|Year : 2020 | Volume
| Issue : 4 | Page : 224-230
Favorable long-term esthetic, functional, and sensory outcome and preferability of distal digital replantations
Private Aesthetic Plastic and Reconstructive Surgery Office, Bursa, Turkey
|Date of Submission||16-Sep-2019|
|Date of Acceptance||09-Jan-2020|
|Date of Web Publication||28-Sep-2020|
Dr. Ayhan Okumus
Private Aesthetic Plastic and Reconstructive Surgery Office, Ihsaniye Mah., Ilknur Sok., Bulvar 224 Sitesi B/10, Nilufer, Bursa
Source of Support: None, Conflict of Interest: None
Background: To evaluate long-term esthetic, functional, and sensory outcome and preferability of distal digit replantations with respect to contralateral intact finger. Materials and Methods: A total of 63 single-or multi-digit clean cut amputations distal to distal interphalangeal joint (DIPJ) involving nail fold in 45 consecutive patients (mean 29 years, 26 males, 19 females) who underwent replantation surgery between 2010 and 2016 were included in this study. Esthetic outcome, functional, and sensory outcome were assessed in the postoperative 6 months, 1 year, and 3 years. Results: Single-digit amputation was noted in 34 patients including thumb (n = 9), index finger (n = 10), middle finger (n = 7), ring finger (n = 7), and little finger (n = 1). Multi-digit amputations were evident in 11 patients involving 2 fingers in five patients (index + middle in two patients, middle + ring in two patients, and thumb + index in one patient), 3 fingers in five patients (index + middle + ring in 4 patients and middle + ring + little in one patient), and 4 fingers in one patient (index + middle + ring + little). All patients were operated within the first 4 h of hospital admission. Postoperative 3-year outcome was excellent in 79.3% of operations, good in 14.2%, and acceptable in 6.3% of operations. None of the operations resulted in poor or very poor outcome and none of the patients had functional loss during the entire follow-up period. A very satisfactory sensory outcome with static two-point discrimination test findings of <6 mm was noted in all operations involving nerve repair, while in operations without nerve repair, the sensory outcome was also moderately satisfactory. Conclusion: Our findings indicate excellent long-term esthetic, functional, and sensory outcomes of distal digit replantation. Our findings emphasize consideration of replantation in single-level clear-cut distal digit amputations without avulsion or crush injury as a technique associated with excellent esthetic long-term outcomes.
Keywords: Distal digit amputation, esthetic outcome, functional outcome, replantation, sensory outcome
|How to cite this article:|
Okumus A. Favorable long-term esthetic, functional, and sensory outcome and preferability of distal digital replantations. Turk J Plast Surg 2020;28:224-30
| Introduction|| |
Distal digit amputations are commonly encountered injuries in the emergency care, while there is controversy regarding the best treatment option among the several methods that range from conservative management, local flaps to replantation of the amputated part.,,
Although replantation of distal amputations provide excellent cosmetic outcome by maintaining the digital length, preserving the nail, and improving function, it is not a commonly performed operation in clinical practice, being considered as a technically challenging complex operation associated with longer in-hospital stay and time off from work.,,
However, given the recent advances in microvascular surgery techniques and instruments, there has been a renewed enthusiasm in the replantation in distal digital amputations as a procedure remains superior to any alternative methods of reconstruction in terms of good functional and aesthetic outcome.,,,,
This study was designed to evaluate long-term aesthetic, functional and sensory outcome and preferability of distal digit replantations.
| Materials and Methods|| |
A total of 63 single- or multi-digit clean cut amputations distal to distal interphalangeal joint (DIPJ) involving nail fold in 45 consecutive patients (mean 29 years, 26 males, 19 females) who underwent replantation surgery within the first 6 h of injury by the same surgery team between 2010 and 2016 were included in this study. Patients with a clean-cut single-level amputation (Type I - Guillotine) distal to DIPJ (Tamai zone I and zone II) involving nail fold with maintenance of integrity of amputated part and preservation of joint structure and motility, replanted within 6 h of injury were included in the study [Figure 1], while cases with moderately crushed amputations or crush avulsion (severe crush and/or avulsion injury) and those necessitating postoperative revision surgery were excluded from the study.
|Figure 1: Single level clear cut amputations distal to distal interphalangeal involving nail fold|
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Written informed consent was obtained from each individual for the operative procedures and for the use of patient data for publication purposes.
In accordance with the classification system proposed by Tamai, distal amputations are divided into zone I (tip of finger to the base of the nail, distal to insertion sites for extensor, and flexor tendons not requiring tendon repair) and zone II (base of nail to the DIPJ). Esthetic outcome (based on nail integrity, length of pulp, and angular position of the replanted part as compared with the intact contralateral digit), functional outcome (through range of motion [ROM] in the interphalangeal joints), and sensory outcome (through static two-point discrimination test) were assessed in the postoperative 6 months, 1 year and 3 years (for esthetic and functional outcome) or 2 years (for sensory outcome).
The operations were performed under axillary block. After identification of at least one artery and vein in the stump under microscopy, corresponding artery and vein in the amputated part were prepared. After adequate debridement and cleansing, Kirshner wires were used for fixing the amputated part to the proximal distal phalanx stump. Following anastomosis of artery and vein with 10/0 or 11/0 nonabsorbable sutures, the skin was loosely closed. A paraungual stab incision was made to prevent venous congestion, while topical dripping of heparinized saline was performed immediately after operation. Systemic anticoagulation was achieved through administration of 20,000 units of heparinized saline and 500 mL of low-molecular-weight dextran for 7 days. Heparin was used in each patient. Circular dressing was not used in the operative regions, followed by a very loose dressing where the finger would appear exactly. No leech was required in any patient. The patients were hospitalized for a mean of 7 days between 4 and 10 days.
Digital nerve repair could be performed in 50 of 63 amputations, which were amputations proximal to mid-nail enabling localization of a nerve end.
Aesthetic outcome was assessed in the postoperative 6 months, 1 year, and 3 years among patients with complete recovery, and based on 4-point Likert scale involving scorings related to nail status, length and structural integrity of the pulp, and the degree of proximal angulation of the replanted part as compared with the intact contralateral finger in each patient. Each parameter was scored from 1 to 4 yielding total scores that ranges from 3 (no nail, pulp length ≤1/3 of the intact side, >45° angulation) to 12 (complete nail, same length with the intact side, 0° angulation). Replantation outcome was categorized based on total scores, as excellent (scores 10–12), good (scores 8–10), acceptable (scores 6–8), poor (scores 4–6), and very poor (scores ≤3) [Table 1]. Replanted fingers and contralateral intact fingers were photographed side by side from upper, lower and lateral view.
|Table 1: Assessment criteria for the aesthetic outcome of replantation surgery|
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Functional outcome was assessed based on interphalangeal joint ROM for extension/flexion in each digit with consideration of normal ROM as 15/90° for the thumb and 0/90° for 2nd–5th digits. Sensory outcome was assessed using static two-point discrimination test with consideration of findings <6 mm as normal range.
| Results|| |
Characteristics of amputated digits
Overall, single digit amputation was noted in 34 patients including thumb (n = 9), index finger (n = 10), middle finger (n = 7), ring finger (n = 7) and little finger (n = 1). Multi-digit amputations were evident in 11 patients involving 2 fingers in five patients (index + middle in two patients, middle + ring in two patients and thumb + index in one patient), 3 fingers in five patients (index + middle + ring in four patients and middle + ring + little in one patient), and 4 fingers in one patient (index + middle + ring + little) [Table 2].
|Table 2: Digit characteristics and postoperative aesthetic outcome of replantation surgery|
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Overall, 45 zone 1 and 18 zone 2 amputations were evident based on Tamai classification.
Amputations were due to occupational accidents in 33 patients and occurred while cutting meat in six patients, due to laceration from glass in four patients and due to jammed finger (in a door) injury in 1 pediatric patient. All patients were admitted to our hospital within 2 h of injury and were operated within the first 4 h of hospital admission by the same surgery team [Figure 2].
|Figure 2: Postoperative view of an index finger replanted within the first 4 h of hospital admission (within the first 6 h of injury)|
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Postoperative 6-month, 1-year, and 3-year outcome of replantation surgery
According to replantation assessment criteria, excellent esthetic outcome was noted in 79.3% of operations at the 3rd year, including 47, 49, and 50 of 63 operations at the postoperative 6- month, 1-year, and 3-year assessments, respectively [Table 2] and [Figure 3], [Figure 4]. The outcome was good in 14.2% of operations at the 3rd year, including 9, 10, and 9 operations at the postoperative 6-month, 1-year, and 3-year assessments, respectively [Table 2] and [Figure 5]. The outcome was acceptable in 6.3% of operations at the 3rd year, including 7, 4, and 4 operations at the postoperative 6-month, 1-year, and 3-year assessments, respectively [Table 2] and [Figure 6]. Overall, 3-year success rates ranged from 70.0% in thumb replantations to 100.0% in little finger replantations. None of the operations resulted in poor or very poor outcome at postoperative 6-month, 1-year, or 3-year assessments [Table 2].
|Figure 3: Early and long-term postoperative view of an index finger amputation with an “excellent” replantation outcome in two patients (a and b).(a) Comparative upper and lower view with the intact contralateral side, (b) Comparative upper, lateral, and lower view with the intact contralateral side|
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|Figure 4: “Excellent” outcome (a) in a patient with index finger amputation; preoperative and long-term postoperative view and comparative upper and lower view with the intact contralateral side, (b) in a patient with multi-digit (3rd, 4th, and 5th digits) amputation; preoperative and postoperative long-term and comparative view with the intact contralateral side|
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|Figure 5: Preoperative and postoperative long-term view of a finger amputation with a “good” replantation outcome (a) Total score: 9, (b) Total score: 8, (c) Total score: 9|
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|Figure 6: Preoperative and postoperative long-term view of a finger amputation with an “acceptable” replantation outcome (total score: 7, no nail, maintenance of >3/4 of pulp length with mild step deformity). Comparative view with the intact contralateral side|
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None of the patients had functional loss during the entire follow-up period. ROM of interphalangeal joints was in normal limits in all digits [Table 3].
|Table 3: 6-month, 1-year, and 3-year functional outcome of distal digital replantation surgery|
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In distal digital replantations involving nerve repair (n = 50), sensory outcome was very satisfactory with static two-point discrimination test findings of <6 mm in all operations, while in operations without nerve repair (n = 13), the sensory outcome was moderately satisfactory with static two-point discrimination test findings of 4–6 mm in eight patients, 6–7 mm in four patients, and 8 mm in one patient [Table 4].
|Table 4: Postoperative 2-year sensory outcome of distal digital replantation operations (n=63)|
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| Discussion|| |
Our findings revealed favorable outcome of distal digital replantation for single- or multi-digit clear-cut amputations in terms of preservation of nail, maintenance of pulp length without marked step deformity, or proximal angulation with good to excellent postoperative 6-month, 1-year, and 3-year esthetic, functional, and sensory outcome in majority of operations. This seems to emphasize higher likelihood of achieving esthetic satisfaction with close similarity in structural integrity to the contralateral intact digit in clear-cut distal digit amputations without crush and/or avulsion injury, if they were replanted within 4 h of hospital admission under convenient conditions.
In a case series study including 24 fingertip replantations, long-term outcome in successful cases (86%–88%) was reported to involve nail deformity and pulp atrophy (in six and five patients, respectively), while none of the deformities interfered with daily function or necessitated revision surgery.
In a retrospective analysis of 11 distal digital replantation for fingertip amputations, successful cases (73%) was reported to show good functional outcome and high patient satisfaction after a mean period of 19 months. In another study including 98 amputations distal to the DIP in 82 patients, replantation was reported to be successful in 61.2% of cases with satisfactory cosmetic results in terms of preservation of the nail and finger length.
None of the distal digit replantations was associated with a poor/very poor esthetic outcome in our cohort, which seems to indicate success of distal digit replantation in terms of long-term complications such as nail deformity and pulp atrophy. This seems notable given the concerns about restoration of digital length and pulp in distal digit replantation due to lack of healthy vessels and the absence of proper vascular size for reanastomosis.
In fact, due to smaller vessel diameters and low margin of error during vessel repair, fingertip replantation is considered to be more demanding procedure than proximal digital replantation.
It is also considered to be a more complex and technically challenging procedure that requires skills in supermicrosurgical techniques along with longer hospital stay and time off from work when compared to the primary closure for fingertip amputations.
Accordingly, though technically possible, surgeons have been hesitant to perform distal digital replantation, mainly due to the presumed complexity of the procedure, doubts about the outcome, and perception of a high cost-to-benefit ratio.,, This has been suggested to be associated with a vicious circle, leading to less experience and thus higher risk of failures, ultimately limiting the utility of the operation.
However, as supported by our findings, recent studies indicated the association of distal digit replantation with high survival rates and excellent functional and esthetic results by maintaining the digital length, preserving the nail and improving function, despite technical difficulties.,,
In fact, in a systematic review on outcomes of 2273 distal digital replantations in 30 studies, authors reported a high success rate and good functional outcomes following distal digital replantation with long-term complications included pulp atrophy in 14% of 639 patients in 8 studies and nail deformity in 23% of 635 patients in 8 studies. Authors concluded that the common view regarding the risk of little functional gain after distal digit replantation was not based on scientific evidence.
Given that replantation surgery remains delicate and technically demanding surgery, well-defined selection criteria have been adopted for replantation procedures. This seems in accordance with the identification of good to excellent long-term outcome in majority of distal digital replantations in our patients who were selected based on the presence of single-level clear-cut amputation without avulsion/crush injury and operated within 6 h of injury and 4 h of hospital admission.
Notably, some microsurgeons, particularly those who place a greater emphasis on maintaining body integrity and physical appearance, become adopting a more liberal approach with good results.,,,,,, This emphasizes the consideration of classical indications for distal digital replantation as a general guide rather than strict rules.,,,,,,
In a case series of four patients including three patients with absolute contraindications for digital replantation according to classical criteria (multilevel amputation, avulsion of the thumb; index amputation proximal to the insertion of the flexor digitorum superficialis) and 1 patient with a relative contraindication (very distal digital amputation), authors reported association of replantation with good functional and esthetical in all cases. Authors emphasized the likelihood of digital replantation to still be offered to patients who do not meet the standard criteria, if better outcome is expected as compared with other techniques and patients accept the risks, costs, and time off work.,
Other techniques for the treatment of distal digit amputations include nonoperative treatment such as allowing healing by secondary intention, shortening of the finger with primary closure, and local, regional, and even free flaps.,, Nonetheless, several complications are considered likely with these techniques such as unesthetic appearance, nail deformity, shortness of the finger, persistent pain, sensory problems, and decreased ROM or need for revision surgery as well as donor site problems.,,, Although technically more difficult, the expected functional and esthetic benefits of distal digit replantation is considered to surmount those of primary closure and distal fingertip replantation remains superior to any alternative methods of reconstruction in fingertip amputations.,,,,
In a past study among 45 patients with 49 distal amputations, higher rate of success was reported in patients with <180 min of door-to-surgery time (95.0%) compared to patients with longer door-to-surgery time (65.5%), while the injury-to-surgery time was not determined to be associated with surgical outcome. In this regard, implementation of replantation surgery within 4 h of hospital admission in our patients seems also to be associated with favorable outcome, emphasizing consideration of a modifiable time goal for good functional and esthetic outcome after digital replantation.
| Conclusion|| |
Our findings indicate excellent long-term esthetic, functional, and sensory outcomes of distal digit replantation. In this regard, our findings emphasize consideration of replantation in single-level clear-cut distal digit amputations without avulsion or crush injury as a technique associated with excellent esthetic long-term outcomes. An experienced microsurgery team and appropriate patient selection are crucial for the postoperational success of distal digital replantation. Nonetheless, it should be noted that while reconstruction with other techniques remains still possible in unsuccessful replantations, it is not possible to replant an amputated digit treated already with other methods within the first 6 h of injury.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]