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Acta Ortopédica Brasileira

Print version ISSN 1413-7852

Acta ortop. bras. vol.23 no.1 São Paulo Jan./Feb. 2015

http://dx.doi.org/10.1590/1413-78522015230101026 

Original Article

Prognostic factors on survival rate of fingers replantation

José Queiroz Lima Neto

Alberto De Carli

Hugo Alberto Nakamoto

Gustavo Bersani

Bruno Eiras Crepaldi

Marcelo Rosa de Rezende

1Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

ABSTRACT

Objective:

To evaluate the factors that influence the survival rate of replantation and revascularization of the thumb and/or fingers.

Methods:

We included fifty cases treated in our department from May 2012 to October 2013 with total or partial finger amputations, which had blood perfusion deficit and underwent vascular anastomosis. The parameters evaluated were: age, gender, comorbidities, trauma, time and type of ischemia, mechanism, the injured area, number of anastomosed vessels and use of vein grafts. The results were statistically analyzed and type I error value was set at p <0.05 .

Results:

Fifty four percent of the 50 performed replantation survived. Of 15 revascularizations performed, the survival rate was 93.3%. The only factor that affected the survival of the amputated limb was the necessity of venous anastomosis.

Conclusion:

We could not establish contraindications or absolute indications for the replantation and revascularization of finger amputations in this study. Level of Evidence III, Retropective Study.

Key words: Replantation; Finger injuries; Amputation, traumatic

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.1 - 3 Most of these injuries occur in the workplace, especially for the male population at productive ages.4 - 6 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.5 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.7

With the advent of microsurgical techniques,8reimplantation 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.8 - 11 However, the first replantation of a human upper limb was performed only in the 60s. In 1962, Malt and McKhann12 reimplanted the arm of a 12 year old child. Tamai and Komatsu,13 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%.14 - 17

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 areas18 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)

Table 1. Factors evaluated to determine reimplantation survival and revascularization of thumb and/or fingers. 

Patient related factors Trauma related factors Surgical procedure related factors
Age Mechanism Number of anastomosed arteries
Comorbidities Cutting injuries Number of anastomosed veins
Systemic Hypertension Crushing Use of venous graft
Habits (Smoking) Avulsion
Ischemia time
Ischemia type: hot or cold
Injury zone (Verdan) Osteoarticular injury location

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)

Table 2. Need to perform venous anastomosis and reimplantation success. 

Need of venorrhaphy Reconstructed fingers Success (n) Success (%) Statistical Test P value
Revascularizations 15 14 93.3% Fisher's Exact Test 0.006 0.004
Reimplantation 50 27 54%

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)

Table 3. Surgical technique employed and success of procedure. 

Surgical Technique Number of reconstructions Number of successful reconstructions Successful reconstructions (%) Statistical test P value
Number of reconstructed veins
One 20 8 40% Pearson chi-square = 2.630 0.105
Two or more 30 19 63.3%
Graft for arteriorrhaphy
Yes 16 9 56.25% Fisher's Exact Test 0.560
No 49 32 65.3%
Need of venorrhaphy
Revascularizations 15 14 93.3% Fisher's Exact Test 0.006
Reimplantation 50 27 54%

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.19 - 25

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.19 , 24 - 27

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 studies24 - 27 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.

Table 4. Factors evaluated and reimplantation success rate. 

Factors Reconstructed fingers Success (n) Success (%) Statistical Test P value
Smoking
Yes 15 11 73.3% Fisher's Exact Test 0.543
No 50 30 60%
Hypertension
Yes 8 7 87.5% Fisher's Exact Test 0.240
No 57 34 59.6%
Amputated finger
Thumb 28 14 50% Pearson chi-square=7.317 0.120
Index 11 7 63.6%
Medium finger 12 10 83.3%
Ring finger 9 5 55.5%
Minimum finger 5 5 100%
Verdan zone
I 14 7 50% Pearson chi-square=1.467 0.480
II 43 29 67.4%
III 7 4 57.1%
Osteoarticular injury
Simple fracture 28 15 53.6% Pearson chi-square=2.433 0.296
Comminuted fracture 31 21 67.7%
Pure sprain 6 5 83.3%
Trauma mechanism
Cutting 54 33 61.1% Pearson chi-square=0.595 0.743
Crushing 8 6 75%
Avulsion 3 2 66.6%
Fracture/sprain location
Metacarpal 8 5 62.5% Pearson chi-square=4.133 0.530
Proximal phalanx 29 16 55.2%
Medial phalanx 10 7 70%
Distal phalanx 1 0 0%
Inter-proximal phalangeal 10 8 80%
Inter-distal halangeal 7 5 71.4%

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.

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Citation: Lima Neto JQ, De Carli A, Nakamoto HA, Bersani G, Crepaldi BE, Rezende MR. Prognostic factors on survival rate of fingers replantation. Acta Ortop Bras. [online]. 2015;23(1):16-8. Available from URL: http://www.scielo.br/aob.

Work developed at no LIM 41 - Laboratory of Medical Investigation of the Musculoskeletal System, Department of Orthopedics and Traumatology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.

Received: July 02, 2014; Accepted: September 01, 2014

Correspondence: Marcelo Rosa Resende, Instituto de Ortopedia e Traumatologia do HC-FMUSP, Rua Dr. Ovídeo Pires de Camargo, 333, 05403-010 São Paulo, SP, Brazil. bivitelino@uol.com.br

All the authors declare that there is no potential conflict of interest referring to this article.

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