Wednesday, October 29, 2003 - 8:15 AM

Reassessing the Indications for Digit Replantation: A Meta-Analysis of Functional Outcomes

Michael Bolton, MD, Anureet K Bajaj, MD, Allen Gabriel, MD, and Subhas Gupta, MD, CM, PhD.

Introduction: The purpose of this study was to evaluate published reports from the last 12 years regarding functional outcomes of replanted digits to assess the appropriateness of the currently accepted indications for digit replantation.

Methods: We performed an extensive Medline search for the period from 1990 to 2002 inclusive combining keywords characterizing digital replantation and functional outcome. All clinical studies concerning digital replantation and outcome were considered, including series and single case reports. The period of publication was limited to studies published from 1990 to 2002 in order to avoid redundancy with older studies republished in new and larger series. All total or subtotal amputations with inadequate circulation distal to the metacarpal head were considered and grouped according to locations salient to outcome: (1) thumb, (2) distal to PIP, and (3) "other". The pool of patients was evaluated for age, sex, and level of replant. Injuries were classified as involving either single or multiple digits at either a single or multiple level zone of injury. Type of injury was classified as avulsion, crush, or guillotine. Major risk factor categories included smoking status and prolonged ischemia and patient-specific co-morbidities. Significant surgical procedures contributing to outcome were analyzed, including number of artery and vein anastamoses, composite skin grafting, and tendon repair. Major functional outcomes analyzed included sensation, grip strength, and Chen Score, patient satisfaction with function and patient satisfaction with appearance. Significant complications associated with replantation were studied, including degenerative joint disease, cold intolerance, and arterial thrombosis.

Results: Overall and subset viable replantation and functional status data were calculated. Type of injury was the most important factor influencing immediate and late outcome, with guillotine producing the best outcome, and avulsion producing the worst. Regular cigarette smoking resulted in poor immediate survival rate, and prolonged ischemia time had a significant influence in final functional outcome. Studies advocating and performing single digit (non-thumb) replantation were additionally considered as a segregate data set. Average Chen grade scores were calculated for all the evaluated patients.

Conclusion: Only when performed for the correct indications, replantation of digits produces acceptable functional outcomes. Current indications may require certain modifications.