Functional Outcomes of Secondary Procedures in Upper Extremity Replantation and Revascularization

Abstract

IntroductionTraumatic amputation of the upper limb has significant associated morbidities and disabilities. After successful replantation surgery, the micro-surgeons’ tasks are far from over. The replanted and revascularized segments have numerous functional restrictions and need various corrective secondary procedures. The aim of our study was to compare the functional results after secondary procedures by administering the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire to patients who had successful upper limb replantation and revascularization.Materials and methodsThis prospective observational study involved 40 patients who had a partial or complete amputation of the upper limb and underwent secondary procedures to correct function after successful replantation and revascularization surgery. The patients’ functional outcomes after various secondary procedures were recorded using the QuickDASH questionnaire.ResultsThe mean QuickDASH score for thumb injuries was 42.3 pre-surgery but improved to 29.5 after secondary procedures, which was statistically significant (CI 11.12-14.87, p<0.01). The mean difference in the QuickDASH scores for finger injuries was also statistically significant: 45.5 preoperation and 33.7 postoperation (CI 9.89-13.70, p<0.01). For wrist injuries, the mean QuickDASH score was 52.8 presurgery and was 46.3 postoperatively (CI 1.81-6.58, p=0.0023). The QuickDASH scores of the patients with arm and forearm injuries showed no statistically significant improvement, with a preoperation score of 58.3 declining to 55.2 (p=0.98). The overall replantation and revascularization scores were 49.725 and 41.175 pre and postoperation, respectively (CI 8.35-8.75, p<0.01).ConclusionThe study finds that the level and mechanism of injury are important predictors of the functional outcomes of the replantation and revascularization of amputated upper-limb appendages. Most replanted and revascularized upper limbs have numerous functional limitations, and achieving good functional results requires one or more secondary procedures, whose type depends on various factors such as the injury type and mechanism. The QuickDASH results for functional outcomes before and after secondary procedures indicate that it is an easy-to-use, reliable, and effective measure of functional outcomes.

Predictors of Success following Microvascular Replantation Surgery of the Upper Extremity in Adult Patients

“…9 The present data were unable to capture surgeon and hospital volume. Although these factors have been predictors of success in other orthopedic procedures, 2,3,20 neither factor has been predictive of successful replantation in a large review of the National Inpatient Sample. 21–23 Cho et al’s 23 investigation was able to demonstrate that patients with superior insurance products were more likely to undergo replantation, which the present data did not reflect, likely as a result of the present study’s limited power.…”

“…Most often, this occurs at the level of the digit. 2 Many patients who sustain injuries in remote areas of the United States cannot receive replantation and instead undergo a revision amputation secondary to a lack of microsurgery centers or necessary equipment, 3 while for other patients amputation is preferred due to decreased cost, quicker return to work, maintained adjacent joint range of motion, and normal sensation in residual digit. 4,5…”

“…For instance, no clear anticoagulant protocol is clearly superior. 3,7,10 The purpose of this retrospective database study is to ascertain which factors are associated with successful replantation in the upper extremity. We hypothesize that younger patient age and patients without comorbidities are more likely to have successful replantation procedures.…”

“…Most often, this occurs at the level of the digit. 2 Many patients who sustain injuries in remote areas of the United States cannot receive replantation and instead undergo a revision amputation secondary to a lack of microsurgery centers or necessary equipment, 3 while for other patients amputation is preferred due to decreased cost, quicker return to work, maintained adjacent joint range of motion, and normal sensation in residual digit. 4,5 It is generally accepted that indications for replantation include amputations proximal to the wrist, thumb(s), multiple digits, single-digit distal to the flexor digitorum superficialis tendon insertion, and all amputations in children.…”

“…8 The survival rates vary greatly among studies, ranging from 50% to 90%. 2,3,6 Patients with more than three comorbidities have a significantly higher rate of failed replantation, and patients with peripheral vascular diseases have an even greater relative risk of failure. 9 However, these data have been extrapolated primarily from retrospective case series, as there exists no large database on this rare and complex surgical procedure.…”