Digital Replantation and Revascularization in Patients Over 60 Years of Age—Contraindication or Benefit? Analysis of 59 Cases

Negative opinions are widespread regarding replantation and revascularization in patients of advanced age – of interest, often expressed by pioneers in microsurgery, today beyond the age of 60 years themselves. However, beside a few case reports, no large study has clarified the outcome in this growing population of healthy and active elderly patients who may have quite different functional and socioeconomic demands, compared to younger individuals.

Between 1989 and 2003, a total of 63 fingers and 22 thumbs were microsurgically reattached in 59 (11 female and 48 male) patients, aged over 60 (mean: 64, maximum: 82) years at the authors' institutions. All hospital charts were reviewed. Twenty-seven patients were questioned in a detailed survey and completed the DASH (disability of arm, shoulder, and hand) questionnaire (0 = no impairment, 100 = complete disability), estimating general daily life activity and evaluating pain and cold intolerance by visual (0 = no pain, 100 = intolerable pain) and verbal analogue (1 = no pain, 4 = intolerable pain) scales. Twenty-three patients were re-examined, including radiologic and clinical assessment of grip and pinch strength and two-point-discrimination. The function of the reattached digits was graded according to Burton' s system (1981), considering socioeconomic factors, range of motion, sensibility, strength, aesthetics, view of the patient and the surgeon (minimum = 0, maximum = 100 points).

The mean follow-up time was 4.3 (minimum 1, maximum 14) years. Most injuries were caused by circular saws (76%). In 26 patients, a single, in 19, a double, and in 6, a triple digit injury had occurred, and 7 patients had lost four digits. There were no bilateral injuries. Of a total of 84 fingers and 27 thumb amputations in 59 patients, of 63 fingers, 23 could be primarily reattached. Forty-four fingers and 13 thumbs survived, accounting for a success rate of 70% and 59%, respectively. Three digits were reattached heterotopically to replace the thumb, and two for the index. An average of 1.2 (maximum = 4) additional operations (aside from reamputations) were performed. At the time of the accident, 71% were already retired. Eleven of the 17 who were still working could resume their previous occupations. The overall mean DASH score was 39 (5 to 79) points.

Concerning cold intolerance, 13 of 27 patients experienced a severity of at least 80 of 100 (average: 54, range: 20 to 100). The mean Burton score was 60 (range: 14 to 100) points, and half of the re-examined patients reached at least 70 of 100 points. Retrospectively, no patient would have preferred primary amputation.

The authors concluded that chronological age alone should not be a contraindication for digital replantation and revascularization. Decisions should be based on a careful consideration of the injury, the health status, and individual desire of the individual, and not on an arbitrary age limit. Elderly active patients may profit significantly, despite modest functional results. Restored body integrity alone seems to be an important factor in these patients.