Supermicrosurgical Experience pertaining to Replantation of Tamai Zone 1 Fingertip Amputations

Abstract

With the advent of supermicrosurgery, the replantation of very distal finger amputations has become possible. The choice between replantation or flap surgeries in the treatment of Tamai Zone I finger amputations continues to be a matter of debate. This study aims to evaluate replantation results in Tamai Zone 1 finger amputations. The demographic characteristics and clinical results of 39 patients undergoing replantation for a Tamai Zone 1 finger amputation between 2018 and 2021 were retrospectively analyzed. The Cold Intolerance Severity Score (CISS), two-point discrimination test (2-PD) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were calculated and recorded after a minimum follow-up period of 6 months. The great majority of patients were males (92.3%, n=36) who had suffered the injuries during work accidents (89.7%, n=35). The socioeconomic status of the patients showed a homogeneous distribution. Replant survival was achieved in 69.2% (n=27) of all fingers. The duration of the surgical procedure in patients who underwent vein repair was significantly longer (p<0.001). However, there was no significant relationship between vein repair and survival rate (p=0.348). This study shows that replantation is a surgical intervention that should be given priority in patients with Tamai Zone 1 amputations. In most cases of unsuccessful replantation, secondary recovery results are also acceptable. Future studies with larger case series are needed.

Zusammenfassung

Die Fortschritte in der Supermikrochirurgie machen Replantationen extrem peripherer Fingeramputationen möglich. Ob bei einer Fingerendgliedamputation in Zone Tamai I eine Replantation oder eine lappenplastische Defektdeckung erfolgen sollte, ist jedoch weiterhin Gegenstand von Diskussionen. Diese Studie untersucht deshalb die Ergebnisse nach Replantation von Fingerendgliedamputation in Zone Tamai I. Die demographischen Daten und klinischen Ergebnisse von 39 Patienten, bei denen im Zeitraum von 2018 bis 2021 eine Replantation bei einer Fingerendgliedamputation in Zone Tamai I erfolgte, wurden retrospektiv analysiert. Dabei wurde die Kälteempfindlichkeit mittels des Cold Intolerance Severity Scores (CISS), die Zwei-Punkt-Diskrimination und der Quick-DASH erfasst, wobei die Nachuntersuchungszeit minimal 6 Monate betrug. Die Mehrheit der Patienten war männlich (92,3%, n=36) und hatte sich die Verletzung bei einem Arbeitsunfall zugezogen (89,7%, n=35). In 27 Fällen (69,2%) überlebte das Replantat. Erfolgte eine Venenanastomose, dauerte die Operation signifikant länger (p<0,001). Allerdings hatte die Durchführung einer Venenanastomose keinen signifikanten Einfluss auf die Überlebensrate des Replantates (p=0,348). Aufgrund der Ergebnisse geben wir der Replantation bei Fingerendgliedamputationen in Zone Tamai I den Vorzug gegenüber sonstigen Maßnahmen. Ist diese nicht erfolgreich, lässt sich trotzdem meist durch eine sekundäre Wundheilung ein akzeptables Resultat erzielen. Weitere Studien mit dem Ziel der Entwicklung eines Therapiealgorithmus sind sinnvoll.

Key words

Tamai Zone 1 - supermicrosurgery - vein repair - artery repair

Schlüsselwörter

Tamai Zone I - Supermikrochirurgie - Venenanastomose - Arterienanastomose

Introduction

Traumatic amputations of the fingers at various levels are common injuries which have severe consequences besides cosmetic problems, including loss of employment, work force, and function. With the development of microsurgery, replantation of severed limbs became possible, preservation of a certain level of baseline structural integrity [1]. However, with developing experience and advances in microsurgical techniques, supermicrosurgery emerged as a surgical modality that has made it possible to repair vessels smaller than 0.5 mm in diameter, thereby enabling replantation of exceedingly smaller amputated fragments in distal regions and under worse circumstances [2] [3] [4] [5] [6].

The most commonly used classification system for the evaluation of fingertip amputations was the Tamai classification. In this classification, fingertip amputations are divided into two regions; Zone I: Distal to lunula. Zone II: Distal interphalangeal (DIP) Joint to lunula [7].

In the past, there have been studies reporting the results of replantation of Tamai Zone 2 and more proximal finger amputations, but only a few studies have reported the results of replantation at more distal (Tamai Zone 1) regions [8] [9]. In distal-level injuries, the debate about utilizing replantation, local flaps, or other similar repair techniques that require less microsurgical experience is still ongoing [10] [11] [12] [13]. Although acceptable results can be obtained with local flaps and other methods despite technical difficulties and long surgical times, the gold standard is still the replantation of the segment, if it can be done at all [11].

In this report, we aimed to analyze the demographic, clinical characteristics and surgical results of patients who underwent replantation and revascularization for Tamai Zone 1 finger amputation in the same center and by the same surgeon.

Patients and Methods

Patients who underwent replantation due to complete Tamai Zone 1 amputation ([Fig. 1]) between December 2018 and June 2021 were included in this retrospective evaluation. Replantation was performed for 42 fingers in a total of 40 patients. All procedures were performed in the same center and by the same surgeon (C.P.). During this period, patients who applied with complete amputation were operated for replantation, regardless of the type of injury or other criteria, given that the amputated part was brought.

Inclusion criteria: All patients with Tamai Zone 1 fingertip amputation who underwent replantation between the specified dates were included.

Exclusion criteria: Patients who did not agree to sign written informed consent to participate were excluded.

All patients attended follow-up for a minimum of 6 months postoperatively. None of the patients were lost to follow-up. One patient was excluded because he did not provide consent to participate. Therefore, a final total of 39 patients with replantation were included in this report.

Demographic and clinical characteristics of the patients were examined ([Table 1]). In the postoperative follow-up, patients were evaluated with the Cold Intolerance Severity Score (CISS), 11-item Quick Disabilities on the Arm Shoulder and the Hand (QuickDash) qustionary and Static 2-Point Discrimination Test (2-PD). These tests were evaluated 6 months after each operation by another surgeon (U.M.) who worked at the same center but did not participate in the treatment.

Fig. 1 Replantation of a 35-year-old male’s long finger with a Tamai Zone 1 total amputation. a. Preoperative b. Postoperative c. Late postoperative the appearance of the nail d. Late postoperative appearance of the pulp.

Table 1 Demographic and Clinical Data of the Patients.

	Sex	Age	d/nd	Finger	MI	Vein Repair	Op. T. (‘)	IPD	Survival	FuT(m)	RtW(m)
1	m	31	d	Little	G		75	3	+	11	3
2	m	25	d	Thumb	C		82	4	–	10	7
3	m	45	d	Index	G		94	3	+	8	3
4	m	52	d	Ring	C		99	4	+	6	4
5	m	27	d	Ring	G		105	3	+	10	4
6	m	33	d	Index	C		132	5	–	12	4
7	m	42	d	Ring	G		79	3	+	11	8
8	m	35	d	Long	G		110	6	–	10	9
9	m	37	nd	Little	C		107	4	–	9	3
10	m	41	d	Long	C	+	147	6	–	11	7
11	m	39	d	Long	G		99	4	+	10	9
12	m	51	nd	Ring	C		93	3	+	9	3
13	m	36	nd	Ring	C		82	4	–	9	9
14	m	27	d	Ring	C		122	7	+	9	4
15	m	35	d	Little	G	+	183	9	+	10	3
16	m	44	d	Long	C		95	3	+	11	3
17	m	41	d	Index	G	+	157	4	+	13	10
18	f	41	d	Long	G		86	4	+	8	3
19	m	30	nd	Index	C		99	4	–	8	4
20	m	55	d	Little	C		76	5	+	9	3
21	m	43	d	Index	G		81	6	+	10	8
22	m	35	d	Long	G	+	166	5	+	11	7
23	m	37	d	Ring	C		81	4	–	10	3
24	m	32	nd	Little	C		93	3	–	9	3
25	f	21	d	Ring	C		97	4	–	9	8
26	m	31	d	Long	C		123	4	+	9	4
27	m	30	d	Long	G		90	4	+	8	4
28	m	47	d	Index	C		73	5	+	10	4
29	m	43	d	Little	G		77	5	+	10	8
30	m	33	d	Ring	C		82	3	–	7	3
31	m	40	d	Long	G	+	163	7	+	6	4
32	m	27	d	Index	C		85	4	+	7	3
33	m	33	d	Little	C		79	3	–	7	7
34	m	40	d	Long	C		94	5	+	6	3
35	m	37	d	Long	G	+	164	4	+	6	4
36	m	30	d	Ring	C		76	3	+	6	4
37	f	29	d	Little	G		89	4	+	7	4
38	m	22	d	Index	G		97	5	+	6	4
39	m	45	nd	Index	G		76	3	+	7	3

m: male f: female d: dominat hand nd: non-dominant hand MI: mechanism of injury G: Guillotine C: Crush; Op.T(‘).: Operation Time, minutes IPD: In-patient days FuT: Follow-up Time RtW: Return to Work m: months.

All patients were informed verbally and in written form, and signed informed consent forms before being included. Ethic approval was obtained from the institutional review board. All pre-specified steps of this research were conducted in accordance with the Declaration of Helsinki.

Operative Technique

Five operations were performed under local digital blockade and the remaining 34 operations were performed under general anesthesia. In 10 patients, fixation was carried out with k-wire. No additional intervention was made for osteosynthesis in 29 patients. All steps of the operation were performed under an operating microscope (M525 F50 Leica Microsystems, Wetzlar, Germany) with a magnification range of 4.5X-25X. Operations performed under digital block utilized a finger tourniquet, while surgeries under general anesthesia utilized tourniquet application at the arm level. Ten minutes before tourniquet use, 5000 IU heparin bolus IV was administered to patients. 10/0 or 11/0 nylon (Ethilon- Ethicon Somerville, New Jersey) sutures were used for vascular anastomoses. Single artery end-to-end anastomosis was performed in all patients. If there was a suitable vein, vein repair was performed, otherwise no intervention was performed. Nerve repair was not performed in any patient, and vein grafting was not used. For artery repair, 4 or 5 end-to-end sutures were placed.

After surgery finalization, short arm splint and bulky dressing were applied to all patients. The dressing was changed for circulatory evaluation six times a day during the first three postoperative days. For venous drainage, bleeding of the nail bed and heparin injection was applied to the replanted part.

For postoperative antibacterial prophylaxis, first generation cephalosporin (cefalexin, intravenous; IV) 1 gram was administered twice daily. Paracetamol 1 gram IV, diclofenac sodium 25 mg IV, and tramadol IV were administered as analgesics, in the listed order, when necessary. Additionally, dextran 500 mg/12 h infusion was administered for 3 days postoperatively. Acetylsalicylic acid was given 300 mg/day peroral and 0.4 ml of low molecular weight heparin was administered two times per day subcutaneously.

At the end of the 3rd postoperative day, the patients were evaluated for discharge. The viability of the replanted part was determined according to color change. If necessary, patients’ hospital stay was extended up to 7 days.

None of the patients were reoperated during hospitalization. Following discharge, patients were asked to continue acetylsalicylic acid (300 mg/day) peroral for 1 month. Discharged patients were scheduled for control visits every 3 days for the first 15 days. After 15 days, they were followed up for a minimum of 6 months with monthly controls.

Fig. 2 Replantation of a 52-year-old male’s ring finger with Tamai Zone 1 total amputation. a. Preoperative b. Postoperative d. Late postoperative.

Statistical Analysis

Statistical analysis was performed using the IBM SPSS for Windows version 22.0 software (IBM, Armonk, NY, USA). Descriptive data for quantitative variables were expressed as mean±standard deviation (when parametric assumptions were met) or median (25–75% quartile, IQR) values (for non-parametric data), and as number and frequency for categorical variables. In the statistical evaluation of the data, the independent samples t-test was used for determination of differences in quantitative variables meeting parametric assumptions, while the Mann-Whitney U test was used for non-parametric variables. Chi-square tests were used to compare categorical variable distributions. A p value of<0.05 was considered statistically significant.

Results

Demographic characteristics of the patients showed a homogeneous distribution. Overall, 92.3% (n=36) were males and 7.6% (n=3) were females. Median age of the patients was 36 (30–42) years, and 89.7% (n=35) of the injuries were caused by work accidents, while 10.2% (n=4) were caused by home accidents. In 15.3% (n=6) of the patients, there were additional accompanying injuries such as lacerations or tendon injury. With regard to injury types, 46.1% (n=18) were guillotine-type cuts and 53.8% (n=21) were crush-type injuries. 84.6% (n=33) of the injuries occurred in the dominant hand. Distribution of injuries according to fingers were as follows: the thumb (2.5%, n=1), index finger (23%, n=9), long (28.2%, n=11), ring (25.6%, n=10), little finger (20.5%, n=8).

Replantation survival was seen in 69.2% (n=27) of all fingers ([Fig. 2]), while necrosis was observed in 28.7% (n=12). When we examined the survival rate according to the injury mechanism, it was seen that guillotine injuries survived at a rate of 94.4% (n=17) and a rate of 47.6% (n=10) for crush injuries. When necrosis was observed, self-amputation of the pieces was expected and a watchful waiting approach was chosen for the follow-up of secondary healing, except for one patient who underwent re-surgery via the v-y flap technique. Vein repair was performed in 15.3% (n=6) of the patients. There was no significant relationship between vein repair and replant survival (p=0.348); however, the operation duration of patients who underwent vein repair was found to be significantly longer than those who had only underwent artery repair (p<0.001). The median operation duration was 94 (81–110) minutes. Reconstruction was performed with a v-y flap in only one patient. Cold intolerance was observed in one patient according to the CISS. The mean 2-PD value was 4.3 ± 0.56. Mean QuickDASH score was 10.07 ± 10.

There was no significant difference in 2-PD and QuickDASH scores between patients with successful replantation and those with secondary healing after necrosis (p>0.05). The median duration of hospitalization was 4 (3–5) days, overall follow-up period was 9 (7–10) months, and time until return to work was 4 (3–7) months. It was observed that the time to return to work was significantly longer in patients with necrosis who were followed-up with secondary healing (p<0.05).

No significant difference was observed when the success of the operation was compared according to age, smoking and the injured finger (p>0.05). When evaluated according to the mechanism of injury, it was observed that success was significantly more likely in patients who had suffered from guillotine-type injuries (p=0.019).

Discussion

In this report, it is seen that good results can be obtained with the replantation of Tamai Zone 1 fingertip amputations. Contrary to what is known, it was observed that the surgical time was not excessive, particularly in cases where the operation was completed with only arterial repair. It has been observed that patients with unsuccessful replantation at this level can be left for secondary healing and obtain acceptable results without a second surgical intervention. In terms of injury mechanism, success for guillotine-type injury was found to be significantly higher, similar to the findings of previous studies [2] [8] [14].

In the present report, a total of 12 patients experienced necrosis of the replant. One of these subjects underwent further treatment with a v-y flap, whereas the remaining 11 patients did not undergo amputation or flap re-surgery. In these patients, a close follow-up to observe the natural self-amputation of replants was carried out, and secondary healing was awaited. In the great majority of these patients, cosmetic outcomes were acceptable (exemplified by [Fig. 3]). There was no significant difference in 2-PD and QuickDASH scores between patients with successful replantation and those with secondary healing after necrosis. In a study evaluating treatment options in distal finger injuries, it was reported that conservative treatment options are always available rather than surgical treatment, and good results can be obtained by applying a semi-occlusive dressing (following the wound with a transparent adhesive dressing) [15]. To the best of our knowledge when considering replantation of total amputations, among other case series’ involving such patients [16] [17], this report is the first to perform close follow-up and investigate outcomes in patients who developed necrosis after Tamai Zone 1 replantation.

Fig. 3 Failure after replantation of a 19-year-old male’s index finger with Tamai Zone 1 total amputation. Pre-operative, post-operative, necrosis development, self-amputation, and secondary healing processes have been shown (a to i), respectively.

Although there was no significant difference between the patients with and without vein repair in terms of replant survival, patients who underwent vein repair in our report constituted a small proportion of all patients. While there are studies reporting that vein repair positively affects outcome, there are studies reporting that only artery repair is sufficient [6] [18] [19] [20]. This issue is still a matter of debate and we think that if the appropriate vein is found during the operation, it should be repaired.

Another debate is whether nerve repair is necessary. In our clinic, we do not routinely perform nerve repair in patients with Tamai Zone 1 amputation, which is a factor that shortens surgery duration. Therefore, none of the patients included had undergone nerve repair. There was no significant difference between the 2-PD results of the patients who were followed up for secondary recovery and those with successful replantation. Our data demonstrates that patients without nerve repair also have acceptable clinical outcomes. Furthermore, no previous studies have shown that 2-PD and cold intolerance outcomes are similar among patients with necrosis and those deemed to have successful replantation. This particular result of our study indicates that nerve repair may indeed be unnecessary in patients with Tamai Zone 1 replantation, thereby demonstrating that surgery duration can be shortened–possibly increasing the likelihood of replant survival. In previous studies, it was similarly reported that nerve repair did not have a positive effect on the results of fingertip replantation [21].

There are publications investigating whether replantation in distal digital amputations is worth the effort. Due to the good results that can be obtained with these procedures, it has been reported that fingertip replantation should be attempted if the surgical risks are minimal and if desired by the patient [10]. Various innervated perforator-free flaps, venous flaps, and arterial island flaps have been described as alternatives to replantation [12] [13] [20]. However, if we exclude local advancement flaps, these flap techniques are also relatively difficult techniques and it often operation times are not as short as suggested. In distal finger amputations there are not only operative, but also conservative options, in particular the semi-occlusive dressing treatment. In this report, we find that success can be achieved with a short surgical time, especially with artery repair, and it is acceptable to perform watchful waiting for secondary healing in case of unsuccessful replantation. For this reason, we think that if the amputated part is brought, replantation is a better option and surgeons with necessary equipment should not refrain from replantation due to outcome concerns. In cases where replantation is not possible or when perioperative findings strongly suggest poor outcome, good results can still be obtained by utilizing flap alternatives.

Nail-related problems are common occurrences in fingertip injuries. Previous studies have shown the presence of nail deformity in 23% and finger pulp atrophy in 14% of subjects with fingertip injury [16]. The mechanism of injury is crucial with regard to the development of nail deformity. Clean-cut (guillotine-type) injuries are rarely found to cause nail deformity [22] [23]. These studies suggest that vein repair is critical to prevent nail bed problems. Despite the fact that the number of patients who underwent vein repair in the present report is very low, we did not observe nail-related problems that necessitated re-surgery. The fact that patients who experienced self-amputation also did not have nail-related problems is another remarkable finding of this report. With regard to other research on this topic, it has been shown that local advancement flaps lead to hook-nail deformity in 29% to 35% of patients [24]. We did not observe any complications relating to the cosmetic or functional characteristics of patients who underwent replantation.

There is limited evidence regarding the necessity of bone fixation in such patients. Available studies on this topic suggest the application of k-wire for this purpose [1] [16] [25]. In a single randomized controlled trial focused on this topic, it was reported that bone fixation was not required [14]. Furthermore, the authors suggested that not using k-wire for this purpose contributed to increased venous drainage from the bone medulla. We performed bone fixation with k-wire in 10 patients, but bone fixation was not utilized in 29 patients. We think that bone fixation is not necessary during the operation unless deemed definitely necessary by the surgeon, as this procedure will unnecessarily prolong surgery duration.

It has been shown that fingertip replantation can be performed under a digital block [4]. Five of our cases were operated under digital block anesthesia. However, we have seen that patient compliance is low when performing such a delicate operation and the relatively long duration of the surgery makes it difficult for both patients and surgeons. In one patient, in whom we applied a finger tourniquet, venous stasis developed in the distal phalanx region. Despite the fact that circulation returned to normal without the need for additional intervention, it is evident that long-term finger tourniquet application may cause catastrophic results.

The main limitations of this research are that it was retrospective and the number of cases was not very high. On the other hand, the gender distribution and socioeconomic levels of the patients show an almost homogeneous distribution. In addition, we consider the fact that all operations were performed in the same hospital and by the same surgeon to be one of the strengths of the present research.

Conclusion

As a result, we think that replantation for Tamai Zone 1 fingertip amputation should be given priority with respect to the findings of our report. Additionally, artery-only repairs appear to be sufficient, and this approach can shorten surgical time. Furthermore, rather than planning re-surgery in patients with unsuccessful replantation, it appears that watchful waiting for self-amputation and secondary healing leads to acceptable results. If replantation is not possible, many flap options are available and can achieve good results. We believe that future studies with larger case series will provide clarity on the utility of this approach.

Autorinnen/Autoren

Assitant Prof. Dr. Çağdaş PAMUK
He completed his medical education at Akdeniz University and completed his Orthopedics and Traumatology Specialization training at Kocaeli University. Since 2017, he has been closely interested in trauma surgery and continues his studies. In the hospital where he still works, he performs 200–250 hand and microsurgery operations per year in a region with a population of 4 million, which is the reference hand and microsurgery hospital of the region. At the same time, he continues his academic studies as a faculty member in the physical therapy and rehabilitation department of Rumeli University.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 16 April 2022

Accepted: 23 June 2022

Article published online:
30 August 2022