Abstract

INTRODUCTION

Amputation is defined as total or partial surgical or traumatic separation of a part of the whole body. The amputation of a finger is a common injury with important consequences and can cause psychological changes, permanent functional deficit and inability to work. Moreover, it also brings large direct and indirect financial loss to the patient and to the society.¹1. Conn JM, Annest JL, Ryan GW, Budnitz DS. Non-work-related finger amputations in the United States, 2001-2002. Ann Emerg Med. 2005;45(6):630-5.

2. Harvey FJ, Harvey PM. A critical review of the results of primary finger and thumb amputations. Hand. 1974;6(2):157-62. ^{- 3}3. Gruneberg R, Spence AJ. Finger amputations and ability to work. Hand. 1974;6(3):236-42. Most of these injuries occur in the workplace, especially for the male population at productive ages.⁴4. Centers for Disease Control and Prevention (CDC). Nonfatal occupational injuries and illnesses--United States, 2004. MMWR Morb Mortal Wkly Rep. 2007;56(16):393-7.

5. Barmparas G, Inaba K, Teixeira PG, Dubose JJ, Criscuoli M, Talving P, et al. Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg. 2010;76(11):1214-22. ^{- 6}6. Panagopoulou P, Antonopoulos CN, Dessypris N, Kanavidis P, Michelakos T, Petridou ET. Epidemiological patterns and preventability of traumatic hand amputations among adults in Greece. Injury. 2013;44(4):475-80. In a study based on the NTDB (National Trauma Databank) from 2000 to 2004 6,155 patients underwent finger amputation in the US, accounting for 69.1% of amputations.⁵5. Barmparas G, Inaba K, Teixeira PG, Dubose JJ, Criscuoli M, Talving P, et al. Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg. 2010;76(11):1214-22. There is no national data in Brazil on the incidence of traumatic amputations of fingers.

Amputations can be divided into complete or incomplete. In complete amputations, the portion of the injured member is completely separated from the proximal stump. Incomplete amputations are those in which, although presenting a connection to the amputated portion, there is a need for anastomosis, at least of one artery to maintain the viability of the member.⁷7. Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001;26(6):572-81.

With the advent of microsurgical techniques,⁸8. Tamai S. History of microsurgery--from the beginning until the end of the 1970s. Microsurgery. 1993;14(1):6-13.reimplantation emerged as an alternative for the treatment of these lesions. Reimplantation of a member experimentally in animal model was successfully held at the beginning of the 20th Century.⁸8. Tamai S. History of microsurgery--from the beginning until the end of the 1970s. Microsurgery. 1993;14(1):6-13.

9. Carrel A, Guthrie C. Complete amputation of the thigh with replantation. Am J Med Sci. 1906;131:297-301.

10. Gillies H, Reid DA. Autograft of the amputated digit. Br J Plast Surg. 1955;7(4):338-42. ^{- 11}11. Lapchinsky AG. Recent results of experimental transplantation of preserved limbs and kidneys and possible use of this technique in clinical practice. Ann N Y Acad Sci. 1960;87:539-71. However, the first replantation of a human upper limb was performed only in the 60s. In 1962, Malt and McKhann¹²12. Malt RA, McKhann C. Replantation of severed arms. JAMA. 1964;189:716-22. reimplanted the arm of a 12 year old child. Tamai and Komatsu,¹³13. Komatsu S, Tamai S. Successful replantation of a completely cut-off thumb: case report. Plast Reconstr Surg. 1968;42:374-7. in 1968, firstly reported a microsurgical replantation of a finger. Since then, several centers around the world organized themselves in order to provide proper treatment to amputees, with success rates exceeding 50%.¹⁴14. Chiu HY, Lu SY, Lin TW, Chen MT. Transpositional digital replantation. J Trauma. 1985;25(5):440-3.

15. Urbaniak JR. Replantation. In: Green DP, editor. Operative hand surgery. New York: Churchill Livingstone; 1982. p. 811.

16. Urbaniak JR. Thumb reconstruction by microsurgery. Instr Course Lect. 1984;33:425-46. ^{- 17}17. Tamai S. Current status of orthopaedic microsurgery in Japan. Personal experience and review of the literature. Clin Orthop Relat Res. 1984; (184):24-33.

MATERIALS AND METHODS

This is a retrospective study to evaluate the factors influencing the survival of replantation and revascularization of thumb and/or other fingers. This article was approved by the Institution's Ethics Committee in accordance with the protocol No. 759,220.

This study comprised all patients treated from May 2012 to October 2013 at our department with partial or total amputation of thumbs or fingers, involving Verdan areas¹⁸18. Manske PR. History of flexor tendon repair. Hand Clin. 2005;21(2):123-7. 1, 2 or 3 that had blood perfusion deficit and vascular anastomoses to maintain the viability of the injured part. The study excluded those who, despite having been indicated for reimplantation, it did not take place due to lack of local conditions or failure to present distal perfusion after arterial anastomosis.

Data were collected from medical records of patients undergoing replantation, revascularization and/or regularization of amputations. In the results, we assessed the correlation between finger survival of those who were submitted to reimplantation and/or revascularization and the patients' factors related to trauma and surgical procedure. (Table 1)

For data storage, an Excel^(r) spreadsheet for MAC was used. Subsequently, data were imported into SPSS 20.0 for MAC software for statistical analysis. Descriptive statistics was performed and measurements such as mean and standard deviation were used as a degree of central tendency and variability of the data. The Kolmogorov-Smirnov test was used to test the distribution of the data. For analysis of inferential statistics, logistic regression models were used with the stepwise method, so in every step of the procedure the most important variable, in statistical terms, was the one that produced the biggest change in log-likelihood in relation of the model that did not contain the variable. The value accepted as the type I error was p≤0.05.

RESULTS

During the study period, 50 reimplantation and 15 revascularizations were performed in 45 patients. Thirty-five patients underwent reimplantation/revascularization of one finger, three of two fingers, five of three fingers, one of four fingers and one of five fingers. The mean age of patients was 36 years old (range 3-75). (Figure 1) Of these patients, two (4.4%) were women and 43 (95.6%) were men. Cutting injuries were the main mechanism of injury in 54 (83%) cases, three (4.6%) were avulsion injuries and eight (12.3%) were crush injuries. The majority (73.3%) of patients had lesions in the non-dominant hand. Of the 65 procedures performed, 28 (43%) involved the thumb, 11 (16.9%) the index finger, 12 (18.4%) the middle finger, nine (13.8%) the ring finger and five (7.6 %) the little finger.

Figure 1.
Mean age of patients.

Workplace accidents corresponded to 55.6% of patients and the majority worked in civil construction (48.8%) or the industry (13.3%). The average ischemia time was 8.39 hours, 7.57 hours in the fingers that did not survive and nine hours in successful reimplantation/revascularization. (Figure 2) Nine (20%) patients were smokers and five (11.1%) patients had hypertension. No replantation or revascularization was performed in patients with a history of type II diabetes mellitus, alcoholism or psychiatric illness.

Figure 2.
Mean ischemia times.

Regarding the injured area of the fingers, 44 (67.7%) of the fingers were injured in Verdan zone 2, 14 (21.5%) in zone 1 and seven (10.8%) in zone 3. Twenty-eight presented simple fractures trait, 31 were comminuted and six pure dislocations without bone injury. Eight amputations had metacarpal fractures, 29 in the proximal phalanx, 10 on medial phalanx and one on the distal phalanx. Ten had fracture-dislocation at the proximal inter-phalangeal level and six at the distal inter-phalangeal.

Among the 50 reimplantation performed, only 20 had a reconstructed vein and on 30 cases there were two or more venorrhaphies. In all cases, only one arterial anastomosis was performed. Sixteen replantation required vascular graft for arterial anastomosis and no finger submitted to revascularization required venous graft.

Of the data analyzed, the only one that showed a statistically significant difference was the need for venous anastomosis. Of the 50 reimplantations performed 27 (54%) fingers survived. Of the 15 revascularization performed, only one did not survive, which represents a 93.3% survival rate. (Table 2)

DISCUSSION

Given an amputation case, many factors are determinant to make the decision whether to reimplant it or not. We must consider what are the real chances of success of the procedure in terms of survival and functional recovery for actually indicate reimplantation. Therefore, there is a need to define objective parameters that can signal to the prognostic factors of this procedure. (Table 3)

Current literature suggests some indications for reimplantation, such as thumb amputations, multiple fingers amputations, partial hand amputation, any level of amputations in children, wrist or forearm amputation or single distal finger insertion of the superficial flexor of the finger.¹⁹19. Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am. 1998;23(5):783-91.

20. Meyer VE. Hand amputations proximal but close to the wrist joint: prime candidates for reattachment (long-term functional results). J Hand Surg Am. 1985;10(6 Pt 2):989-91.

21. O'Brien BM. Replantation surgery. Clin Plast Surg. 1974;1(3):405-26.

22. O'Brien BM, Miller GD. Digital reattachment and revascularization. J Bone Joint Surg Am. 1973;55(4):714-24.

23. May JW Jr, Gallico GG 3rd. Upper extremity replantation. Curr Probl Surg. 1980;17(12):635-700.

24. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5):390-8. ^{- 25}25. Ipsen T, Lundkvist L, Barfred T, Pless J. Principles of evaluation and results in microsurgical treatment of major limb amputations. A follow-up study of 26 consecutive cases 1978-1987. Scand J Plast Reconstr Surg Hand Surg. 1990;24(1):75-80.

The following conditions are considered relative contraindications for reimplantation, because of their lower survival rates and/or poor functional outcome: crush injuries or member avulsion, amputations at multiple levels, prolonged ischemia, single finger amputation proximal to the finger superficial flexor insertion (mainly index and little finger), amputations in patients with systemic diseases or associated severe injury, severe atherosclerosis and psychiatric patients without proper treatment.¹⁹19. Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am. 1998;23(5):783-91. ^{, 24}24. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5):390-8.

25. Ipsen T, Lundkvist L, Barfred T, Pless J. Principles of evaluation and results in microsurgical treatment of major limb amputations. A follow-up study of 26 consecutive cases 1978-1987. Scand J Plast Reconstr Surg Hand Surg. 1990;24(1):75-80.

26. Patradul A, Ngarmukos C, Parkpian V. Major limb replantation: a Thai experience. Ann Acad Med Singapore. 1995;24(Suppl 4):82-8. 8572534. ^{- 27}27. Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. 2006;10(3):124-9.

The anastomosis of two or more veins showed a higher survival rate than when only one vein was sutured, however, the result was not statistically significant (p=0.105). (Table 3)

Although several studies²⁴24. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5):390-8.

25. Ipsen T, Lundkvist L, Barfred T, Pless J. Principles of evaluation and results in microsurgical treatment of major limb amputations. A follow-up study of 26 consecutive cases 1978-1987. Scand J Plast Reconstr Surg Hand Surg. 1990;24(1):75-80.

26. Patradul A, Ngarmukos C, Parkpian V. Major limb replantation: a Thai experience. Ann Acad Med Singapore. 1995;24(Suppl 4):82-8. 8572534. ^{- 27}27. Dec W. A meta-analysis of success rates for digit replantation. Tech Hand Up Extrem Surg. 2006;10(3):124-9. have shown higher failure rates in anastomoses of replantation in smokers, this association was not observed in our study group (p=0.267). (Table 4) Therefore, despite data showing the negative effects of smoking on blood flow, limb replantation can be attempted associated to encourage smoking cessation in the postoperative period.

CONCLUSION

In this study, possibly due to the low number of cases, the only factor that directly affected the survival of the amputated limb was the need of venous anastomosis. Therefore, it was not possible to establish contraindications or absolute indications for reimplantation/revascularization aiming at survival of the amputated finger.

REFERENCES

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