Replantation


164 Replantation


Serge Goekjian MD FRCS (C)1, Lucas Gallo BHSc MD (c)2, and Achilleas Thoma MD MSc3


1 Division of Plastic Surgery, University of Toronto, ON, Canada


2 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada


3 Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


Clinical scenario



  • You are paged to the Emergency Department to see a 20‐year‐old male carpenter with a traumatic amputation of the index and long digits of his dominant hand in a table saw accident. The injury occurred at the level of the proximal phalanx.
  • The injury occurred three hours prior to Emergency Department presentation. The amputated digits were placed on ice following the injury. Hemostasis was achieved through direct pressure to the area of injury.
  • Radiographs of the stump and amputated digits show clean amputations.
Schematic illustration of Tamai classification of zones in digital amputation: zone I (distal to lunula), zone II (proximal to lunula, distal to DIP joint), zone III (proximal to DIP joint, distal to insertion of FDS tendon), and zone IV (proximal to FDS tendon insertion, distal to MP joint).

Figure 164.1Tamai classification of zones in digital amputation: zone I (distal to lunula), zone II (proximal to lunula, distal to DIP joint), zone III (proximal to DIP joint, distal to insertion of FDS tendon), and zone IV (proximal to FDS tendon insertion, distal to MP joint). DIP, distal interphalangeal; PIP, proximal interphalangeal; MP, metacarpophalangeal. Source: Lee et al.4


Top three questions



  1. In patients requiring replantation, how many veins should be anastomosed when performing digital replantation to achieve optimal outcomes?
  2. In patients undergoing replantation, does prophylactic anticoagulation and/or do antithrombotic agents ordered postoperatively prevent thrombosis compared to placebo or control?
  3. In patients who have undergone replantation, does early range of motion (ROM), compared to delayed ROM, restore total ROM more effectively?

Question 1: In patients requiring replantation, how many veins should be anastomosed when performing digital replantation to achieve optimal outcomes?


Rationale


In 1978, Tamai et al. reported that two veins should be anastomosed for each artery repaired during digital replantation.1 In contemporary practice, there exists little consensus among microsurgeons regarding the optimal number of veins that must be repaired when performing digital replantation surgery (Table 164.1).2


Clinical comment


Though bone, tendon, and nerve repair correlates with long‐term functional outcomes, venous outflow remains the most important factor influencing replantation success in the immediate postoperative period.2,3 While a surgeon may not have a choice on the matter if only one or multiple veins are not present, the question is: what if multiple veins exist? How many should one repair per digit? While it is considered to be favorable to anastomose as many veins as possible, a balance must be achieved between ischemia time, survival rate, and overall operation time.4


Available literature and quality of the evidence


At present, the highest‐quality evidence for venous anastomosis in the setting of digital replantation consists of retrospective cohort trials. Seven retrospective cohort studies were identified consisting of 1317 replanted digits (level III evidence).24–9


Findings


A retrospective cohort study by Ryu et al. assessed the relationship between the number of venous anastomoses and replantation survival in 143 cases.5 No significant correlation was identified between the number of veins anastomosed and replantation survival (p = 0.689).


Efanov et al. reviewed 101 digital replantations and concluded that single vein repair corresponded to an increase in replantation failure when compared to two vein anastomoses (p = 0.032; risk ratio [RR] = 1.27; 95% confidence interval [CI]: 0.991–1.343).2 A significant increase in replantation failure was also demonstrated in cases of no vein repair versus two vein anastomoses (p = 0.008; RR, 1.49; 95% CI: 1.026–1.735). However, no significant difference was identified between one vein versus no vein anastomosis (p = 0.502; RR = 1.179; 95% CI: 0.834–2.102].


Huang and Yeong (n = 31) as well as Neto et al. (n = 50) failed to reach statistical significance when comparing one vein versus no vein anastomosis (p >0.05) and one vein versus multiple vein anastomosis (p = 0.105), respectively.6,7


Lee et al. and Matsuda et al. (n = 847 total digital replantations) provided recommendations for optimal venous anastomosis at each Tamai amputation zone (Figure 164.1).4,8


Zone 1



  • Lee et al. (n = 162) recommended the repair of at least one vein. The authors demonstrated statistically significant survival in digits with one repaired vein versus no vein repair (p = 0.008).4
  • Matsuda et al. (n = 21) showed no difference in survival with no vein versus one vein repair at this level.8

Zone 2



  • Lee et al. (n = 203) recommended the repair of at least as many veins as arteries and demonstrated that vein anastomosis versus no vein repair resulted in a significant increase in replant survival (p = 0.001).4
  • Matsuda et al. (n = 46) recommended the repair of at least one vein and demonstrated a significant difference in survival between no vein versus one vein repair.8

Zone 3



  • Lee et al. (n = 182) recommended that at least two veins be anastomosed, and demonstrated statistical significance when they compared venous anastomosis versus no anastomosis (p = 0.025).4
  • Matsuda et al. (n = 63) demonstrated statistical significance between one vein versus two vein anastomoses and therefore recommended that at least two veins be repaired at this level.8
  • A study by Chaivanichsiri and Rattanasrithong (n = 61) reported a statistically significant benefit by repairing at least one vein at Tamai zone 3, but reported no significance when more than one vein was anastomosed.9

Zone 4



  • Lee at al. (n = 84) demonstrated a significant replantation survival benefit with venous repair (p = 0.001) and recommended an equal ratio of artery to vein anastomosis.4
  • Matsuda et al. (n = 86) reported a significant increase in survival when two or more veins were repaired versus no repair; however, there was no significant difference between one vein anastomosis versus two or more veins. Thus, Matsuda et al. recommended that only one vein be repaired at this level.8

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Replantation

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