Abstract
Background The clinical results of replantation for an amputated distal finger are functionally acceptable. However, few reports exist regarding sequential clinical postoperative recovery. The purpose of this study was to examine the clinical recovery at every 3 months up to 1 year postoperatively.
Methods Nineteen patients (16 patients were men), representing 19 fingers with complete amputation at Tamai's zone 1 and replanted successfully, were included in this study. Total active motion (TAM), grip strength (GS), Semmes–Weinstein monofilament (SW) test result, static two-point discrimination (s2PD), and Disability of the Arm, Shoulder, and Hand (DASH) score questionnaire results were obtained postoperatively at 3, 6, 9, and 12 months. Pulp atrophy and nail deformity were assessed at 12 months postoperatively.
Results The postoperative %TAM (compared to the uninjured side, 81.8 ± 18.1 at 3 months vs. 91.5 ± 11.9 at 6 months, p < 0.01), %GS (compared with the uninjured side, 61.3 ± 25.9 at 3 months vs. 78.3 ± 20.4 at 6 months, p = 0.02), s2PD (excellent and good/poor; 7/12 at 3 months vs. 18/1 at 6 months, p < 0.01), and DASH scores (26.1 ± 23.1 at 3 months vs. 12.0 ± 12.9 at 6 months, p < 0.01) recovered significantly from 3 to 6 months but did not change significantly from 6 months onward. The SW test results showed a significant recovery between 3 and 12 months postoperatively (2.83 and 3.61/4.31, 6.65, and undetectable, 1/18 at 3 months vs. 7/12 at 12 months, p = 0.04). The DASH score at 12 months postoperatively was significantly associated with %TAM ( r = −0.64, p < 0.01) and %GS ( r = −0.58, p < 0.01) at 12 months postoperatively and age ( r = 0.52, p = 0.02). Five fingers had pulp atrophy and four fingers had nail deformity.
Conclusion This 1-year follow-up study showed the sequential clinical recovery after replantation for complete amputation in Tamai zone 1. Postoperative %TAM, %GS, and the DASH score recovered significantly between 3 and 6 months but significant recovery up to 1 year was not observed.
Keywords: finger amputation, replantation, zone 1, clinical recovery
Introduction
In 1965, Komatsu and Tamai reported the first successful digital replantation. 1 Since then, the development of instruments and established knowledge have widened the indications for replantation up to distal finger amputation, although high microsurgical techniques are required. Replantation has the advantage of reconstructing the lost segment with the original tissue and preserving the nail, length of the finger, and good soft tissue coverage with adequate sensibility without the expense of donor site morbidity. 2 The outcome of replantation for an amputation proximal to the insertion of the flexor digitorum superficialis is not good; however, distal finger replantation has a good recovery that is better than that of amputation closure with regard to pain, functional outcome, and patient satisfaction. 2 3 4 5 6 Some postoperative follow-up studies over 1 year have been reported; recently, one study with a 10-year follow-up after distal finger replantation described functional and cosmetic outcomes at the last follow-up. 2 3 7 8 9 10 11 12 13 However, few reports exist regarding sequential clinical postoperative recovery after replantation for complete amputation of a finger. The purpose of this study was to investigate the sequential functional outcomes and subjective postoperative outcomes in patients treated with replantation for a complete amputation in Tamai zone 1 (that is, an amputation distal to the nail base). 5
Materials and Methods
Patients
Between 2015 and 2019, we attempted replantation for all patients with finger amputation when the patient wanted to undergo the procedure and the overall condition of the patient permitted. Twenty-eight consecutive patients, representing 30 fingers, with complete amputation in Tamai's zone 1 of the index, middle, ring, and little fingers were replanted by a single surgeon (K.Y.). Among these, patients who replanted successfully, older than 18 years in age, followed-up postoperatively at every 3 months up to 1 year, had an amputation of a single finger, and had undergone no additional surgical procedures were included. Patients who had an incomplete amputation, multiple amputations, not followed-up postoperatively for up to 1 year, and whose native language was not Japanese were excluded. The etiology of injury was categorized according to the classification by Yamano. 14
Surgical Procedure
Replantation was performed under regional anesthesia or general anesthesia. First, the amputated part was examined under an operating microscope. After minimal debridement without shortening the bone, the terminal branch of the digital artery, the central one of distal transverse palmar arch in most patients was identified and marked using 10–0 nylon. Second, an artery in the proximal side stump was identified. When the terminal branch of the digital artery was not feasible for replantation, the dissection was performed up to the distal transverse palmar arch and the artery was tagged with 10–0 nylon or a temporary vascular clip. One Kirschner's wire was inserted into the distal phalanx longitudinally to achieve bony stability. In the cases with a proximal fracture or comminuted fracture of the distal phalanx, the distal phalanx and distal interphalangeal joint (DIP) were fixed with wire. In other cases, only the distal phalanx was fixed with wire.
One artery was anastomosed using 10–0 or 11–0 nylon in an end-to-end fashion after confirming the normal intima. When a gap existed between the distal and proximal terminal branches of the digital artery, a vein graft was harvested from the volar wrist. If the proximal terminal branch of the digital artery was damaged, then one side of the distal transverse palmar arch with a smaller caliber was ligated and transposed distally and anastomosed to the distal artery. The vein and nerve were not repaired. A fish-mouth incision at the pulp was formed to control bleeding and thereby manage venous congestion. After skin closure and applying a wound dressing, a long arm splint was applied to immobilize and elevate the affected extremity.
Postoperative Therapy
From 7 to 10 days postoperatively, 120 U of prostaglandin E1, 12,000 U of urokinase, and 5,000 to 18,000 U of heparin were intravenously administered daily. The dose of heparin was adjusted based on the activated partial thromboplastin time and the bleeding condition of the fish-mouth incision.
Heparin-soaked gauze was applied on the fish-mouth incision. External bleeding was continued for 7 to 10 days. When congestion of the finger occurred, a medical leech was used.
The splint was removed at 1 week postoperatively. At this point, occupational therapy was started. A return to work was allowed when the injured finger was protected until bony union. After bony union was confirmed with plain radiography, the wire was removed and free usage of finger was allowed.
Postoperative Evaluation
Patients were evaluated postoperatively at 3, 6, 9, and 12 months. The active range of motion of finger was measured by using a standard goniometer. Total active motion (TAM) was compared with that of the uninjured side (%TAM). Grip strength (GS) was measured with a digital dynamometer (MG 4800; Charder Medical, Taichung City, Taiwan) and compared with the GS of the uninjured side (%GS).
Sensory recovery was assessed using the Semmes–Weinstein monofilament (SW) test and static two-point discrimination (s2PD). The threshold of the SW test was interpreted as follows: green (2.83) indicated “normal”; blue (3.61), “reduced tactile sensation”; purple (4.31), “reduced protective sensation”; and red (6.65), “residual sensation.” 15 The result of s2PD was defined, as follows: “excellent,” 2 to 6 mm; “good,” 7 to 15 mm; and “poor,” greater than 16 mm. 16
The subjective outcome was obtained by using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Pulp atrophy was assessed with gross inspection, compared with the uninjured side. Nail deformity was also assessed using the classification by Hasuo et al. 7 Bone union was examined by using plain radiography at 12 months postoperatively. The return-to-work status and postoperative complications were also investigated.
Statistical Analysis
For fracture of the distal phalanx, the fractured part was assessed by three equally classified parts: distal, middle, and proximal. To analyze the results of the SW test, we combined the 2.83 and 3.61 groups and 4.31, 6.65, and undetectable groups. To analyze the results of the s2PD, we combined the excellent and good groups. For numerical variables, the data are shown as the average and standard deviation. The Mann–Whitney U -test was used for analysis between the two groups. The Bonferroni test was used for the analysis of the results between the postoperative periods. The relationships between numerical variables were evaluated using Pearson's correlation coefficients. The Chi-square test or Fisher's exact test was used for categorical variables. The McNemar test was used for assessing the SW test and s2PD between two postoperative periods. Significance was set at p -value less than 0.05.
All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan) which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). It is, more precisely, a modified version of R Commander which is designed to add statistical functions frequently used in biostatistics. 17
This prospective observational cohort study was approved by the Institutional Review Board. All patients provided written informed consent for publication.
Results
Patients with successful replantation included 22 fingers (survival rate, 73%); three patients were excluded (two with a follow-up of < 1 year and one whose native language was not Japanese). The remaining 19 patients (16 men and 3 women), representing 19 fingers, were included in this study. The injured side was the right in 8 fingers and the left in the rest of the 11 fingers. The numbers of the involved index, middle, ring, and little fingers were eight, five, five, and one, respectively. All patients were right-hand dominant. The average age at surgery was 41.5 ± 14.4 (range: 18–68) years. The mechanism of injury was avulsion in 15 fingers and crush injury in four fingers, according to the classification by Yamano. 14 Eighteen patients sustained the injury during their work. The fractured part of the distal phalanx was distal in 11, middle in 5, proximal in 2, and none in 1. The distal phalanx and DIP joints were fixed in 6, while only the distal phalanx was fixed in 13. The average duration of pin fixation was 72.3 ± 17.2 (range: 35–98) days.
The postoperative results of the %TAM were 81.8 ± 18.1 at 3 months, 91.5 ± 11.9 at 6 months, 93.0 ± 13.4 at 9 months, and 90.6 ± 13.4 at 12 months ( Fig. 1 ). A significant difference existed postoperatively between 3 and 6, 3 and 9, and 3 and 12 months ( p < 0.01, < 0.01, and 0.04, respectively). Furthermore, the relationship between %TAM at 12 months postoperatively and DIP fixation with wire was assessed. There was no significant difference between %TAM at 12 months postoperatively and distal phalanx fixation with or without DIP fixation (with DIP fixation, 90.6 ± 13.4 and without DIP fixation, 90.5 ± 14.7; p = 0.90).
Fig. 1.
Sequential change in the total active motion of the injured finger, compared with uninjured side. Values are presented as the average ± the standard deviation. An asterisk indicates a significant difference between two postoperative periods ( p < 0.05). M, months postoperatively.
The postoperative results of the %GS were 61.3 ± 25.9 at 3 months, 78.3 ± 20.4 at 6 months, 84.7 ± 20.0 at 9 months, and 89.8 ± 19.7 at 12 months ( Fig. 2 ). A significant difference existed postoperatively between 3 and 6, 3 and 9, and 3 and 12 months ( p = 0.02, < 0.01, and < 0.01, respectively).
Fig. 2.
Sequential change in the grip strength of the injured finger, compared with the uninjured side. Values are presented as the average ± the standard deviation. An asterisk indicates a significant difference between two postoperative periods ( p < 0.05). M, months postoperatively.
The results of the SW test are shown in Fig. 3 . A significant difference existed postoperatively between 3 and 12 months ( p = 0.04). Seventeen (89.5%) of 19 patients had better than purple results (i.e., diminished protective sensation).
Fig. 3.
The sequential change in the results of the Semmes–Weinstein monofilament test. An asterisk indicates a significant difference between two postoperative periods ( p < 0.05). M, months postoperatively.
The results of the s2PD test are shown in Fig. 4 . A significant difference existed postoperatively between 3 and 6, 3 and 9, and 3 and 12 months ( p < 0.01, < 0.01, and 0.04, respectively).
Fig. 4.
The sequential change in the results of the static two-point discrimination test. An asterisk indicates a significant difference between two postoperative periods ( p < 0.05). E, excellent; G, good; M, months postoperatively; P, poor.
The results of the disability/symptom component of DASH score postoperatively were 26.1 ± 23.1 at 3 months, 12.0 ± 12.9 at 6 months, 13.1 ± 14.9 at 9 months, and 16.1 ± 15.6 at 12 months ( Fig. 5 ). A significant difference existed postoperatively between 3 and 6, 3 and 9, and 3 and 12 months ( p < 0.01, < 0.01, and 0.02, respectively).
Fig. 5.
The sequential change in the Disability of the Arm, Shoulder, and Hand score (disability/symptom). The values are presented as the average ± the standard deviation. An asterisk indicates a significant difference between two postoperative periods ( p < 0.05). M, months postoperatively.
Significant correlations were observed between the DASH score at 12 months and the %GS at 12 months ( r = −0.58, p < 0.01), the DASH score at 12 months and the %TAM at 12 months ( r = −0.64, p < 0.01), and the DASH score at 12 months and age ( r = 0.52, p = 0.02). No significant difference existed postoperatively at 12 months between the DASH score and the SW test or between the DASH score and s2PD.
Pulp atrophy occurred in five (26.3%) fingers. Nail deformity occurred in four (21.1%) fingers. All fingers were classified as having a slight deformity. No significant differences existed between the DASH score at 12 months and pulp atrophy or nail deformity. Pulp atrophy was significantly associated with s2PD (that is, the number of good and excellent s2PD/pulp atrophy + , 3/5 fingers versus s2PD/pulp atrophy–, 12/14 fingers; p = 0.02). Plain radiography showed bony union of the distal phalanx in all patients.
Medical leeches were used for 14 (73.6%) fingers to manage postoperative congestion. No significant differences existed between the use of medical leeches and pulp atrophy or between the use of medical leeches and nail deformity.
Regarding the etiology of avulsion and crush injury, the %TAM (92.9 ± 12.2 vs. 81.9 ± 16.1), %GS (89.3 ± 19.9 vs. 91.6 ± 22.0), SW test (2.83 and 3.61/4.31, 6.65, and undetectable, 5/10 vs. 2/2), s2PD test (excellent and good/poor, 11/4 in vs. 4/0), and DASH score (16.1 ± 15.7 vs. 16.2 ± 17.7) at 12 months postoperatively were evaluated. Pulp atrophy (4/15 vs. 1/4) and nail deformity (3/15 vs. 1/4) occurring in avulsion and crush injuries were noted. Medial leeches were used in 13 of 15 patients with avulsion and in 1 of 4 patients with the crush injury.
Sixteen (84.2%) patients returned to their previous work, on average, at 90 ± 57.3 days postoperatively. The DASH score (for work) at 1 year postoperatively in these patients was 20.3 ± 25.6.
In the postoperative period, no patient required a blood transfusion. Two patients had stenosing tenosynovitis of the finger (the injured finger in one patient and the finger next to the injured finger in one patient). One patient had an ipsilateral stiff shoulder. These effects were resolved in all three patients with conservative treatments.
Discussion
This study showed that the postoperative %TAM, %GS, s2PD, and DASH scores recovered significantly from 3 to 6 months, and that these outcomes did not change significantly from 6 to 12 months. Sensory recovery, as assessed with the SW test, showed a slow recovery and significant difference between 3 and 12 months postoperatively. The subjective outcome (that is, the DASH score at 12 months postoperatively) was significantly associated with the %TAM at 12 months and the %GS at 12 months postoperatively. These results suggest the importance of obtaining a good %TAM and %GS at 6 months postoperatively to achieve a good DASH score at 12 months postoperatively.
A systematic review of the replantation of distal digital amputation (that is, zones 1 and 2) reported good functional outcomes as follows: the sensory recovery, based on 2PD, was on average 7 mm; the prevalence of pulp atrophy was on average 14%; the prevalence of nail deformity was 24%; and 97% of patients returned to work. 18 The outcomes of replantation of the digital amputation in zone 1 in previous reports are listed in Table 1 . The postoperative periods for the assessment of outcomes varied.
Table 1. Functional results of replantation in zone 1 in previous reports.
| Ref. | No. of fingers (cases) | Age (y) | FU (mo) | GS (%) | TAM (%) | s2PD (mm) | m2PD (mm) | SW (prop < p , %) |
|---|---|---|---|---|---|---|---|---|
| 12 | 16 (16) | 26 (1–41) | 12 (6–18) | NA | NA | 6.1 (2–8) | NA | NA |
| 2 | 23 (23) | 38 (16–62) | 53 (24–96) | 83 (50–100) |
NA | NA | NA | G2/B19/P1/R1 (95.7) |
| 8 | 12 (12) | 36 (19–56) | 15 | NA | 92 (79–100) | 5.9 (3–11) d | B4/P8 (100) | |
| 7 a | 10 | 36 (18–57) | 25 (6–62) | NA | NA | 7.4 (8–15) | NA | G2/B5/P2/R1 (90) |
| 9 | 91 (87) | 35 (14–54) | 12 | NA | NA | < 6: 85 fingers d | <5.07: 87 fingers (95.6) | |
| 13 | 38 (31) | 24 (6–40) | 16 (6–48) | NA | NA | 7.2 (3–11) | 4.6 (3–6) | G11/B23/P3/R1 (97.4) |
| 11 b | 10 (10) | 6 (4–10) | 26 (8–36) | NA | NA | 4.5 (3.2–5.0) | NA | NA |
| 10 | 13 (12) | 32 (23–48) | 16 (12–) | NA | NA | 7.5 (3–11) | NA | G4/B7/P1/R1 (92.3) |
| 3 c | 12 (11) | 50 (18–66) | 195 (120–246) | 96 (80–100) | NA | NA | 4.5 (2–7) | B8/P2/R2 (83.3) |
Abbreviations: B, blue; FU, follow-up period, average (range); G, green; GS, grip strength; M, month; m2PD, moving two-point discrimination, average (range); NA, not applicable; No., number; P, purple; prop < p , proportion better than purple; R, red; Ref., reference; s2PD, static two-point discrimination, average (range); SW, Semmes–Weinstein monofilament test; TAM, total active motion.
Note: The data are presented as average (range) except number of fingers, number of cases, and SW test.
One incomplete amputation was included.
Fingers with available data were extracted.
Fingers with zone-1 amputation were extracted.
s2PD or m2PD was not described.
There were the results of %TAM at an average of 15 months postoperatively 8 and %GS at an average of 53 months, 2 and 15 years and 15 months 3 postoperatively reported in one and two reports, respectively. The findings of the former study 8 were similar to ours and the findings of the latter study 2 3 indicated that a better GS may be obtained with a longer follow-up. Good range of motion of the finger and grip strength could be obtained in patients with replantation in zone 1, even during a short follow-up.
In Tamai zone-1 replantation, the distal phalanx was fixed with one or two longitudinal wires, and tendon repair was not necessary because the amputation level was distal to the tendon attachment. We assessed the relationship between %TAM and the fixation method with or without DIP joint fixation, but no significant difference was observed in the fixation method of the distal phalanx. Therefore, we believe that it is important to obtain good finger motion for preventing tendon adhesion and joint contracture. The main result of our study was that the %TAM recovery was observed up to 6 months postoperatively and was different from the clinical recovery of the volar plate fixation of the distal radius fracture in which continued improvement up to 12 months postoperatively was observed. 19 People related to the replantation treatment, including surgeons, therapists, and patients, should know the pattern of the clinical recovery. Additionally, finger motion exercise, with edema and aggressive pain control, is essential for obtaining good finger motion up to 6 months postoperatively.
With regard to sensory recovery, nerve injury was treated with various treatments: nerve repair in one study, 9 nerve repair when possible in two studies, 10 11 no treatment was described in one study, 20 and the nerve was not repaired in five studies, 2 3 8 12 13 and also in our report. The results of the SW test recovered over diminished protective sensation (that is, better than purple) in 17 (89.5%) of 19 patients in our study. The SW test was assessed in seven reports, 2 3 8 9 10 13 20 and the proportion of better than purple results was generally larger in these reports than in ours. The results of the SW test in our study may not have reached a plateau during the short follow-up of 1 year; therefore, more recovery may be expected with a longer follow-up period.
In our study, sensory assessment using s2PD at 12 months postoperatively was on average 6.9 mm (range: 2–15 mm; it was undetectable in four fingers). This result for detectable s2PD was also similar to that of previous reports. 8 9 10 11 12 13 20
Our study showed that pulp atrophy was significantly associated with a poor result on the s2PD, as reported previously. 12 Pulp atrophy may be associated with the crush type of injury and postoperative vascular status; therefore, the sensory receptor of Meissner's corpuscle which corresponds to the quickly adapting fiber system might be damaged. 21 22 However, Ozcelik et al showed images of the recovery of pulp atrophy in one patient from 6 to 40 months postoperatively. 13 Hayashi et al suggested that fingertip atrophy improves over time. 3 Based on these results and opinions, sensory recovery could be expected in a longer follow-up period.
Nishi et al 23 and Hasuo et al 7 reported nail regeneration in digit replantation after amputation in zones 1 and 2. They reported that nail regeneration was determined by the level of amputation, extent of damage to the sterile and germinal matrix, and postoperative circulatory conditions. Nine of 27 zone-1 patients in the report by Nishi et al and 13 of 21 zone-1 patients in the report by Hasuo et al had a nail deformity. In our study, no significant difference existed between nail deformity and the use of medical leeches, although we used medical leeches for postoperative congestion. Medical leeches may control congestion well and lead to a reduced frequency of nail deformity.
Limitations
This study had several limitations. We showed an association between the factors and outcomes, but we could not assess these confounders by using multivariate analysis because the number of patients was small. Pinch activity of the radial fingers is important for daily living; however, we could not gather and analyze pinch strength because some patients complained of pain in the short follow-up period. In the future, we would like to analyze the clinical outcomes with a longer follow-up period and to compare these outcomes with those of this 1-year follow-up study.
Conclusion
In conclusion, this 1-year follow-up study of replantation for complete amputation at Tamai zone 1 revealed that the total active motion, grip strength, s2PD, and DASH score improved significantly from 3 to 6 months postoperatively and did not show a significant change from 6 months postoperatively. However, the SW test results showed a significant recovery between 3 and 12 months postoperatively. We propose that, to obtain a good subjective outcome, obtaining finger motion and grip strength at 6 months postoperatively is important.
Footnotes
Conflict of Interest None declared.
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