https://orcid.org/0000-0002-3943-3052
Abstract
A retrospective study were presented to compare functional and cosmetic outcomes in relation to local flap reconstruction or fingertip replantation in cases of zones I and II amputation. Outcomes were evaluated using Semmens Weinstein monofilament, Weber DiskCriminator, total active motion (TAM) assessment and Michigan Hand Questionnaire after a 1-year follow-up.
Introduction
Generally accepted indications for replantation or revascularization are amputation of the thumb or multiple digits, and all types of amputations in children [Citation1–3]. However, improvements in microvascular techniques and advanced instruments [Citation4,Citation5], patient’s preferences [Citation6,Citation7], technical abilities as well as surgeon’s preferences [Citation8,Citation9] may broaden perspectives in specific contexts. Surgical procedures have been highly standardized and well-described [Citation10–12] reporting favorable outcomes in replantation and revascularization that differ between institutions, ranging from 93% to 55% and according to different investigators [Citation13–16]. Success rates may be attributable to the training and expertise of the surgeon [Citation17] as well as the level of injury, mechanism of injury, complete versus subtotal amputation, age, sex, general health, smoking status, ischemia time, patient selection, and other factors [Citation3,Citation8,Citation13,Citation17,Citation18]. Early complications after replantation and revascularization may be arterial or venous thrombosis, usually within the first 2 days [Citation19,Citation20] mainly in smokers [Citation21,Citation22]. Late complications are tendon adhesion, malunion and nonunion, stiffness, insensibility, neuroma, and cold intolerance [Citation3,Citation7,Citation23–25]. Revision amputation represents an alternative correction for wound closure. Microsurgical procedures may not be performed therefore, local flap applications are considered an option, to avoid further finger shortening [Citation26–29]. Such surgical treatments are challenging procedures and necessitate expertise on behalf of the surgeon to operate adequately on small vessels. Replantation and homodigital flaps were herein studied retrospectively in two groups analyzing subjective and objective outcomes in relation to quality of life impact and to further understand the efficacy of such surgical options.
Materials and methods
Eighteen patients were selected among over 200 patients treated within the previous 5 years and were included in the study. Patients were initially evaluated in the emergency department. The Tamai level of amputation () was assessed according to the established classification system described [Citation28–30]. The decision to adopt a local flap or perform replantation was commonly made by patients post consultation with the first surgeon and consideration of potential risks and benefits. Exclusion criteria were previous finger trauma or wrist nerve decompression, associated traumas on the same finger proximal to IPD joint, minor lesion solvable with V-Y flap, heterodigital flaps, replantation failure, and all events of failure regarding the main treatment or cases requiring surgical revision. Patients were divided into two groups R and F, referring to ‘replantation’ or ‘reconstruction with homodigital flaps’. Such flaps as the Venkataswami or the Elliot flap were used, according to established and previously described techniques [Citation25,Citation26] (). The thumb was involved in six trauma-related cases in the replantation group and in three cases in the local flap group, while long fingers were respectively injured in two and seven cases. Amputation involved Tamai I zone in 14 cases, five in Group R and nine in Group F, and Tamai II in four cases, respectively in three cases in the R Group and one in the F Group. In all cases, bone fixation was achieved with Kirschner wires and micro suture was performed with an end-to-end 10/0 nylon suture. In the F Group, flap fixation on fingertip was routinely obtained with a 23 Gauge needle to reduce potential suture-related ischemic injury on the distal part of the flap. In two cases belonging to Group R, dorsal venous anastomosis was performed, whereas in all other cases venous drainage was achieved by bleeding from nail bed. In the R Group no digital collateral nerve was sutured. In the F Group all flaps were sensitive in accordance with standard technique. No case needed further interventions to achieve end results. Patients receiving replantation were postoperatively treated with enoxaparin (4000 IU) for 21 days and Cardioaspirin (100 mg) was administered at one tablet per day during hospitalization and prescribed post hospitalization for a total of 30 days. K wires were removed after 4 weeks, after X-ray control. Minor complications were observed such as venous congestion which was successfully treated with Hirurdo Officinalis. No infection was recorded. Two cases of wound dehiscence and two cases of hypertrophic scar were detected. A rehabilitation program post-surgery was administered in all cases within 10 days. A minimum 1-year follow-up was conducted and objective evaluation was carried out on both the injured and non-injured contralateral areas. Finger flexion and extension was measured using total active motion (TAM) [Citation31]. Nerve recovery was assessed with the Weber diskCriminator test and Semmens-Weinstein monofilament test [Citation32,Citation33]. Subjective outcomes were analyzed using a self-administered questionnaire, specifically, the Michigan Hand Questionnaire (MHQ) [Citation34,Citation35] ().
Table 1. Patients data.
Table 2. Surgical data.
Statistical analysis
All data were statistically analyzed using a Mann-Whitney parametric test. TAM and MHQ results were further assessed with a non-parametric Student’s T test. All data were presented as mean +/− standard deviation.
Results
Patient characteristics
Eight replantations and ten homodigital flaps were performed in 18 patients. The injuries were mainly trauma-related and due to manual handling. The mean age of the patients was 47 years (22–69 years) and all patients were male. Healing was uneventful in the total of patients. Secondary surgery was not required in either group. Patient data including mechanism of injury, occupation and smoking history were collected ().
Treatment outcomes
A statistical comparison between two groups regarding functional outcomes was obtained with TAM results [Citation31], Semmens-Weinstein monofilament test [Citation33] and Weber test [Citation32] measured after at least 12 months post-surgery. Mean values in R Group and in F Group were respectively 130° and 162° for TAM, 0.235 g and 0.781 for SW values and 6.6 and 6.5 mm for Weber test (). Statistical analysis failed to show significant differences in TAM, SW and Weber results (p > 0.05) (). As regards subjective evaluation of the functional and aesthetic outcomes, MHQ was administered to all patients. The MHQ global score revealed incremental improvement in Group R (84.25%) compared to Group F (68.20%) (). Statistical analysis of these results showed a significant difference (p 0.034) ().
Table 3. MHQ values.
Table 4. Statistical results.
Case 1
A 32-year-old patient suffered a radical amputation caused by machinery within Tamai zone 1. We firstly performed bone fixation with two longitudinal Kirshner wires. Tendon repair was not required due to distal position of the amputation in relation to the tendons in zone 1. We thus proceeded to repair one artery, but vein anastomosis was impracticable. We then managed external bleeding by nail removal and scarification of the nail bed. Nerve suture was not conducted since spontaneous sensory recovery was expected in zone 1 replantation (). Heparin (10,000 U) was administered for 6 days during hospitalization and then enoxaparin (4000 U) was prescribed post hospitalization for a further 15 days. Cardioaspirin (100 mg) was administered at one tablet per day during hospitalization and later prescribed for a total of 30 days. Hand therapy with active motion and passive motion was initiated at 1 week after surgery. During follow-up, no infectious events, temperature intolerance nor chronic pain occurred. On follow-up observation at 1 year, the aesthetic aspect of the finger was acceptable, the nail was plane, and the replanted finger had recovered an adequate range of motion and protective sensation ().
Figure 1. Tamai zone 2 thumb amputation. (A) Distal stump dorsal view; (B) Distal stump volar view; (C) Distal stump X-rays; (D) Immediate reimplantation dorsal view; (E) Immediate reimplantation volar view; (F) Immediate reimplantation X-rays.
Figure 2. Tamai zone 2 thumb replantation 1 year post. (A) Dorsal view; (B) Volar view; (C) X-Rays view; (D) Kapandji score evaluation; (E) Thumb flexion volar view; (F) Thumb flexion dorsal view.
Case 2
A 45-year-old patient suffered a complete frayed-cut amputation and fingertip avulsion by electric saw on the right ringer finger within Tamai zone 1. We performed an oblique triangular advancement flap (Venkataswami flap) (). Dextran was administered throughout hospitalization at a rate of 2.1 mL/h. Active motion was started at 4 days and passive motion at 1 week as post-operative therapy. During follow-up, no complications of infection, temperature intolerance, or chronic pain were observed. At the follow-up observation at 1 year, the amputated finger had recovered satisfactory range of motion and protective sensation, mild pulp atrophy was observed, and nail disfigurement was evident ().
Figure 3. Tamai zone 1 fourth finger amputation. (A) Distal stump dorsal view; (B) Distal stump degloved; (C) Proximal stump X-rays; (D) Proximal stump dorsal view; (E) Proximal stump volar view; (F) Venkataswami digital flap.
Figure 4. Tamai zone 1 fourth finger reconstruction 1 year post. (A) Extension in volar view; (B) Flexion in volar view; (C) Extension in dorsal view; (D) Extension in ulnar view; (B) Flexion in ulnar view; (F) Extension in radial view.
Discussion
Over 200 complex finger lesions had presented at our emergency department in less than 5 years, mainly caused by workplace accidents or domestic injury caused by saws or wood splitters. Local conditions are fundamental for replantation as well as patient compliance. Distal phalanx replantation is considered a challenging surgical procedure and requires supra microsurgical skills. In Tamai I and II zone, vessel caliber is often less than 1 mm, the nerve is not usually visible after trauma and the veins are occasionally inaccessible [Citation36–37]. Authors have previously suggested performing veins identification and anastomosis at a later stage which we found, nonetheless, limiting due to poor outcomes [Citation38] including patient stress towards surgical procedures, medicinal administration requirements and operative room occupation. However, successful distal replantation has often yielded optimal functional and cosmetic results [Citation39]. A stiff distal interphalangeal (DIP) joint may be a consequence of distal replantation and may not be totally debilitating, enabling, thus restoration of a finger function notwithstanding incomplete IPD range of motion. Moreover, nerve recovery is often spontaneous in such small tissue, despite neural suture not being performed [Citation40]. The surgical technique is extremely demanding, and vascular outflow is not always observable due to the specific distal lesion or to the trauma mechanism with vein disruption. In these cases, bleeding is obtained from the scarified nail bed over the following days. The homodigital flap may, on the other hand, facilitate the course of recovery. We opted for the homodigital flap due to the inaccessibility of replantable tissue in ten patients notwithstanding optimal expectations. Finger shortening and wound suture tension are common events but in the case of abundant bone and viability, the conservation of finger length is mandatory and may be obtained via coverage of the fingertip with a local flap albeit it being a more challenging procedure compared to direct closure. Herein we examined the functional and cosmetic outcomes obtained in zone I and II amputation level according to Tamai, treated with replantation of the amputated segment or with coverage using a local flap according to the Venkataswami [Citation25] or the Elliot technique [Citation26]. Results revealed no statistically significant differences between Group R and Group F in terms of TAM and sensibility. All parameters were evaluated and compared to the contralateral and unaffected side. Even though the digital nerves were not repaired in all the subjects belonging to Group R, the mean Semmens-Weinstein was 0.235 g, which was slightly lower than in Group F, but with no statistical significance observed. Nerve repair is therefore not fundamental in such a very distal replantation attributable to independent return of sensibility as well as the short distance required by the regenerating nerve branches to grow towards the fingertip. Similarly, Weber values showed significant results in both groups. Differences were detected in the MHQ results where patients in Group R reported greater satisfaction concerning functional and aesthetic outcomes achieved by digital distal replantation, compared to Group F expressing less appreciation as regards the same outcomes. This result was supported by a statistical significance. MHQ results failed to reveal an association regarding other collateral trauma in the same hand. This outcome may be attributable to the subjective appreciation of an anatomical finger replacement, or to the thumb being affected more frequently during replantation procedures. The unique role of the first finger compared to long fingers and its replacement could be valued more positively. Numerous patients in Group F presented a long scar and its course through the joint, similarly to patients in Group R. Despite an appropriate operative flap raising technique which prevented the formation of straight or perpendicular scars on the longitudinal axis of the finger, the scar still involved the metacarpophalangeal joint in both Venkataswami and Elliot flaps. Patients mainly reported dissatisfaction with this complication, especially in cases of hypertrophic tissue formation that could be avoided with a rigorous rehabilitative program associated to ultrasound and massage. Nonetheless, patients were impervious to perinervous scar tissue or the slight nerve stretching due to flap advancement. Other predictable cosmetic alterations such as hook nail deformity, pincer nail deformity was present in Group F. No patients required further surgical intervention due to cosmetic refinements, despite results could be improved with a Bakhash [Citation41], that have been proposed to our patients. The limitations of our study included the small patient sample, the different types of local flaps performed and the inclusion of trauma to thumb and long fingers. A larger patient sample would provide more accurate results. In selected cases replantation and homodigital flaps could be performed in Tamai zone I and II amputation to avoid finger shortening [Citation42]. Results showed that homodigital flaps were effective in terms of functional outcomes restoring finger function and avoiding supramicrosurgical treatment. As regards subjective appreciation, patient’s compliance, individual needs and expectations still represent an important element in surgical planning. In some cases, improved patient satisfaction may account for lengthy hospitalization stays and costs required in replantation procedures. Skills in ‘supra-microsurgery’ on behalf of the surgeon should be considered impartial to decision-making in relation to individual patient’s needs.
Ethical approval
The study respects all ethical requirements in its objectives and methodologies. All patients, the subjects of our study, donated their consensus to scientific treatment and publication of their clinical circumstances and images. We obtained written informed consent from all patients. This study was approved by our Internal Ethical Committee without recording in public registry considering the this study was not a clinical trial.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Acknowledgments
The authors are grateful to Giuseppina Caraglia, mother tongue expert, University of Naples ‘Vanvitelli’ for performing English revision.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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