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J Reconstr Microsurg 2018; 34(04): 250-257
DOI: 10.1055/s-0038-1626692
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes

Ledibabari Mildred Ngaage
1   School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
,
Georgette Oni
2   Department of Plastic Surgery Addenbrooke's Hospital, Cambridge, United Kingdom
,
Rudolph Buntic
3   Department of Microsurgery, Buncke Clinic, San Francisco
,
Charles M. Malata
2   Department of Plastic Surgery Addenbrooke's Hospital, Cambridge, United Kingdom
4   Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
5   Anglia Ruskin University, School of Medicine, Cambridge & Chelmsford, United Kingdom
,
Gregory Buncke
3   Department of Microsurgery, Buncke Clinic, San Francisco
› Author Affiliations
Further Information

Publication History

22 July 2017

31 October 2017

Publication Date:
06 March 2018 (online)

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Abstract

Background Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit.

Methods A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength.

Results Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts.

Conclusions The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.

Keywords

digit replantation - preoperative management - hand surgery - Buncke protocol

Supplementary Material

 

  • References

  • 1 Komatsu S, Tamai S. Successful replantation of a completely cut-off thumb: case report. Plast Reconstr Surg 1968; 42 (04) 374-377
    CrossrefPubMedGoogle Scholar
  • 2 Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011; 128 (03) 723-737
    CrossrefPubMedGoogle Scholar
  • 3 Yu H, Wei L, Liang B, Hou S, Wang J, Yang Y. Nonsurgical factors of digital replantation and survival rate: a metaanalysis. Indian J Orthop 2015; 49 (03) 265-271
    CrossrefPubMedGoogle Scholar
  • 4 Medling BD, Bueno Jr RA, Russell RC, Neumeister MW. Replantation outcomes. Clin Plast Surg 2007; 34 (02) 177-185 , vii–viii
    CrossrefPubMedGoogle Scholar
  • 5 Chung KC, Alderman AK. Replantation of the upper extremity: indications and outcomes. J Am Soc Surg Hand. 2002; 2 (02) 78-93
    CrossrefPubMedGoogle Scholar
  • 6 Ma Z, Guo F, Qi J, Xiang W, Zhang J. Effects of non-surgical factors on digital replantation survival rate: a meta-analysis. J Hand Surg Eur Vol 2016; 41 (02) 157-163
    CrossrefPubMedGoogle Scholar
  • 7 Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg [Br] 2001; 26 (06) 572-581
    CrossrefPubMedGoogle Scholar
  • 8 National Institute for Health and Care Excellence. Fractures (complex): assessment and management. Manchester and London, UK; February 2016. NICE guideline (NG37)
    PubMedGoogle Scholar
  • 9 Win TS, Henderson J. Management of traumatic amputations of the upper limb. Br Med J 2014; 348: g255
    CrossrefPubMedGoogle Scholar
  • 10 Lloyd MS, Teo TC, Pickford MA, Arnstein PM. Preoperative management of the amputated limb. Emerg Med J 2005; 22 (07) 478-480
    CrossrefPubMedGoogle Scholar
  • 11 American College of Surgeons. Advanced Trauma Life Support Guidelines. 8th ed. Chicago, IL, USA: J Trauma Acute care Surg; 2011
    Google Scholar
  • 12 Azzopardi EA, Whitaker IS, Laing H. Perceptions of correct preoperative storage and transfer of amputated digits: a national survey of referring emergency departments. J Plast Reconstr Aesthet Surg 2008; 61 (11) 1418-1419
    CrossrefPubMedGoogle Scholar
  • 13 Oomman A, Tickunas T, Javed M. , et al. Changes in perceptions regarding correct preoperative storage and transfer of amputated digits: a 5-year follow-up. Microsurgery 2014; 34 (01) 76-77
    CrossrefPubMedGoogle Scholar
  • 14 Tamai S. Twenty years' experience of limb replantation–review of 293 upper extremity replants. J Hand Surg Am 1982; 7 (06) 549-556
    CrossrefPubMedGoogle Scholar
  • 15 Flatt AE. Our thumbs. Proc Bayl Univ Med Cent 2002; 15 (04) 380-387
    PubMedGoogle Scholar
  • 16 Breahna A, Siddiqui A, Fitzgerald O'Connor E, Iwuagwu FC. Replantation of digits: a review of predictive factors for survival. J Hand Surg Eur Vol 2016; 41 (07) 753-757
    CrossrefPubMedGoogle Scholar
  • 17 Southard JH, Belzer FO. Organ preservation. Annu Rev Med 1995; 46: 235-247
    CrossrefPubMedGoogle Scholar
  • 18 Lotens WA, van de Linde FJG, Havenith G. Effects of condensation in clothing on heat transfer. Ergonomics 1995; 38 (06) 1114-1131
    CrossrefPubMedGoogle Scholar
  • 19 Farnworth B. A numerical-model of the combined diffusion of heat and water-vapor through clothing. Text Res J 1986; 56 (11) 653-665
    CrossrefPubMedGoogle Scholar
  • 20 Fudge J. Preventing and managing hypothermia and frostbite injury. Sports Health 2016; 8 (02) 133-139
    CrossrefPubMedGoogle Scholar
  • 21 Partlin MM, Chen J, Holdgate A. The preoperative preservation of amputated digits: an assessment of proposed methods. J Trauma 2008; 65 (01) 127-131
    CrossrefPubMedGoogle Scholar
  • 22 Buntic RF, Brooks D. Standardized protocol for artery-only fingertip replantation. J Hand Surg Am 2010; 35 (09) 1491-1496
    CrossrefPubMedGoogle Scholar
  • 23 Salemark L, Wieslander JB, Dougan P, Arnljots B. Effect of low and ultra low oral doses of acetylsalicylic acid in microvascular surgery. An experimental study in the rabbit. Scand J Plast Reconstr Surg Hand Surg 1991; 25 (03) 203-211
    CrossrefPubMedGoogle Scholar
  • 24 Bannister CM, Chapman SA. The influence of systemic aspirin on rat small diameter vein grafts: a scanning electron microscopic study. Surg Neurol 1980; 13 (02) 99-108
    PubMedGoogle Scholar
  • 25 Heggers JP, Robson MC, Manavalen K. , et al. Experimental and clinical observations on frostbite. Ann Emerg Med 1987; 16 (09) 1056-1062
    CrossrefPubMedGoogle Scholar
  • 26 Jubbal KT, Zavlin D, Suliman A. The effect of age on microsurgical free flap outcomes: an analysis of 5,951 cases. Microsurgery 2017; 37 (08) 858-864
    CrossrefPubMedGoogle Scholar
  • 27 Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery 2002; 22 (02) 57-61
    CrossrefPubMedGoogle Scholar
  • 28 Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury 2000; 31 (01) 33-40
    CrossrefPubMedGoogle Scholar