This paper reviews a 14-year experience with artery-only replantation of digits distal to the level of the DIP joint using periungual incision and continuous heparin drip to prevent and treat venous congestion. 144 fingertips at this level were replanted without venous anastomoses. Venous congestion was prevented by a small stab incision in the pariungual tissues and a continuous drip of Heparin solution for 5 days. The patients all received oral aspirin (600mg/day) for 14 days, IV Dextran 500ml/day for 5 days, and IV Heparin 3000IU every 4hrs for 2 weeks. If venous congestion was observed by visual inspection after discontinuation of the continuous heparin drip on day 5, the drip was restarted and continued until the part survived without the drip and external bleeding. 101/144 fingertips survived. The patient records were retrospectively reviewed for sex, age, level of injury, mechanism of amputation, and cause of injury. The length of heparin drip administration was calculated, averaging 7.6 days (range, 5-14 days). A direct correlation was noted between patient age (grouped by decade) and the length of external bleeding required, ranging from 5.5 days in patients under 10 to 12.5 days in patients older than 60. As expected, the mechanism of injury affected the need for external anticoagulation, with guillotine amputations requiring 5.9 days, avulsions 8.0 days, and crush injuries requiring 8.2 days. These results were statistically significant. Level of injury and sex failed to show any significant difference in the number of days of heparin drip required for survival.
This study presents a large group of very distal amputations successfully treated with artery-only replantation and a combination of internal and external anticoagulation to prevent venous congestion of the part. The approach is a novel one, and is unarguably successful, if one considers only the survival of the part as the criterion for success. However, although the authors mention the universality of bleeding complications and the need for transfusion in their paper, they do not comment on the specifics of these problems. There is no data on the amount of blood loss encountered, the number of transfusions required during the anticoagulation protocol, or the frequency or nature of complications related to such an aggressive combination of anticoagulation drugs administered simultaneously over a one to two week period. There is ample experience with simultaneous administration of intravenous Dextran and heparin in high therapeutic doses for more than very brief periods to warrant extreme caution in the routine use of this drug combination. Given the fact that the parts are, by definition, very distal and amenable in many cases to closure by alternate primary methods, (ie, revision amputation, advancement flaps, thenar or other distant flaps), without the risk of prolonged bleeding and transfusion, one must consider the risks versus benefits of this approach in all but the most unusual circumstances. In addition, no data is presented on the outcomes of these replantations. Were the procedures successful in any functional way? Were the results comparable or superior to more traditional methods of primary management of extremely distal amputations? Was adequate protective sensation achieved in a significant number of cases? The observation that survival of very distal replantations requires a shorter period of anticoagulation to treat venous congestion is an interesting one with practical importance. But the mechanisms by which they reach this conclusion are not supported with enough data to warrant clinical application in a broader setting.
Plastic and Reconstructive Surgery