Digit replantation results in better outcomes vs revision amputation

BOSTON — Among patients who sustained a traumatic digit amputation, investigators found less pain, better appearance, easier performance of activities of daily living and improved satisfaction for patients who underwent digit replantation compared with patients who underwent revision amputation.

Perspective from R. Glenn Gaston, MD

Kevin C. Chung, MD, MS, presented results of the study at the American Society for Surgery of the Hand Annual Meeting.

Using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction and Effectiveness collaboration, he and his colleagues collected patient demographics, functional outcomes, Michigan Hand Questionnaire-SF36 and the NIH Patient-reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores among 323 patients with finger amputations. Of this group, 170 patients were treated with replantation and 153 were treated with revision amputation.

“We found that single amputation distal to [the] interphalangeal joint gives the patient better outcomes,” Chung said in his presentation here. “This is something technically difficult, but we all know that [distal interphalangeal] DIP joint replantation is analogous to a DIP fusion and the results of that are better in terms of PROMIS, DASH and [proximal interphalangeal] PIP motion.”

However, Chung added there was no difference in outcomes between replantation and amputation for a single-digit proximal PIP joint. For the thumb, he noted no differences in outcomes between the two groups for proximal IP joints. When the IP joint is distal to the thumb, Chung said there were no differences in outcomes except for the metacarpophalangeal joint, which had better results.

“That is surprising given that no one in this room would not try to replant a thumb,” Chung said. “However, we were unable to show that in this particular study and that is probably the impetus for a prospective study.”

Patients with either two-digit amputation or two finger and thumb amputation had no differences in patient-reported outcomes whether they underwent replantation or revision amputation, according to Chung. Patients who underwent replantation of three fingers or more had better outcomes compared with patients who underwent revision amputation, he noted. – by Casey Tingle

Reference:

Chung KC, et al. Paper 66. Presented at: American Society for Surgery of the Hand Annual Meeting; Sept. 13-15, 2018; Boston.

Disclosures: This research was supported by the Plastic Surgery Foundation. Chung reports no relevant financial disclosures.

Perspective

R. Glenn Gaston, MD

This well-designed multicenter study compares the functional and psychological benefits of replantation vs revision amputation for digital loss and demonstrates that the Michigan Hand Questionnaire-SF36 is a useful metric for evaluating this patient population. The title of the study is somewhat misleading when one considers the results. Surprisingly, the results of replantation were only superior to revision amputation in two clinical scenarios: for amputations distal to the PIP for single digits and for amputation of three or more fingers. More surprising was the finding that replantation was not superior to revision amputation in terms of PROMIS scores when performed for the thumb or in the scenario of a two-digit amputation with or without thumb involvement.

Selection bias is of concern considering factors such as injury severity, crushing or avulsion mechanisms, smoking status and significant medical comorbidities will contribute to a higher rate of revision amputation. Anticipated outcomes of a clean, lacerated amputation that undergoes replantation are quite different than a crush-avulsion revision amputation and could in fact further skew the results.

This study is timely as there has been considerable discussion as to the role of regional replant centers especially given the national trend of decreased replantation, and a better understanding of ideal replant candidates is critical. The FRANCHISE group is applauded for its pursuit of NIH funding to support further research into this clinical topic.

R. Glenn Gaston, MD

Chief of hand surgery

Atrium Health

Charlotte, North Carolina

Disclosures: Gaston reports no relevant financial disclosures.