing injury, and vein grafting is beneficial because it allows for complete excision of damaged vessel and the creation of an anastomosis with less tension.11 There is at least one animal study corroborating this clinical experience.45 Replantation without Digital Nerve Repair Nerve repair generally accompanies vascular repair in replantation surgery. However, a number of studies have demonstrated that for injuries
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distal to the distal interphalangeal joint, nerve repair may not lead to better functional outcomes. Chung’s group found that 50 percent of the patients in their meta-analysis of Tamai zone I and II injuries obtained an average two-point discrimination of 7 mm without nerve repair. Similarly, Hattori et al. found that, without nerve repair, 96 percent of patients obtained protective sensation,16 and Hasuo et al. found no significant difference between Tamai zone I and II injuries with or without nerve repair.17 Thus, for injuries distal to the distal interphalangeal joint, nerve repair may not be necessary.9,16,46–48
SPECIAL CONSIDERATIONS Regionalization of Care With the high technical demand of replantation surgery, the time commitment to the procedure and postoperative care, and the limitation of resources and reimbursements, fewer surgeons and hospitals are performing replantation procedures.49 A study of members of the American Society for Surgery of the Hand demonstrated that only 56 percent of respondents performed replantation procedures and that 62 percent of those individuals performed fewer than five per year. Furthermore, many members of the Society reported inadequate confidence and disappointment in results, creating a cycle where insufficient experience may lead to an even lower likelihood of attempting to perform replantation.49 The majority of procedures are now being performed at academic centers or Level I trauma centers, which are available within 100 miles of the majority of hand surgeons,49,50 although the need for the identification and coordination of regional centers may be increasing.51 Arguments for regionalization of health care are that it may lead to better outcomes and lower costs. However, the decision of whether to transport patients for replantation surgery should be made carefully. Inappropriate transfers are common, and a majority of patients who are transferred for replantation may never undergo the procedure either because of a desire of the patient to return to work quickly, economic reasons (mean total charges for all upper extremity replantation procedures were $42,561 versus $27,541 for alternative treatments in one study), and/or the patient being a poor candidate (e.g., unfavorable injury mechanism, medical comorbidities).50,52,53 In addition, air transportation itself carries a prohibitive cost if the transfer is inappropriate.52 Transferring physicians should
Volume 133, Number 2 • Upper Extremity Replantation help patients make an informed decision before transfer, and efforts should focus on the development of telemedicine to facilitate regionalization of care and appropriate triage.52 When the decision to not replant an amputated part is made, the reasoning should be discussed thoroughly with the patient and documented, and details of the injury and preservation of the amputated part should be recorded carefully. It is also advisable to obtain photographs of the affected hand and severed part and to consider sending the amputated portion to the pathology department for proper cataloging.54 Jeffrey B. Friedrich, M.D. Division of Plastic Surgery University of Washington 325 9th Avenue, Box 359796 Seattle, Wash. 98104 [email protected]
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Plastic and Reconstructive Surgery • February 2014 36. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg. 1998;102:711–721. 37. Nikolis A, Tahiri Y, St-Supery V, et al. Intravenous heparin use in digital replantation and revascularization: The Quebec Provincial Replantation program experience. Microsurgery 2011;31:421–427. 38. van Adrichem LN, Hovius SE, van Strik R, van der Meulen JC. The acute effect of cigarette smoking on the microcirculation of a replanted digit. J Hand Surg Am. 1992;17:230–234. 39. Sanmartin M, Fernandes F, Lajoie AS, Gupta A. Analysis of prognostic factors in ring avulsion injuries. J Hand Surg Am. 2004;29:1028–1037. 40. Akyürek M, Safak T, Keçik A. Fingertip replantation at or distal to the nail base: Use of the technique of artery-only anastomosis. Ann Plast Surg. 2001;46:605–612. 41. Nazerani S, Motamedi MH, Ebadi MR, Nazerani T, Bidarmaghz B. Experience with distal finger replantation: A 20-year retrospective study from a major trauma center. Tech Hand Up Extrem Surg. 2011;15:144–150. 42. Scheker LR, Becker GW. Distal finger replantation. J Hand Surg Am. 2011;36:521–528. 43. Ito H, Sasaki K, Morioka K, Nozaki M. Fingertip amputation salvage on arterial anastomosis alone: An investigation of its limitations. Ann Plast Surg. 2010;65:302–305. 44. Yan H, Jackson WD, Songcharoen S, et al. Vein grafting in fingertip replantations. Microsurgery 2009;29:275–281. 45. Gravvanis AI, Tsoutsos DA, Lykoudis EG, et al. Microvascular repair following crush-avulsion type injury with vein grafts: Effect of direct inhibitors of thrombin on patency rate. Microsurgery 2003;23:402–407; discussion 408. 46. Ozcelik IB, Tuncer S, Purisa H, et al. Sensory outcome of fingertip replantations without nerve repair. Microsurgery 2008;28:524–530.
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47. Faivre S, Lim A, Dautel G, Duteille F, Merle M. Adjacent and spontaneous neurotization after distal digital replantation in children. Plast Reconstr Surg. 2003;111:159–165; discussion 166. 48. Wong C, Ho PC, Tse WL, Cheng S, Chan DK, Hung LK. Do we need to repair the nerves when replanting distal finger amputations? J Reconstr Microsurg. 2010;26:347–354. 49. Payatakes AH, Zagoreos NP, Fedorcik GG, Ruch DS, Levin LS. Current practice of microsurgery by members of the American Society for Surgery of the Hand. J Hand Surg Am. 2007;32:541–547. 50. Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am. 2011;36:1835–1840. 51. Richards WT, Barber MK, Richards WA, Mozingo DW. Hand injuries in the state of Florida, are centers of excellence needed? J Trauma 2010;68:1480–1490. 52. Ozer K, Kramer W, Gillani S, Williams A, Smith W. Replantation versus revision of amputated fingers in patients air-transported to a level 1 trauma center. J Hand Surg Am. 2010;35:936–940. 53. Amis B, Friedrich J. Differences in treatment of digital amputation injuries based on community transfer versus tertiary initial presentation. Hand (NY) 2012;7:259–262. 54. Bastidas N, Cassidy L, Hoffman L, Sharma S. A single-institution experience of hand surgery litigation in a major replantation center. Plast Reconstr Surg. 2011;127: 284–292. 55. Tamai S. Twenty years’ experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg Am. 1982;7:549–556. 56. Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. A new classification of the amputation level for the distal part of the fingers. J Jpn Soc Microsurg. 1990;3:54–62.
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. (Plast. Reconstr. Surg. 133: 333, 2014.)
T
raumatic hand amputations are devastating injuries with significant psychological and socioeconomic consequences. Since the advent of limb and digit replantation in the 1960s, thousands of procedures have been performed.1,2 Initially, all potentially viable amputated parts were replanted with a focus on improving replant survival. However, with advances in surgical methods and changes in the distribution of health care resources, the focus has shifted to maximizing function and surgical efficiency. Thus, although surgeons can now perform even the most technically demanding procedures, such as the replantation of digital tips in children,3 more recent work has focused on patient selection and minimization of surgical costs. At the same time, surgeons must balance these efforts with a popular cultural belief that any severed part can be replanted.4,5 With this understanding, current concepts in replantation surgery largely focus on preoperative From the Division of Plastic Surgery, University of Washington Received for publication February 4, 2013; accepted April 24, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000437254.93574.a8
identification of the patients and injuries most likely to have an excellent functional outcome and the most efficient techniques to deliver this result. This review examines the latest indications for replantation and expected outcomes and variations in venous and nerve repair, reviews special circumstances, and examines future directions in replantation surgery.
INDICATIONS AND CONTRAINDICATIONS FOR REPLANTATION The general indications and contraindications for replantation are summarized in Table 1. Patient age, mechanism and extent of injury, overall health, likely functional outcome, and the patient’s motivation are a few of the factors considered before replantation. Thumb replantation is usually attempted because of its important
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • February 2014 Table 1. Indications for and Contraindications to Upper Extremity Replantation Indications Amputation of the thumb Multiple-digit amputations Mid-palm/hand amputations Single finger amputations distal to the flexor digitorum superficialis insertion Any amputation in a child Contraindications Severe crush injuries Multilevel amputations Concomitant life-threatening injuries Single finger amputations proximal to the flexor digitorum superficialis insertion Patients unable to comply with rehabilitation program Prolonged normothermic ischemia time
biomechanical function and its utility in pinch and grip (Fig. 1). The thumb provides 40 to 50 percent of hand function, and even with limited range of motion, a successfully replanted thumb is more functional than any other reconstructive procedure or prosthetic device.4 Similarly, replantation of multiple digits is usually indicated because of the potential debilitating loss of hand function associated with these injuries (Figs. 2 and 3). In some cases, transpositional replantation may be required and many surgeons prioritize restoration of thumb and middle finger function to preserve at least rudimentary pinch and grip. Nonthumb single-digit replantation remains controversial,
Fig. 1. (Above) Preoperative and (below) postoperative views of thumb amputated at the level of the proximal phalanx with a band saw.
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Fig. 2. (Left) Preoperative view of four fingers amputated by a table saw. (Center) Immediate postoperative view of the four replanted digits. (Right) One-week postoperative image demonstrating nonviable index finger despite multiple therapeutic interventions.
Fig. 3. Long-term postoperative result following flexor and extensor tenolysis and prolonged hand therapy. Note the limited motion of the middle finger proximal interphalangeal joint.
as a replanted finger with limited function may negatively affect overall hand dexterity.5 Amputations distal to the insertion of the flexor digitorum superficialis are often attempted because digit function with preserved proximal interphalangeal joint motion is enhanced by the additional length, even if the distal interphalangeal joint is stiff or fused.6 Mid-palm amputations should generally be replanted, as any successful procedure will have superior function compared with a prosthetic device. However, these patients often have poor recovery of intrinsic muscle function and replantation is typically more successful if performed at the level of the palmar arch than at the level of the common digital arteries.7 Finally, replantation should be attempted for any injury in a child. Replantation is relatively contraindicated for severely crushed or mangled body parts,
amputations occurring at multiple levels, in patients with concomitant life-threatening injuries, patients with atherosclerosis, and in patients who are unlikely to comply with future rehabilitation (Figs. 4 and 5). Replantation of a single digit at the proximal phalanx or proximal interphalangeal joint is contraindicated because of the limited motion that is restored, although exceptions may be made for patients in manually demanding professions, such as musicians.
INJURY FACTORS AFFECTING REPLANTATION OUTCOMES Mechanism of Injury The type of injury is one of the most important determinants of survival rates and functional outcomes.5 A meta-analysis by Dec demonstrated
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Plastic and Reconstructive Surgery • February 2014 that sharply amputated fingers have the highest rates of survival (91.4 percent) compared with crush and avulsion injuries (68.4 and 66.3 percent, respectively).8 These differences in mechanism-dependent survival have been corroborated by other studies.9,10 Despite these data, the indications for ring avulsion injuries have expanded from only Urbaniak type II injuries (incomplete avulsion with damage of artery or vein) to include type III injuries (avulsion injury with complete degloving of both dorsal and palmar skin and blood supply) because of good outcomes with replantation of digits with a preserved proximal interphalangeal joint and flexor digitorum superficialis tendon.11–13 New studies have shown improvements in overall survival of ring avulsion injuries with advances in microsurgical technique, such as the use of vein grafts. Although only six patients with type III ring avulsion injuries were presented, all survived, with a mean total arc of motion of 195 degrees and mean two-point discrimination of 8.6 mm.11 All patients in the study were satisfied with the outcome and would choose replantation over amputation.11 Similarly, improved functional outcomes have been observed, challenging traditional notions that Urbaniak type III injuries are a contraindication for replantation. For example, although a recent meta-analysis of over 400 ring avulsion injuries demonstrated a mean survival rate for complete avulsions of 66 percent (thumb, 68 percent; other digits, 78 percent), it found better than expected functional outcomes with respect to finger total active arc of motion and two-point discrimination.13 Distal Amputations The insertion of the flexor digitorum superficialis is an important anatomical marker when deciding whether to attempt replantation. Studies have demonstrated that active range of motion is increased in patients with single-digit replantation distal to the flexor digitorum superficialis insertion, with an average of 82 degrees compared with 35 degrees with a more proximal amputation.6,14,15 Survival rates of distal phalangeal replantation are also good, with an overall rate of 86 percent and with no major difference observed for Tamai zone I or II injuries (Table 2).9 Additional studies support this finding, with survival rates of distal tip injuries (past the start of the nail plate) reported to be 85 percent.16 With respect to functional outcomes, use of the Ishikawa grading system allows for more detailed analysis (Table 2). Mean range of motion
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at the distal interphalangeal joint based on level of injury has been reported as 60 to 80 percent compared with the opposite side for subzone II injuries and subzone III injuries, but only 30 percent for subzone IV injuries because of bony fixation.17 Mean pinch strength and mean grip strength showed no significant difference based on Ishikawa level of injury.17 Thus, the question of whether to replant a distal tip injury versus revision amputation becomes an important one, especially with subzone IV injuries. Proposed advantages of replantation include preserved digital length, protective sensation, preservation of the nail, and conservation of joint motion. A recent study by Hattori et al. found no difference in grip strength when comparing distal tip replantation versus stump revision, but the replanted group demonstrated increased range of motion at the proximal interphalangeal joint, more frequent use of the replanted digits, and decreased pain.16 Paresthesias and cold intolerance were not significantly different between the two groups; however, it is important to note that the f ollow-up time in the amputation group was significantly shorter.16 Finally, Disabilities of the Arm, Shoulder and Hand scores were reportedly better for index and middle finger replantation versus amputation, likely because of preserved length and maintenance of tripod pinch, but separate Disabilities of the Arm, Shoulder and Hand scores for ring and small finger were not reported.16 Thus, with variable follow-up times, no separate reporting of functional outcomes per digit, and lack of information regarding subzone of injury, the results of this study are difficult to interpret. Based on this information, replantation should be favored for subzone I to III injuries. However, for subzone IV injuries, given the low likelihood of functional range of motion at the distal interphalangeal joint, revision amputation may be considered, especially in ring or small finger Table 2. Classification of Distal Fingertip Amputation According to Tamai* and Ishikawa† Anatomical Location Midpoint of nail to fingertip Base of nail to midpoint of nail Distal to midpoint between DIP and base of nail Proximal to midpoint between DIP and base of nail
Tamai
Ishikawa
Zone I
Subzone I Subzone II Subzone III
Zone II
Subzone IV
DIP, distal interphalangeal joint. *Tamai S. Twenty years’ experience of limb replantation: Review of 293 upper extremity replants. J Hand Surg Am. 1982;7:549–556. †Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. A new classification of the amputation level for the distal part of the fingers. J Jpn Soc Microsurg. 1990;3:54–62.
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Fig. 4. Preoperative photographs and radiographs of the hand and four fingers amputated at multiple levels with a radial arm saw. The central amputation mass contained the thumb and was amputated through the carpus. The digits were amputated through the bases of the proximal phalanges. Some would consider this multiple level type injury to be a relative contraindication to replantation.
injuries in patients who desire a faster return to work (4 months versus 1 month), and those who are willing to accept a possibly painful stump.16 Hand Amputation Unless severely mangled or crushed, all palmand wrist-level hand amputations should be replanted. In a study of patients with transmetacarpal injuries, replantation had an 86 percent success rate, and all patients were overall satisfied with their surgical outcome and would choose replantation again if given the choice.7 Over half the patients in this study achieved nearly normal sensation,7 which is improved compared with prior studies.18 However, approximately 50 percent of patients did require secondary
procedures and all patients reported cold intolerance, although this improved in 50 percent of the patients.7 Relatively good results have been reported with wrist and proximal wrist level amputations.19,20 In a small series of complete amputations at the radiocarpal joint, Hoang found that patients regained 60 to 80 percent of contralateral wrist and finger range of motion, with all patients able to use the hand for pinch and grasp.19 However, intrinsic muscle function was limited, especially in cases of prolonged ischemia. A temporary vascular shunt should be considered if ischemia time exceeds 6 hours, and in these patients, arterial inflow should be reestablished before rigid internal fixation to allow accumulated toxins to
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Fig. 5. Postoperative results of replantation before tenolysis and corrective osteotomy of the small finger. Note malrotation of the small finger.
clear through transected veins.20 Fasciotomies of the hand, forearm, and arm may also be required. Ischemia Time Irreversible ischemic injury occurs in muscle tissue after 2 to 4 hours of warm ishemia and 6 to 8 hours of cold ischemia time, but digits lack muscle tissue and are thus less susceptible to ischemic damage (tolerating up to 6 to 12 hours of warm ischemia and 12 to 24 hours of cold ischemia time).21 Despite these well-established guidelines, successful digit replantation after 33 hours of warm and 94 hours of cold preservation, respectively, have been reported,22,23 as has successful hand replantation after 54 hours of cold ischemia.24 With more proximal amputations and in the setting of prolonged ischemia time, one can consider interosseous muscle stripping to prevent later necrosis or fibrosis. Dec’s meta-analysis of ischemia time for all digit replantations identified two studies and demonstrated an odds ratio for survival of 2.08 with ischemia times less than 12 hours (93.1 percent compared with 86.7 percent). However, these results are difficult to interpret because of variations in reported ischemia time and grouping, the lack of indication of whether warm or cold ischemia was used, and small sample size.8 A more recent study demonstrated that with cold preservation, ischemia time did not affect survival, but 33 hours was the longest time reported.10 Only one study analyzed ischemia times greater than 24 hours (31 amputations total), and no correlation
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between ischemia time and postoperative outcomes was identified.21 The digit replantation survival rate after 24 hours was 65 percent in this study. Based on available evidence, cold ischemia time should play little role in deciding whether to perform a replantation unless the amputated part contains significant muscle (i.e., forearm). Ischemia time should also not preclude transfer to a replantation facility, although more data are needed regarding the effect of prolonged ischemia on functional outcomes and survival.
PATIENT CHARACTERISTICS AFFECTING REPLANTATION OUTCOMES Age Children show better functional recovery than adults, and replantation should almost always be attempted in the pediatric population.25,26 In addition, replanted parts appear to demonstrate normal growth.27,28 However, comparing replantation success rates between children and adults is difficult because of variable reporting of age and the lower threshold for surgery in children. Although medical comorbidities, decreased nerve regeneration, and decreased range of motion make elderly patients less likely to undergo replantation,25,29–31 recent studies have not demonstrated higher perioperative morbidity, and the only age-related differences were higher rates of transfusion and increased need for support after discharge.32
Volume 133, Number 2 • Upper Extremity Replantation Age alone should not be a contraindication for replantation, with functional demand, American Society of Anesthesiologists score, and likelihood of successful rehabilitation being more important factors.32,33 Anticoagulation Replantation thrombosis is the most feared short-term postoperative complication. Most thrombosis occurs in the vein because of its relatively low flow state. A variety of antiplatelet and antithrombotic agents, including aspirin, intravenous heparin, intraluminal heparin, low-molecular-weight heparin, dextran, and prostaglandin derivatives have been used prophylactically to avoid this complication. Many of the principles regarding pharmacologic treatment of replanted digits and hands are extrapolated from the free flap surgery literature. Aspirin is the most commonly used agent. Although clinical studies have never shown aspirin to be effective in decreasing the rates of either venous or arterial thrombosis in microsurgery, few studies have shown increased rate of complications. In light of evidence for the use of aspirin in other circulatory problems such as cerebrovascular accidents, carotid stenosis, and myocardial infarctions, the use of aspirin is widespread.34 The safety profile is further enhanced by evidence that demonstrates low-dose aspirin, in combination with subcutaneous heparin or low-molecular-weight heparin for deep vein thrombosis prophylaxis, poses no increased risk.35 Several studies have shown no benefit of heparin over aspirin alone for the prevention of microvascular thrombosis.35,36 A recent study by Nikolis et al. evaluated the role of aspirin, aspirin with subcutaneous heparin, and aspirin with intravenous heparin infusion in replantation surgery.37 Local complication rates for hematoma, thrombosis, venous congestion, ischemia and/or partial necrosis, and infection were recorded. The use of intravenous heparin did not correlate with higher rates of successful replantation but was found to increase local complications three-fold.37 In addition, when the study analyzed two distinct time cohorts, no change in overall replantation survival was observed (95.4 percent versus 95.1 percent) despite a decrease in the use of intravenous heparin from 35.1 percent to 14.6 percent.37 Although the routine use of intravenous heparin following digital replantation and revascularization is not indicated,37 there are several instances where it may be warranted. These indications include clinical evidence of severely
atherosclerotic vessels, unresectable intimal damage (i.e., crush and avulsion injuries), intraoperative thrombus, or following successful thrombolysis.34,37 In addition, heparin irrigation should be used during the time of vessel anastomosis to reduce platelet aggregation and prevent arterial thrombus.10,34 Smoking Although smoking is known to impair microcirculation in a replanted digit,38 its effect on replantation survival is unclear. One study of ring avulsion injuries demonstrated that smoking history had no effect on replantation survival.39 Similarly, a study analyzing preoperative risk factors demonstrated that a history of smoking had no effect on survival, but did show that postoperative smoking negatively impacted surgical outcomes.10 These data contradict an older study of over 500 digit replantations that showed the digits of smokers were saved at a rate of 61.1 percent compared with 96.7 percent for nonsmokers.5 Thus, the data are inconclusive. In our practice, smoking history has minimal influence on the decision to perform replantation surgery unless it is clear the patient will continue to smoke postoperatively, but patients are warned that they may have a higher risk for complications and failure.
SURGICAL TECHNIQUE AFFECTING REPLANTATION OUTCOMES Replantation without Digital Vein Repair It has been previously shown that the number of venous anastomoses in a replant procedure correlates with survival, and anastomosis of two or more veins is generally superior to single-vein anastomosis.14 However, this dictum may not be applicable to Tamai zone I and II injuries (Table 2), and the available data are contradictory, espe eta-analysis by cially for zone I injuries.9,10,40 The m Sebastin and Chung found an overall survival rate of 87 percent for Tamai zone I and II injuries with vein repair (performed in 63 percent of replantations), leading to a statistically significant 10 percent increase in survival for both zones, which is similar to the survival rate of 87 percent published by Nazerani et al., where an artery or vein was used for outflow in all zone I and II replantations.9,41 The meta-analysis by Sebastin and Chung does not subdivide by the Ishikawa classification as did other studies that demonstrated similar survival rates with artery-alone and alternative methods of venous drainage including paronychial stab
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Plastic and Reconstructive Surgery • February 2014 incision, topical dripping of heparinized saline, venous drainage through the medullary cavity and shaving of the nail bed or skin over the pulp combined with heparin-soaked pledgets.10,42,43 These studies evaluated specific subzones of injury and found that venous repair may only be required in subzone IV and that replanted digits can survive with any method of venous drainage in subzone II (80 percent survival) and III (83 percent survival) injuries.17,43 In addition, the number of venous anastomoses (none, one, or two) was not found to be an independent predictor of replantation survival for distal injuries in a retrospective analysis of over 200 patients.10 Based on the available data, the lack of a suitable vein does not preclude replantation in our practice for subzone I to III injuries if alternative venous drainage methods are available. Utility of Vein Grafts Vein grafts provide a reliable method of creating tension-free anastomosis when bone shortening is limited or when the zone of injury is large. Several studies have demonstrated the reliability of vein grafts in microsurgical and replantation surgery, including distal fingertip amputations, and have shown that vein grafts do not increase the rate of thrombosis or decrease replant survival.44 However, determining when to use a vein graft is challenging, especially when it is difficult to assess the degree of vessel damage and the amount of resection that is necessary to obtain normal intima. Avulsion injuries are a subset of amputations where vein grafts may lead to increased replant survival. Intimal damage can extend beyond the level of vessel transection by as much as 4 cm and thus aggressive resection is warranted.11 In one study analyzing crush or avulsion injuries, primary venous anastomosis was more likely to fail compared with bleeding or perimedullary drainage, but vein grafting was found to have better outcomes compared with venous anastomosis alone.10 The poor outcomes seen in avulsion injuries may be attributable to shearing injury, and vein grafting is beneficial because it allows for complete excision of damaged vessel and the creation of an anastomosis with less tension.11 There is at least one animal study corroborating this clinical experience.45 Replantation without Digital Nerve Repair Nerve repair generally accompanies vascular repair in replantation surgery. However, a number of studies have demonstrated that for injuries
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distal to the distal interphalangeal joint, nerve repair may not lead to better functional outcomes. Chung’s group found that 50 percent of the patients in their meta-analysis of Tamai zone I and II injuries obtained an average two-point discrimination of 7 mm without nerve repair. Similarly, Hattori et al. found that, without nerve repair, 96 percent of patients obtained protective sensation,16 and Hasuo et al. found no significant difference between Tamai zone I and II injuries with or without nerve repair.17 Thus, for injuries distal to the distal interphalangeal joint, nerve repair may not be necessary.9,16,46–48
SPECIAL CONSIDERATIONS Regionalization of Care With the high technical demand of replantation surgery, the time commitment to the procedure and postoperative care, and the limitation of resources and reimbursements, fewer surgeons and hospitals are performing replantation procedures.49 A study of members of the American Society for Surgery of the Hand demonstrated that only 56 percent of respondents performed replantation procedures and that 62 percent of those individuals performed fewer than five per year. Furthermore, many members of the Society reported inadequate confidence and disappointment in results, creating a cycle where insufficient experience may lead to an even lower likelihood of attempting to perform replantation.49 The majority of procedures are now being performed at academic centers or Level I trauma centers, which are available within 100 miles of the majority of hand surgeons,49,50 although the need for the identification and coordination of regional centers may be increasing.51 Arguments for regionalization of health care are that it may lead to better outcomes and lower costs. However, the decision of whether to transport patients for replantation surgery should be made carefully. Inappropriate transfers are common, and a majority of patients who are transferred for replantation may never undergo the procedure either because of a desire of the patient to return to work quickly, economic reasons (mean total charges for all upper extremity replantation procedures were $42,561 versus $27,541 for alternative treatments in one study), and/or the patient being a poor candidate (e.g., unfavorable injury mechanism, medical comorbidities).50,52,53 In addition, air transportation itself carries a prohibitive cost if the transfer is inappropriate.52 Transferring physicians should
Volume 133, Number 2 • Upper Extremity Replantation help patients make an informed decision before transfer, and efforts should focus on the development of telemedicine to facilitate regionalization of care and appropriate triage.52 When the decision to not replant an amputated part is made, the reasoning should be discussed thoroughly with the patient and documented, and details of the injury and preservation of the amputated part should be recorded carefully. It is also advisable to obtain photographs of the affected hand and severed part and to consider sending the amputated portion to the pathology department for proper cataloging.54 Jeffrey B. Friedrich, M.D. Division of Plastic Surgery University of Washington 325 9th Avenue, Box 359796 Seattle, Wash. 98104 [email protected]
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