This retrospective series evaluates the results of distal finger replantation in 450 patients (510 digits) over a 15-year period. Patients ranged in age from 2-68 years. Sixty-eight percent were single-digit replants. Injuries included both sharp and crush mechanisms. The most commonly injured and replanted digit was the index in this series (30%). All replantations involved anastomosis of at least one artery. Artery alone replants were performed in 25 digits, 1 artery/1 vein in 115 digits, 1 artery/2 veins in 240 digits, more than 2 arteries/2 veins in 130 digits. The levels of the amputations varied but and all were in Zone I, distal to the eponychial base. Postoperative regimen included the use of Dextran for 5 days, aspirin and dipyridamole for 7-10 days, urokinase and prostaglandin E1 for 3-5 days. The authors evaluated their results using the success of replantation, active range of motion of the terminal joint and complications. Overall success of the replantations was 92%. The success rates were directly proportional to the number of vessels repaired, from 68% with one artery alone to 99% with more than 2 arteries and 2 veins. Sensory return was inconsistently reported, as many of the digits had replanted areas too small to accurately assess with standard techniques. Failures were treated with attempted salvage techniques, including heparinization and nail bed trauma as well as leeches, but no overall salvage rate is mentioned. All 25 of the single artery alone replants had the use of heparinized saline drip applied to a traumatized nail bed for 7 days. Eleven of those cases also required leeches. Only 68% of them survived.
The authors present their results of heroic efforts at distal finger replantation in a large series. They are to be commended on their technical expertise and skill. As anyone who has attempted replantations distal to the eponychial base is aware, these cases can be very technically challenging. They leap, however, to some fairly grandiose conclusions which review of their very limited analysis does not clearly support. They state that, "we believe that in zone I injuries, replantation is the best procedure." Their analysis shows an overall high rate of surgical success, measured as survival of the amputated part. However, they do not compare their results with that of other techniques. Thus, their conclusion is not supported.
Furthermore, no attempt was made to evaluate or report important criteria which have an enormous impact on the overall success of these procedures, namely patient satisfaction, pain, functional outcomes other than range of motion of the terminal joint, return to activities/work, hospitalization time and costs, or morbidity of their procedures (such as the need for transfusions, infection, or subsequent re-operation). All of these factors need to be taken into careful consideration before recommending distal finger replantation to an injured patient.
Furthermore, 30% of their patients had amputation of the index finger. Experience and multiple series have shown that the results of replantation in the index finger do not equal the results in other digits, especially where considerations of patient satisfaction and return to functional use are concerned. Lastly, replantation at the base of the eponychial fold of an injury involving bone, nail matrix, and soft tissue differs vastly from microsurgical replantation of more distal pulp-only injuries. The criteria for selection of microvascular anastomosis versus less-involved but also highly-successful techniques must be explored. In all but the rarest of cases, this analysis does not support the authors claim that, "in zone I injuries, replantation is the best procedure."
Fingertip, Injury, Replantation, Microvascular, Anastomosis