| | Distal phalanx replantation using the delayed venous method: A high success rate in 21 cases without specialised technique☆☆☆Received 7 October 2006; accepted 11 February 2007. published online 06 April 2007. Summary BackgroundThe purpose of the study was to show that the delayed venous method provides a high success rate in distal phalanx replantation, and does not require the use of specialised techniques. Vein anastomosis is the most important factor determining the ‘take rate’ in treatment of distal phalanx amputation. However, blood flow in the distal phalanx subdermal vein is lost immediately after an accident, making it difficult to find the collapsed vein and to perform vein anastomosis in the initial surgery. Therefore, we have chosen to perform a two-stage surgical procedure, and we have obtained excellent results with this method. MethodsThe two-stage delayed venous method for vein anastomosis was first reported in 2005. This surgical procedure includes initial arterial anastomosis, delayed expansion of the vein, and subsequent vein anastomosis in a second surgery. ResultsThe delayed venous method was used in 21 cases. Expansion of veins of up to 1 mm or more resulted in a high success rate (85.7%) in procedures performed by a junior microsurgeon. In contrast, the success rate for distal phalanx replantation is extremely low in other techniques because of difficulty with vein anastomosis. ConclusionsThe delayed venous method allows relatively easy anastomosis of the subdermal vein of the distal phalanx. Furthermore, the procedure was performed by a junior microsurgeon with less than 2 years experience, showing that the method does not require special training. Therefore, it is a useful operative technique for treatment of amputated fingers by a non-specialised plastic surgeon. The success rate in distal phalanx replantation is very low1, 2, 3, 4; in finger tip replantation cases the most important factor in determining the take rate is vein anastomosis, but the finger tip subdermal vein collapses immediately after occurrence of a wound, making it very difficult to find the vein. Furthermore, the vessel wall is thin and weak, creating difficulties for vein anastomosis. In contrast, artery anastomosis can be performed more easily in such cases, and therefore we have adopted a technique, the so-called delayed venous method, in which artery anastomosis is performed in the initial surgery and the search for and anastomosis of the vein is delayed until a second-stage operation. We have obtained excellent results with this technique, and here we provide details of several cases. Tamai first succeeded with replantation following thumb amputation in 1965, and subsequently the success rate of replantation has improved rapidly. This has been due to improvements in operative microscopes and other surgical instruments, as well as advances in methodology. Consequently, cases of finger tip replantation have increased, but it remains difficult to obtain good results due to technical problems with vein anastomosis. The delayed venous method was described by Koshima et al. in 2005,1 and this new concept has improved the success rate in finger tip replantation. The purpose of treatment of finger amputation is to maintain finger length, retain the nail, maintain a sense of perception and feel, and minimise pain. In addition, it is necessary to select a method of treatment that takes into account the general conditions, age, sex, and body complications of the patient. We have examined the delayed venous method in comparison to similar operative techniques, and here we report our results for this method as performed by a junior microsurgeon with less than 2 years experience of microsurgery. Patients and methods  Between April 2005 and March 2006, 21 distal phalanges of completely amputated fingers in 21 patients (20 males and one female) were replanted under digital-block anaesthesia, using the delayed venous method. The patients ranged in age from 18 to 84 years old. Replantation succeeded for 18 fingers but failed for three, giving a success rate of 85.7%. All treated fingers were successfully drained by additional single, double or triple venous drainage with a vein graft. Surgery in all cases was performed using local anaesthesia of the digital block. Avascularisation with a Neraton tube is first performed in the finger proximal to the phalanx, and the surgical procedure is begun from the dissection of the artery. Because spontaneous recovery can be expected in zone 1, the digital nerve need not be forcibly sutured. For nerve suture for restitution of perception, one or more sutures are prepared in zone 2. Finding the collapsed vein is often difficult, and in most cases only the central hypodermic vein can be found, after which it is marked by 10/0 nylon. After bone fixation, anastomosis of the artery is started; since arterial walls are thicker than those of veins, performance of artery anastomosis is not too difficult at the zone 1 level, because the artery may still be very thick, not collapsed. 12/0 or 11/0 nylon is used for this purpose, and nerve suture is performed continuously during the process. Finally, the tourniquet is released and an attempt is made to observe venous return. However, in most cases a vein for possible anastomosis is not found, and this point is considered to be the end of the first surgery. Postoperatively, the finger tip usually becomes congested with blood after 8–12h, and a second surgery is then performed. Under these conditions, the diameter of the subdermal vein is enhanced by up to 1mm or more, making it much easier to locate the vein. Vein anastomosis is performed by finding the central vein marked in the primary surgery using 11/0 or 10/0 nylon. A venous graft is required if even a small amount of tension is introduced by anastomosis. Furthermore, the success rate increases if anastomoses of two or three veins can be performed. Results Successful finger replantation was achieved in 18 of 21 cases, giving an overall success rate of 85.7%. The success rates were 80% and 100% for zone 1 and zone 2 wounds, respectively. All the successful cases did not show congestion after the second surgery, and did not require venesection, milking, or application of a medical leech. None of the 21 cases required blood transfusion. One vein anastomosis was performed in 11 cases, anastomoses of two veins were performed in nine cases, and three vein anastomoses were performed in one case. The three cases that did not have a successful outcome all entered a state of ischaemia after surgery, and all resulted in sphacelation. Three case examples are given in the following paragraphs. Case 1 Images for case 1 are shown in Figure 1, Figure 2, Figure 3, Figure 4. The patient was a 48-year-old man who sustained complete amputation of the distal phalanx of the left ring finger. Under digital block anaesthesia, two arterial anastomoses were performed in the first operation. Postoperative venous congestion of the replanted finger occurred 12h after the primary replantation. Two additional venous drainage sites were created with vein grafts from the same donor site, under digital block anaesthesia. Postoperatively, congestion of the finger decreased and replantation was completely successful without additional treatment. Case 2 Images for case 2 are shown in Figure 5, Figure 6, Figure 7. The patient was a 51-year-old man who sustained complete amputation of the distal phalanx of the left middle finger. Under digital block anaesthesia, one arterial anastomosis and one venous anastomosis were conducted in the first operation. Postoperative venous congestion of the replanted finger occurred 22h after the primary replantation. Three additional venous drainage sites were created with vein grafts, under digital block anaesthesia. Postoperatively, congestion of the finger decreased and replantation was completely successful without additional treatment. Case 3 Images for case 3 are shown in Figure 8, Figure 9. The patient was an 18-year-old man who sustained complete amputation of the distal phalanx of the left middle finger. Under digital block anaesthesia, one arterial anastomosis was performed in the first operation. Postoperative venous congestion of the replanted finger occurred 6h after the primary replantation. One venous drainage site was created with vein grafts, under digital block anaesthesia. Postoperatively, congestion of the finger decreased and replantation was completely successful without additional treatment. Discussion The number of cases of treatment of amputated fingers has decreased in Japan because of a decrease in workers’ accident compensation for this procedure, and finger tip amputation now accounts for 60% of treated cases. In cases of zone 1 and zone 2 amputation, artery anastomosis can be performed by an experienced microsurgeon, but vein anastomosis in such cases is very difficult, especially for zone 1 cases. The most common cause of failure of finger tip replantation is vein congestion, and several different techniques for venous drainage have been described.10, 11, 12, 13 External bleeding through a fish mouth incision or removal of the nail bed,5, 6 application of medical leeches,5, 6, 7, 8 and administration of heparinised saline9 are all common approaches. The stress on the patient due to venesection is large in finger tip replantation, and blood transfusion is often required; it has been reported that blood transfusion was needed in 88% of cases. However, our feeling is that finger tip amputation should be viewed as a minor injury, and that blood transfusion in treatment of such cases should be considered as a contraindication. In this context, we believe that the delayed venous method is very effective for avoiding blood transfusion. Moreover, this method does not require advanced microsurgery techniques. This is perhaps surprising, since the subdermal vein wall in the finger tip is very thin and weak, suggesting that advanced microsurgery technology might be necessary for successful vein anastomosis. However, expansion of the hypodermic vein is forced by intentionally congesting the finger tip region, and this enhances the diameter of the hypodermic vein by up to about 1mm prior to the second surgery. Under such conditions, anastomosis can be performed easily, and two or more vein anastomoses may be possible; however, we should emphasise the necessity of a venous graft in this procedure. There are some disadvantages of the delayed venous anastomosis method. Primarily, two operative procedures are needed, if the vein anastomosis cannot be performed in the primary surgery, and this takes additional time. Moreover, this method does not work well when arterial blood flow is not established after the primary surgery. Operative stress on the patient may also be a problem given that two surgeries are required; however, this may be minimised through use of digital block anaesthesia in both procedures. In conclusion, operative outcomes in fracture-finger replantation have improved rapidly through advances in technology and surgical instruments in recent years, but the results for finger tip replantation are still unsatisfactory. The delayed venous method offers a new approach to this therapy, and here we have shown that good results can be obtained with this method. This may lead to finger tip amputation being viewed as a relatively minor injury, for which blood transfusion is contraindicated during treatment; furthermore, it should ultimately be possible for the surgical procedure to be performed routinely and for aesthetic reasons, particularly for children and young women. The key to the success of the procedure is vein anastomosis, and our experience suggests that this can be achieved by a junior microsurgeon using the delayed venous method. References 1. 1Koshima I. Successful delayed venous drainage in 16 consecutive distal phalangeal replantations. Plast Reconstr Surg. 2005;115:149–154. 2. 2Yamano Y. Replantation of the amputated distal part of the fingers. J Hand Surg (Am). 1985;10:211–218. MEDLINE 3. 3Suzuki K, Matsuda M. Digital replantations distal to the distal interphalangeal joint. J Reconstr Micorsurg. 1987;3:291–295. 4. 4Tsai T-M, McCabe SJ, Maki Y. A technique for replantation of the finger tip. Micorsurgery. 1989;10:1–4. 5. 5Pederson WC. Replantation. Plast Reconstr Surg. 2001;107:823–841. MEDLINE |
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6. 6Gordon L, Leitner DW, Bunke HJ, et al. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J Hand Surg (Am). 1985;10:360–364. MEDLINE 7. 7Batchelor AG, Davison P, Sully L. The salvage of congested skin flaps by the application of leeches. Br J Plast Surg. 1984;37:358–360. Abstract |
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9. 9Kim W-K, Lim J-H, Han S-K. Fingertip replantations: Clinical evaluation of 135 digits. Plast Reconstr Surg. 1996;98:470–476. MEDLINE |
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10. 10Koshima I, Soeda S, Moriguchi T, et al. The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers. Plast Reconstr Surg. 1992;89:710. MEDLINE |
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12. 12Fukui A, Maeda M, Inada Y, et al. Arteriovenous shunt in digit replantation. J Hand Surg (Am). 1990;15:160. MEDLINE |
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13. 13Suzuki Y, Ishikawa K, Isshiki N, et al. Fingertip replantation with an efferent A-V anastomosis for venous drainage: clinical reports. Br J Plast Surg. 1993;46:187–191. MEDLINE Department of Plastic and Reconstructive, Aesthetic Surgery, University of Tokyo, Tokyo, Japan  Corresponding author. Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Tel.: +81 03 3815 5411; fax: +81 03 5800 6929.
☆ This research was presented at the 2006 Japanese Society of Plastic Surgery meeting Tokyo, Japan, 1 July 2006. ☆☆ The authors have no financial or other commercial interest in the work described in the manuscript. PII: S1748-6815(07)00124-6 doi:10.1016/j.bjps.2007.02.004 © 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved. | |
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