Postoperative Digit and Hand Replantation Protocols: A Review of the Literature

Abstract

Successful replantation and revascularization of the hand and digit require a skilled team with urgent access to an operating room with microsurgical capabilities. Although careful indications and surgical techniques contribute to success, postoperative management also plays a vital role in the survival of a replanted digit. Previous research has assessed surgical efficiency and techniques to conduct these procedures, but few studies evaluate postoperative protocols to care for patients undergoing these procedures. Because of the lack of high-level evidence specific to replantation, many common postoperative practices related to monitoring, anticoagulation, and diet have been inferred from elective microsurgical procedures, despite notable differences in operating conditions. The highest level of evidence pertaining to digital replantation was found with the use of peripheral nerve blockade, leeching/bleeding, and nicotine use. This review provides an in-depth evaluation of the literature and insight into the rationale and level of evidence that support each postoperative intervention. It highlights institutional variability and a paucity of high-level evidence pertaining to this topic while identifying the areas of future research.

The clinical effectiveness and safety of intravenous unfractionated heparin following digital replantation and revascularization: A narrative systematic review

“…Twenty-six full-text articles were assessed for eligibility. Twenty of these were excluded (Askari et al, 2006;Buntic & Brooks, 2010;Chen et al, 2021;Couteau et al, 2018;Efanov, 2017;Fukui et al, 1989;Herlihy et al, 2020;Li et al, 2012;Lin et al, 2020;Loisel et al, 2010;Luthringer et al, 2020;Maeda et al, 1991;Noguchi et al, 1999;Noh & Hacquebord, 2020;Pickrell et al, 2020;Reissis et al, 2020;Shaterian et al, 2018;Shi et al, 2013).Other than a prospective trial initiated by some members of our research team (NLM, 2021), the search in EBM reviews did not find other ongoing clinical trials, health technology assessment reports or guidelines. The manual search for relevant gray literature did not allow finding relevant studies either.…”

“…Some surgeons performing replantation choose not to use any peri‐operative anticoagulation and report favorable outcomes (Veravuthipakorn & Veravuthipakorn, 2004). Some of the answers may lie in better selection of patients for whom to prescribe heparin (Chen et al, 2021). This is in part illustrated by the Lee et al study, which focused on a very select group of patients where no venous anastomosis was performed.…”

Outcomes of Flexor Tendon Repair in Patients With Concurrent Neurovascular Injuries of Multiple Digits in Zone 1

“…Medications were performed according to the general guidelines for digit revascularization 4–6 . Low-dose aspirin (325 mg) was applied postoperatively for 2 weeks.…”

“…We excluded patients with (1) injuries at the thumb; (2) crush injuries accompanied by phalangeal fractures; (3) flexor tendon injuries without NV involvement; (4) pediatric/adolescent flexor tendon rupture (regardless of NV status); (5) rheumatoid arthritis or related synovial lesions; (6) flexor/extensor tenosynovitis; (7) systemic morbidity associated with an electrodiagnostic abnormality (compressive neuropathy in the upper extremities), including in patients with diabetes mellitus and chronic renal disease; and (8) a history of trauma to the tendons, ligaments, bones, or NV structures below the elbow on the ipsilateral side, and neurological impairment of the ipsilateral arm.…”

“…Medications were performed according to the general guidelines for digit revascularization. [4][5][6] Low-dose aspirin (325 mg) was applied postoperatively for 2 weeks. In addition, heparin (unfractionated or low molecular weight) and thrombolytic agents were not considered.…”