Successful replantation of nine severed segments of four fingers in left hand: A case report / 中华显微外科杂志

This article reports a case, happened in July 2019, of 9 severed segments of 2nd-5th fingers in left hand treated in the Department of Repair and Microsurgery, Zhengzhou Renji Hospital. Through the unified management before surgery, team surgery, three or four fixed-point mattress eversion suture and close observation after surgery. It can effectively prevent the occurrence of vascular compromise. All the replanted fingers survived after the surgery. And the function of the fingers recovered well at 2 years after surgery through early and continuous rehabilitation exercise.

The development and present situation of limb replanting and reconstruction in China / 中国修复重建外科杂志

The replantation of amputated finger (or limb) and the reconstruction of the thumb and fingers started in 1960s in China. With the development of microsurgical techniques, both finger replantation and reconstruction achieved worldwide significant success. And now it is not the survival rate but the function of replanted finger that attracted more attention. Moreover, the breakthrough of particular type of digital replantation has broadened its indications. In terms of reconstruction, not only that a great deal of experiences in dealing with different types of thumb defects was accumulated, but also more micro-surgeons focus on minimal invasion and reducing the damage to the donor area.

The Concept of Door-to-Surgery Time in Distal Digital Replantation

BACKGROUND: Digital replantation has become a well-established technique that has revolutionized hand surgery. One of the most important factors to a successful replantation is less than 12 hours of warm and 24 hours of cold ischemia time. The purpose of this article was to present a concept of door-to-surgery time and test the hypothesis that success in distal digital replantation is associated with this time. METHODS: Forty-five patients with 49 distal amputations were included in the study. Data regarding patient demographics, amputation characteristics, ischemia time, and surgical outcome were collected. Factors related to a successful replantation were analyzed. Fisher's exact test was used for statistical analysis. RESULTS: Type I, II, and III Yamano classification were noted in 11 (22.4%), 11 (22.4%), and 27 (55.1%) amputations. All the digits had arterial anastomoses while 19 (38.8%) digits were replanted without venous anastomosis. The mean door-to-surgery time was 229 minutes. The overall success rate was 77.6%. There were no differences in the survival rates between replantations with or without venous anastomosis. Patients with less than 180 minutes of door-to-surgery time had a significantly better survival rate compared to patients with greater time. CONCLUSION: The overall success rate was 77.6%. Patients with less than 180 minutes of door-to-surgery time had a significantly greater success rate (95.0%) compared to patients with longer door-to-surgery time (65.5%). Further effort must be made to achieve this goal in digital replantation.

Clinical observation of Shangke Huangshui Gauze on preventing vascular crisis after digital replantation / 中成药

AIM To investigate the preventive effects of Shangke Huangshui Gauze (Scutellariae Radix,Coptidis Rhizoma,Phellodendri chinensis Cortex,etc.) on vascular crisis after digital replantation.METHODS Sixty-eight cases of patients with amputated digits meeting the inclusion criteria were randomly divided into observation group (36 cases with 57 fingers) and control group (32 cases with 54 fingers),the former was wet-dressed with Shangke Huangshui Gauze,the latter was bandaged with sterile dry gauze.The observation and comparison were made between the two groups on four coagulation indexes,visual analog scores (VAS),improvement of swelling degrees,the occurrence rates and survival rates of vascular crisis after operation,together with the evaluation of efficacy and adverse reaction.RESULTS In the observation group,the 7th day after operation,the prothrombin time,activated partial thromboplastin time,international normalized ratio,thrombin time and swelling improvement rate were higher than those in the control group;but the fibrinogen and postoperative 4 days' VAS pain score were lower than those in the control group.The incidence rates of vascular crisis and adverse reaction in the observation group were lower than those in the control group,and the survival rate of replanted fingers was higher than that in the control group.CONCLUSION Shangke Huangshui Gauze can prevent the occurrence of vascular crisis after digital replantation to a certain extent without obvious adverse reaction.

Related factors and clinical countermeasures of replantation operation survival / 中国基层医药

Objective To investigate the related factors on survival rate of digital replantation and clinical measures.Methods 27 patients with digital replantation were selected,patients'various aspects relevant factors on the survival rate of digital replantation were analyzed by the single factor analysis and multi-factor Logistic regression.Results 35 fingers were needed to be replanted,the successful rate was 85.7％.There were significant differences in survival rate based on different treatment after injury,different injury reason,use of the vein graft,duration of warm ischemia,whether thrombosis,whether vascular crisis between survival group and non-survival group (x2 =6.386,3.889,4.704,6.176,10.802,4.564,all P ＜ 0.05).The results of multivariate Logistic regression analysis showed that processing method after injury,injury reason,use of the vein graft,warm ischemia time,whether thrombosis,whether vascular crisis were the factors directly affected the survival rate (r =0.902,0.957,0.922,1.825,2.053,1.026,all P ＜ 0.05).Conclusion In order to improve the digital replantation survival rate,patients should be investigated and assessed before digital replantation.The indications should be reasonable selected,factors are compositely considered,preventive measures are taken timely.

Free Flap Coverage of the Finger Defect Caused by Digital Replantation Failure

PURPOSE: In case of the failed replantation, if the patients want to preserve the length of amputated stump, toe transfer is the ideal choice. However, reconstruction of these amputated stump with a free flap can be a useful method when the patients refuse sacrificing their toe. Our purpose of this study is to evaluate availability of functional results and patient satisfaction after this procedure. MATERIALS AND METHODS: From March 2008 to February 2012, we reconstructed the amputated stump with free flap by patients demand. Eleven patients were included, medial plantar artery perforator flap in seven cases and great toe pulp flap in five cases. Follow-up range 12 to 24 months and we evaluate patient satisfaction by using a visual analogue scale (VAS; 1=unsatisfied, 5=excellent) and functional recovery by measuring the range of motion of remaining joint at 12 months after operation. RESULTS: During follow-up period, all transferred free flaps survived and no major complications were noted. Range of motion of remaining joint appeared satisfactory result (15degrees to 100degrees). The VAS patient satisfaction score for aesthetic were five in six patients, four in four patients, and three in one patient. CONCLUSION: In case of the failed digital replantation, if patient refuse toe transfer, it could be useful method to reconstruction with the free flap to preserving maximal length of amputated stump.

Comparison of adverse effect between Cinepazide Maleate and low Molecular Dextran injection after digital replantation surgery / 中华显微外科杂志

Objective Comparing the clinical effect between Cinepazide Maleate and low Molecular weight Dextran,to the one which is more effective,safer and less unhealthy to patients after digital replantation.Methods From April 2010 to April 2012 in our hospital during single finger replantation patients,the observation group 120 cases of postoperative to Cinepazide Maleate injection 320mg/d intravenous drip,the control group of 120 cases treated with low Molecular Dextran 500ml/d IVGTT.Results The effective rate of observe group and control group was 96.67％ and 92.50％,respectively.The difference between the two groups was too small to have statistically significant difference (P ＞ 0.05),but the adverse effect of treatment group was only 5.8％,much lower than 14.17％ in control group however with the statistically significant difference (P ＜0.05).Conclusion Cinepazide Maleate Injection and low Molecular weight Dextran both have apparent effect in patients after digital replantation surgery.Both of them significantly improved microcirculation,enhanced the survival rate of replantation.However Cinepazide Maleate injection has fewer adverse effects,which is one of idea auxiliary medicine and deserved more extensive clinic application in currently microsurgery.

Cirugía reconstructiva de la mano / Hand reconstruction surgery

La cirugía reconstructiva de la mano y el desarrollo de ésta, está ligada al de la microcirugía. Requiere del dominio de varias disciplinas y, por parte del equipo tratante, establecer una estrategia de tratamiento desde el principio. Ideal es realizar toda la reconstrucción en un tiempo para iniciar una movilización precoz. El debridamiento inicial se continúa con la reparación de todos los tejidos de la mano. La cobertura constituye otro paso importante y lo ideal es realizarla en la atención de urgencia. La mano debe iniciar su rehabilitación en forma inmediata ya que lo contrario llevará a la instalación de la rigidez. Cuando no ha sido posible dejar una pinza básica de la mano, la reconstrucción de ésta pasa por el uso de técnicas de transferencias de ortejos a mano. La transferencia del hallux y de otros ortejos hoy son ampliamente usados y con excelentes resultados funcionales.

Reconstructive surgery of the hand and its development, is linked to microsurgery. Requires the mastery of several disciplines, and by the medical treating team, establish a treatment strategy from the beginning. Ideal is to do all the reconstruction at a time to begin early mobilization. The initial debridement is continued with the repair of all tissues of the hand. The coverage is another important and ideally do it in emergency care. The rehabilitation of the hand should start immediately and that otherwise lead to the installation of rigidity. If it is not possible to leave a basic gripper hand, reconstruction of this happens by using transfer techniques from toes to hand. The transfer of the hallux and other toesare widely used today with excellent functional results.

Cause analysis and management of vascular crisis in digital replantation / 中华显微外科杂志

Objective To propose prevention and management of vascular crisis according to cause analysis, and improve the survival rate of digital replantation. Methods The vascular crisis of 132 digits of 98 cases were observed during intraoperative. The replantation was performed under different time and different conditions. The causes of vascular crisis, and propose effective prevention and management of vascular crisis were restrospective analysis. Results From March 2006 to June 2007, 35 amputated digits occurred vascular crisis during intraoperative, 19 amputated digits occurred during postoperative. After using warm physiological saline and injecting the papaverine partly, we proceed operations research with regard to the non-catabatic amputated digits. As result 58 digits survived, the achievement ratio was 89.2%. From July 2007 to March 2009, 10 amputated digits occurred vascular crisis during intraoperative,5 amputated digits occurred during postoperative. After non-surgical treatment, we performed operations research regard to the non-catabatic amputated digits. After blood supply recover, we imbed PCA pump into flex tendinous sheath to avoid the occurrence of vascular crisis postoperative. As result 66 digits survived, the achievement ratio was 98.5%. postoperative 9 cases out of fullow-up, 89 cases follow up ranged from 6 to 8 months. Recovery of the hand function was good. Conclusion Good and adequate anesthetic and an appropriate ambient temperature during operation are important factors to prevent occurrence of vascular crisis in digital replantation. Paying enough attention to these factors can effectively improve the survival rate of replantatian.

Digital Replantation in Industrial Punch Injuries

PURPOSE: Industrial punch accidents involving fingers cause segmental injuries to tendons and neurovascular bundles. Although multiple-level segmental amputations are not replanted to regain function, most patients with an amputated finger want to undergo replantation for cosmetic as much as functional reason. The authors describe four cases of digital amputation by an industrial punch that involved the reinstatement of the amputated finger involving a joint and neurovascular bundle. Amputated segments were replanted to restore amputated surfaces and distal segments. METHODS: A single institution retrospective review was performed. Inclusion criteria of punch injuries requiring replantation were applied to patients of all demographic background. Injury extent (size, tissue involvement), operative intervention, pre- and postoperative hand function were recorded. RESULT: Four cases of amputations were treated at our institute from 2004 to 2008 from industrial punch machine injury. Average patient age was 32.5 years (25~39 years) and there were three males and one female. Sizes of amputated segments ranged from 1.0x1.0x1.2 cm3 to 3x1.5x1.6 cm3. Tenorrhaphy was conducted after fixing fractured bone of the amputated segments with K-wire. Proximal and distal arteries and veins were repaired using the through & through method. The average follow-up period was thirteen months (2~26 months), and all replanted cases survived. Osteomyelitis occurred in one case, skin grafting after debridement was performed in two cases. Because joints were damaged in all four cases, active ranges of motion were much limited. However, a secondary tendon graft enhanced digit function in two cases. The two-point discrimination test showed normal values for both static and dynamic tests for three cases and 9 mm and 15 mm by dynamic and static testing, respectively, in one case. CONCLUSION: Though amputations from industrial punch machines are technically challenging to replant, our experience has shown it to be a valid therapy. In cases involving punch machine injury, if an amputated segment is available, the authors recommend that replantation be considered for preservation of finger length, joint mobility, and overall functional recovery of the hand.

Surgical exploration versus conservative treatment for refractory arterial crisis during the hypersensitive period after digital replantation / 中华创伤骨科杂志

Objective To evaluate the significance of surgical exploration for the refractory arterial crisis daring the hypersensitive period (48 h to 96 h) after replantation of severed fingers.Methods One hundred and seventy-one patients experienced refractory arterial crisis during the hypersensitive period after replantation of the proximal thumb from February 1995 to February,2005 in our department.Eighty-seven of them were managed with surgical exploration,including incision injury (n=6),saw injury (n=17),rotation and avulsion injury (n=30), and crush injury (n=34).Eighty-four cases received conservative treatment,including incision injury (n=6),saw injury (n=16).rotation and avulsion injury (n=29),and crush injury (n=33).In the surgery group,the e- mergent explorations were performed as soon as the refractory arterial crisis arose,If arterial spasm or/and thrombosis were found,the involved parts were resected before the artery ends were anastomosed or the finger artery was repaired by cubital vein graft.In the other group,conservative managements were carried out by using intramuscular injection of 30 mg Papaverine and intravenous injection of 20,000-unit Urokinase in 20 mL normal saline.If symptums were not alleviated after half an hour,the procedures were repeated.The conservative managements also included abirritative antipsychotics and analgesia of anodyne.Meanwhile,the survival state of all the digital replants was observed. Results In the surgery group,78 fingers survived,the surviving rate being 89.7%.In the conservative group,41 fingers survived with a surviving rate of 48.8%.The difference was statistically significant (P＜0.01).No obvious complications happened in the two groups.Conclusion Since surgical exploration is crucial to management of refractory arterial crisis during the hypersensitive period after replantation of severed fingers,it should not be readily abandoned.

Single artery digital replantation.

Microvascular replantations of amputated distal fingers were reviewed in 11 cases in which single arterial repair without venous repair was done. usually, the standard replantation consists of re-anastomosis of arteries and veins. In this study, venorrhaphy could not be achieved since no vein of sufficieny size was found. Survival rate of replanted digits was 68.8 percent (11 from 16 digits), which compared favorably to other reports. This technique offers better cosmetic and functional outcome than reattachment as a composite graft or stump closure. The result of our study confirms the possiblitity of single arterial digital replantation with an acceptable outcome in selected cases. Cases analysis and surgical technique will be discussed in detail.

Quantifying and explore the indication of digital replantation / 中华显微外科杂志

Objective To determine the factors influencing the survival rate and then quantifying the indication in digital replantation. Methods From January 1999 to November 2002,1 231 digit replantations were reviewed retrospectively.Analysis of Logistic regression was carried out between survival rate and injury degree of artery,skin,tendon,bone and nerve,mechanism of injury,severed levels,repassing duration and haemoglobin levels. Records of 50 failed and 50 succeeded fingers were selected at random and discriminant equation was made according to the factor selected by Logistic regression. Results The factors of injury degree of artery and skin,mechanism of injury,severed levedls and haemoglobin levels affected the survival rate significantly.The discriminant equation was that Z=6.42X 1+5.31X 1+4.35X 3+3.26X 4+3.15X 5. Conclusions The five factors mentioned above affect the survival rate of digital replantation.The indication of digital replantation could be quantified with the discriminant equation.