Delayed Digit Replantation: What is the Evidence?

Harbour, Patrick; Malphrus, Elizabeth; Zimmerman, Ryan M.; Giladi, Aviram M.

doi:10.1016/j.jhsa.2021.07.007

Cited by 6 publications

(7 citation statements)

References 44 publications

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“…Many studies cite refrigeration at a temperature of 4-6°C as the ideal preservation method; however, for individuals who do not have access to a refrigerator, wrapping the amputated digit in salinemoistened gauze within a sealed bag that is surrounded by ice is considered to be sufficient. 31,44 Perioperative management of patients with digit amputations includes adequate photographical and radiographical imaging of the amputated digit and the stump, maintenance of hemodynamic stability, and antibiotic therapy. 90 Lastly, the quantity of blood vessels…”

Section: Discussionmentioning

confidence: 99%

“…[22][23][24][25] Furthermore, this dogma has been challenged thoroughly by the recent literature-with some reports of replantation success with ischemia times of up to 42 hours and 94 hours of warm and cold ischemia, respectively. [26][27][28][29][30] While there have been previous studies investigating digit ischemia and preservation on survival rates, 5,31,32 there has yet to be a study that effectively addresses the preservation of the amputated digit, particularly comparing and compounding the effects of time and temperature on digit replantation success. The data primarily compare the success rates of surgeries done within multiple intervals: 0 to 6 hours, 0 to 12 hours, 6 to 12 hours, 0 to 12 hours, and more than 12 hours.…”

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confidence: 99%

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Amputated Digit Replantations

Fijany,

Chaker,

Egozi

et al. 2024

Ann Plast Surg

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Introduction A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates. Methods The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval. Results Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0–12 hours of warm ischemia time (P ≤ 0.05). The odds of survival in the early (0–6 hours) replantation group were around 40% greater than the later (6–12 hours) replantation group (P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers (P ≤ 0.05). Discussion Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Amputated Digit Replantations

Fijany,

Chaker,

Egozi

et al. 2024

Ann Plast Surg

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“…A recent study to find evidence for delayed digital replantation concludes that better data on replantation timing and associated outcomes are needed to support potential policy changes. 36 Two cases of hand replant underwent late vascular thrombosis consequent to inadequate soft tissue cover and infection. We attempted to salvage the hand in both cases with debridement and flap cover; however, the infection did not respond to treatment.…”

Section: Discussionmentioning

confidence: 99%

Review of Replantation Services from a Level One Trauma Center in India

Dash,

Tiwari,

Dawar

et al. 2023

Journal of Hand and Microsurgery

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The aim of this article is to examine the elements that contribute to effective operation of a specialized replantation center and to provide readers with a general idea of the outcome of replantation services in India. A dedicated high-volume center coupled with a sound referral system is the backbone of replantation services in a country. A retrospective study was done on all patients who visited a level 1 trauma center in India from November 1, 2017, to December 31, 2018, for various amputations. The medical records and digital pictures of these patients were extracted from the records and analyzed. During the study period, 77 replants were performed on 63 patients at our center. Males were 68% of the study, mostly belonging to the 20 to 40 years age group (63%). Thirty-four percent of cases were smokers. Agricultural injuries (49%) were the most common cause of amputation. Finger replantation was the most common type of replantation (82%). The rate of successful replantation was highest for scalp (100%) followed by hand (71%) and thumb (67%). Setting up dedicated replantation services is essential, especially in highly populated areas. Manpower, resources, and a protocol-led approach help in achieving optimum results. A multidisciplinary team approach with round-the-clock availability plays a vital role in intraoperative decision-making and planning postoperative rehabilitation.

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“…[1][2][3][4][5] However, many studies contest the importance of minimizing ischemia time given the substantial heterogeneity in assessment and outcome data. [6][7][8][9][10][11][12][13] Digits lack muscle; therefore, ischemia time can be prolonged with appropriate cooling. Furthermore, sleep deprivation and fatigue have been associated with deficits in attention, memory, and decision-making, as well as an increase in risktaking behaviors.…”

Section: Introductionmentioning

confidence: 99%

“…[16][17][18][19] Studies from Europe and Asia have reported the possibility of delaying select overnight replantations. 6,20,21 Cavadas et al 20 reported that amputated digits with less than 12 hours of cold ischemia presenting after 6 PM can undergo delayed replantation in the morning. Ischemia-sensitive replants (transmetacarpal, crush or contaminated, or extended ischemia times) were performed immediately.…”

Section: Introductionmentioning

confidence: 99%