Abstract
Background
Finger replantation is a complex microsurgical procedure that requires optimal conditions for success. Understanding the knowledge and awareness of healthcare professionals regarding finger preservation and replantation can help improve outcomes for patients with amputated fingers.
Methods
A cross-sectional survey was conducted among healthcare professionals, including clinical years medical students, surgical residents, and specialists. The survey assessed participants’ knowledge of factors influencing the finger replantation success, the appropriate management of amputated fingers before surgery, the ideal time for replantation, and key considerations for finger preservation.
Results
Among 197 participants, 81.2% correctly identified finger replantation as a surgical procedure to reattach a severed finger. However, 9.6% incorrectly believed it was a technique to preserve the finger for later reattachment. The most frequently reported barriers to performing finger replantation included lack of training or expertise (78.2%), limited access to specialized surgical instruments (66.5%), and financial constraints (61.9%). Significant differences were found across professional groups regarding perceived barriers, particularly in terms of training, access to surgical instruments, and infrastructure.
Conclusion
While general knowledge of finger replantation is high, key misconceptions and barriers; like limited training, resources, and funding, persist. Improving education, infrastructure, and specialized programs is vital to expanding access and enhance outcomes.
Keywords: Finger replantation, microsurgery, surgical education, barriers to surgery, healthcare resources, resource-limited regions, lower-middle-income country
PLAIN LANGUAGE SUMMARY
What is this article about?
This article looks at what doctors and medical students in Jordan know and think about finger replantation. This is a surgery that tries to put back a finger after it has been cut off. The study asked about their knowledge, opinions, and the problems they face when doing or considering this surgery.
What were the results?
The study included 197 people: consultants, residents, and medical students. They came from different fields like orthopedic, general, emergency, and plastic surgery. Many of them said that finger replantation is hard to do because doctors do not get enough training, hospitals may not have the right tools, and sometimes patients are not treated quickly. Different groups had different views on when this surgery should be done and who should get it.
What do the results mean?
The results show that training, tools, and clear rules are missing, and this makes it hard to do finger replantation. To improve care, hospitals and schools can:
Give doctors more training and practice.
Provide the right surgical tools.
Create clear steps and rules for when and how to do the surgery.
By fixing these problems, patients who lose a finger may have a better chance to get it reattached and live a better life.
ARTICLE HIGHLIGHTS
Finger replantation is a complex procedure with significant functional and psychosocial benefits, yet it remains underutilized in resource-limited settings.
This study explored barriers to finger replantation in Jordan through a cross-sectional survey of healthcare providers.
Key barriers identified included limited availability of microsurgical expertise, insufficient equipment, and lack of standardized protocols.
Differences in perceived barriers were noted across professional groups, with residents and specialists highlighting distinct challenges.
Findings underscore the importance of targeted training, institutional capacity building, and development of national guidelines.
Policymakers and hospital administrators can use these insights to enhance surgical services and improve patient access to replantation.
1. Introduction
Finger replantation, the surgical reattachment of a severed finger, is a highly specialized procedure that aims to restore both function and appearance in patients with traumatic finger amputations [1]. When performed timely and appropriately, it can significantly improve functional outcomes, prevent disability, and enhance quality of life [2,3]. The success of finger replantation depends on timely referral, appropriate surgical technique, and post-operative care [3].
Globally, the success rates of finger replantation have improved due to advancements in microsurgical techniques, better understanding of the physiological processes involved, and the availability of improved tools and technologies [4,5]. However, there remains a significant variability in the rates of replantation across different regions and healthcare systems. In developing countries or regions with limited resources, delayed referrals, lack of specialized expertise, and inadequate training among healthcare professionals often hinder the success of these procedures [6].
In Jordan, despite the growing number of cases involving traumatic amputations, there is limited research focusing on the knowledge, attitudes, and practices of healthcare professionals regarding finger replantation. Understanding the knowledge and perceptions of medical professionals—including surgeons, emergency physicians, trauma specialists, and medical students—about finger replantation can highlight potential gaps in training, clinical practice, and overall healthcare delivery. Additionally, evaluating the barriers to successful replantation, such as delays in referral, limited resources, and lack of confidence among healthcare providers, is essential for improving patient outcomes [7,8]. Similar challenges have been reported in other low- and middle-income countries (LMICs), where limited training, resource constraints, and delayed referrals have affected replantation rates and outcomes [7,9,10], emphasizing the broader relevance of assessing healthcare professional knowledge and practices in resource-constrained settings.
This study aims to descriptively assess the knowledge, attitudes, practices, and perceived barriers related to finger replantation among doctors and medical students in Jordan, and to comparatively examine differences across professional groups. By understanding these factors, we hope to identify areas of improvement in training, policy, and practice to enhance the management of amputated fingers in Jordanian hospitals and medical centers.
2. Methods
2.1. Study design
This study employed a cross-sectional survey design to assess the knowledge, attitudes, practices, and perceived barriers related to finger replantation among doctors and medical students in Jordan.
2.2. Study population and sampling
The study targeted healthcare professionals and clinical trainees across Jordan involved in surgical or emergency care. The population was explicitly defined to include consultants in surgical specialties (general surgery, orthopedic surgery, emergency, and plastic surgery), surgical residents (general surgery and emergency medicine), and medical students in their clinical years (years 4–6). These groups were selected because they represent the core providers and future practitioners responsible for the management of traumatic hand injuries and potential candidates for finger replantation procedures.
A sample size of 200 participants was determined based on feasibility and prior similar survey-based studies, aiming to provide adequate representation across various specialties and training levels while allowing for subgroup analysis.
A convenience sampling technique was employed due to the exploratory nature of the study and the difficulty in obtaining a comprehensive national registry of eligible participants. Recruitment was carried out electronically. The survey was distributed via official institutional mailing lists, professional associations, including the Jordanian Medical Council, specialty-specific and institutional WhatsApp groups targeting consultants, residents, and clinical-year medical students.
All participants were invited to complete the online survey voluntarily, and informed consent was implied through survey submission. Efforts were made to ensure geographical and institutional diversity among respondents to improve the generalizability of the findings across different healthcare settings in Jordan.
2.3. Questionnaire construction and validation
A structured questionnaire was created to assess knowledge of finger replantation procedures, attitudes toward performing the procedure, current practices, and barriers to its implementation. The questionnaire was developed after a thorough literature review and consultation with experts. It consists of four main sections: knowledge of the procedure, attitudes toward it, current practices, and barriers. The questionnaire was reviewed by a panel of trauma and hand surgery experts to ensure content validity. Face validity was assessed by piloting the questionnaire with a small group, and internal consistency reliability was evaluated using Cronbach’s alpha. A coefficient of 0.70 or higher was considered acceptable.
The final version of the questionnaire was administered electronically via an online survey platform. An invitation outlining the study objectives, the voluntary nature of participation, and assurances of confidentiality was sent to potential participants through email and professional networks. Completion of the survey implied informed consent.
2.4. Statistical analysis
Data were analyzed using R statistical package version 4.2.1. Descriptive statistics (means, standard deviations, frequencies, and percentages) was used to summarize demographic characteristics and questionnaire responses. Inferential analyses—including chi-square tests for categorical variables, independent t-tests for comparing the study groups, and one-way ANOVA for comparisons among more than two groups—to assess the relationships between demographic factors and the study outcomes. A significance level of p < 0.05 will be used for all statistical tests.
2.5. Ethical considerations
The study protocol has been reviewed and approved by the appropriate Institutional Review Board in Jordan. Participation is entirely voluntary, and all collected data will be anonymized to protect respondent confidentiality.
3. Results
3.1. Demographic characteristics
A total of 197 respondents completed the survey out of 200 (response rate = 98.5%). The mean age of participants was 30.9 years (SD = 9.5), with ages ranging from 21.0 to 74.0 years. Gender distribution was skewed toward males, with 74.2% were male respondents.
Regarding professional status, half of the respondents were specialists or consultants (n = 99; 50.3%), 31.0% were medical students (n = 61), and the remaining 18.8% (n = 37) were surgical or emergency residents. Among the consultants and specialists surveyed, orthopedic surgeons constituted the largest group (n = 40; 40.4%), followed by general surgeons (n = 35; 35.4%), emergency medicine specialists (n = 16; 16.1%), and plastic surgeons (n = 8; 8.1%).
In terms of experience (or years of study for medical students), the distribution was as follows: 1–5 years of experience/study was reported by 72 respondents (36.5%), 6–10 years by 54 (27.4%), 11–15 years by 17 (8.6%), and more than 15 years by 26 (13.2%). In addition, a small proportion of respondents were in the 4th (n = 3; 1.5%) and 6th (n = 25; 12.7%) years of study, which applied to those still in medical school.
When asked about the type of hospital in which they usually practice, most respondents worked in public hospitals (n = 98; 49.7%), followed by those practicing in university hospitals (n = 53; 26.9%) and private hospitals (n = 43; 21.8%). A minimal number (n = 3; 1.5%) reported working in other settings.
Knowledge regarding finger replantation was also assessed. The majority of respondents (n = 160; 81.2%) correctly identified finger replantation as “a surgical procedure to reattach a severed finger.” In contrast, 19 participants (9.6%) believed that it was “a technique to preserve the finger for later reattachment,” 15 (7.6%) indicated that they did not know what finger replantation entailed, and only 3 (1.5%) thought it involved only the reattachment of bones (Table 1).
Table 1.
Demographic characteristics.
| Overall (N = 197) | |
|---|---|
| Age | |
| Mean (SD) | 30.9 (9.5) |
| Range | 21.0–74.0 |
| Gender | |
| Female | 50 (25.8%) |
| Male | 144 (74.2%) |
| Professional status | |
| Medical student | 61 (31.0%) |
| Specialist/consultant (general surgery, orthopedics, plastic, or emergency) | 99 (50.3%) |
| Surgical or ER resident | 37 (18.8%) |
| Specialist/consultants – specialty | |
| Orthopedics | 40 (40.4%) |
| General | 35 (35.4%) |
| Emergency | 16 (16.1%) |
| Plastic | 8 (8.1%) |
| Years of experience/study (if medical student) | |
| 4th | 3 (1.5%) |
| 6th | 25 (12.7%) |
| 1 to 5 years | 72 (36.5%) |
| 6 to 10 years | 54 (27.4%) |
| 11 to 15 years | 17 (8.6%) |
| More than 15 | 26 (13.2%) |
| In which type of hospitals do you usually practice | |
| Other | 3 (1.5%) |
| Private hospital | 43 (21.8%) |
| Public hospital | 98 (49.7%) |
| University hospital | 53 (26.9%) |
| What is finger replantation? | |
| A process involving only the reattachment of bones | 3 (1.5%) |
| A surgical procedure to reattach a severed finger | 160 (81.2%) |
| A technique to preserve the finger for later reattachment | 19 (9.6%) |
| I don’t know | 15 (7.6%) |
| ER: Emergency, N: Number, SD: Standard Deviation. | |
3.2. Knowledge about finger replantation and preservation
The success of finger replantation is influenced by several critical factors. A majority of respondents (88.32%) identified the time to reattachment as a key factor, followed by proper surgical technique (84.77%). Preservation of the amputated part was also considered highly important (79.70%), with 67.51% noting the availability of advanced surgical tools and 58.88% emphasizing the presence of a microsurgeon. Additionally, the age of the patient was considered an important factor by 59.39% (Figure 1).
Figure 1.
Important factors for finger replantation success: time to reattachment (88.32%), proper surgical technique (84.77%), preservation of the amputated part (79.70%), availability of advanced surgical tools (67.51%), presence of a microsurgeon (58.88%), and patient age (59.39%).
Regarding key steps in the management of an amputated finger before replantation, the majority of respondents highlighted the importance of cleansing the wound area (74.62%) and cooling the amputated finger (63.96%), such as by placing it on ice. Keeping the amputated finger in a moist environment (63.45%) and directly applying a tourniquet to prevent bleeding (29.44%) were also cited, while a smaller percentage (6.60%) were uncertain about these procedures (Figure 2).
Figure 2.
Management of amputated finger steps: cleansing the wound area (74.62%), cooling the amputated finger (63.96%), keeping the finger moist (63.45%), applying a tourniquet if needed (29.44%), and uncertain responses (6.60%).
The ideal time window for performing finger replantation following an amputation varied among respondents. A majority (37.56%) believed that replantation should occur within 4 to 6 hours, while 22.84% favored a window of 1 to 3 hours. Additionally, 20.30% of respondents were uncertain, and 16.75% indicated that replantation could occur within less than 1 hour. Only 2.54% thought that replantation should be performed more than 6 hours after amputation (Figure 3).
Figure 3.
Ideal time for finger replantation procedure: within 4–6 hours (37.56%), 1–3 hours (22.84%), less than 1 hour (16.75%), uncertain (20.30%), and more than 6 hours (2.54%).
For preserving the amputated finger, the most common considerations included using a sterile container for transport (58.38%), cooling (65.48%), and immediate transportation to a medical facility (76.65%). Avoiding contamination (76.65%) and proper handling and saving of the amputated part (77.66%) were similarly prioritized. However, 6.09% of respondents were unsure about these preservation measures (Figure 4).
Figure 4.
Amputated finger preservation consideration: immediate transport to a medical facility (76.65%), proper handling/saving of the part (77.66%), avoiding contamination (76.65%), cooling (65.48%), use of a sterile container (58.38%), and unsure responses (6.09%).
3.3. Attitudes toward finger replantation
The attitudes toward finger replantation were generally positive among the surveyed participants (N = 197). A large majority (51%) strongly agreed that finger replantation should be attempted whenever possible, with an additional 31% agreeing. Only a small proportion (5.1%) disagreed. Regarding confidence in performing or assisting with finger replantation procedures, 28% agreed, while 12% strongly agreed. However, 17% strongly disagreed, and 17% disagreed, across different professional level 18.1% of medical students, 43.2% of residents, and 52.6% of consultants or specialists reported being confident. This highlights a notable gap in self-confidence across training levels, with students reporting the lowest confidence and consultants the highest. The majority (46%) strongly agreed and 39% agreed that finger replantation is critical for improving patient outcomes in traumatic amputations, with a small number (3.6%) disagreeing. When asked if finger replantation should be more emphasized in medical education and training, 43% strongly agreed, and 40% agreed, with only a small percentage (1%) disagreeing. Similarly, 48% agreed and 25% strongly agreed that the benefits of finger replantation outweigh the risks involved, while 1.5% disagreed and 0.5% strongly disagreed (Table 2).
Table 2.
Attitudes toward finger replantation.
| N (%) | |
|---|---|
| I believe that finger replantation should be attempted whenever possible. | |
| Agree | 62 (31%) |
| Disagree | 10 (5.1%) |
| Neutral | 23 (12%) |
| Strongly agree | 100 (51%) |
| Strongly disagree | 2 (1.0%) |
| I am confident in my ability to perform or assist with finger replantation procedures. | |
| Agree | 56 (28%) |
| Disagree | 33 (17%) |
| Neutral | 51 (26%) |
| Strongly agree | 23 (12%) |
| Strongly disagree | 34 (17%) |
| Finger replantation is a critical procedure for improving patient outcomes in traumatic amputations. | |
| Agree | 76 (39%) |
| Disagree | 7 (3.6%) |
| Neutral | 22 (11%) |
| Strongly agree | 90 (46%) |
| Strongly disagree | 2 (1.0%) |
| I think finger replantation should be more emphasized in medical education and training. | |
| Agree | 79 (40%) |
| Disagree | 2 (1.0%) |
| Neutral | 30 (15%) |
| Strongly disagree | 2 (1.0%) |
| Strongly agree | 84 (43%) |
| I believe that the benefits of finger replantation outweigh the risks involved. | |
| Agree | 94 (48%) |
| Disagree | 3 (1.5%) |
| Neutral | 49 (25%) |
| Strongly agree | 50 (25%) |
| Strongly disagree | 1 (0.5%) |
3.4. Practices regarding finger replantation
When asked about involvement in finger replantation procedures, 31.5% of participants had been involved in such procedures, with 68.5% indicating no involvement. Of those who had participated, 38.7% had been involved 1–2 times, 22.6% 3–5 times, and 16.1% 6–10 times. A smaller proportion (21%) had been involved more than 10 times. The majority of respondents (74.1%) encountered cases of traumatic finger amputations primarily in the emergency department, while 10.6% encountered them in surgical wards, 12.7% in trauma centers, and only 2.6% in outpatient clinics. When asked how often finger replantation was attempted, 38.6% reported never encountering such a situation, while 26.9% encountered it rarely, 23.9% occasionally, and 10.7% frequently. Of those involved in replantation, 56.9% had not experienced a successful replantation, 21.3% reported partial reattachment with some loss of function, 15.2% experienced successful reattachment with functional recovery, and 6.6% reported failed replantation (Table 3).
Table 3.
Practices regarding finger replantation.
| N (%) | |
|---|---|
| Have you ever been involved in a finger replantation procedure? | |
| No | 135 (68.5%) |
| Yes | 62 (31.5%) |
| If yes, how many times have you been involved in performing or assisting with finger replantation? | |
| 1–2 times | 24 (38.7%) |
| 3–5 times | 14 (22.6%) |
| 6–10 times | 10 (16.1%) |
| More than 10 times | 13 (21.0%) |
| More than 10 times | 1 (1.6%) |
| Where do you primarily encounter cases of traumatic finger amputations in your practice? | |
| N-Miss | 8 |
| Emergency department | 140 (74.1%) |
| Outpatient clinics | 5 (2.6%) |
| Surgical wards | 20 (10.6%) |
| Trauma center | 24 (12.7%) |
| How often do you encounter a situation where finger replantation is attempted? | |
| Frequently (several times a year) | 21 (10.7%) |
| Never | 76 (38.6%) |
| Occasionally (once or twice a year) | 47 (23.9%) |
| Rarely (less than once a year) | 53 (26.9%) |
| If you have been involved in finger replantation, what was the typical outcome of the procedure? | |
| Failed replantation (no reattachment or non-functional) | 13 (6.6%) |
| I have never been involved in a replantation | 112 (56.9%) |
| Partial reattachment with some loss of function | 42 (21.3%) |
| Successful reattachment with functional recovery | 30 (15.2%) |
3.5. Barriers to successful finger replantation
Several barriers to successful finger replantation were identified by participants. A significant number (78.2%) reported a lack of training or expertise in replantation techniques as a barrier, and 66.5% indicated limited access to specialized surgical instruments, such as microsurgical tools. Delays in patient arrival to the hospital or trauma center were cited by 62.9% as a barrier, while 43.1% noted insufficient hospital infrastructure as a challenge. The lack of a specialized surgical team, including microsurgeons, was identified by 72.6% of participants as a major barrier. Financial constraints or lack of resources for performing advanced surgeries were mentioned by 61.9% of respondents, while 61.4% pointed to lack of patient cooperation or late presentation of amputations. Cultural or societal factors, such as stigma associated with reattachment procedures, were cited by 29.9% of respondents, and 32.5% acknowledged seeing significant barriers to performing finger replantation. Despite these challenges, 67.5% of participants did not identify any significant barriers to performing the procedure (Table 4).
Table 4.
Barriers to successful finger replantation.
| N (%) | |
|---|---|
| Lack of training or expertise in replantation techniques. | |
| No | 11 (5.6%) |
| Not sure | 32 (16.2%) |
| Yes | 154 (78.2%) |
| Limited access to specialized surgical instruments (e.g., microsurgical tools). | |
| No | 21 (10.7%) |
| Not sure | 45 (22.8%) |
| Yes | 131 (66.5%) |
| Delay in the patient arrival to the hospital or trauma center. | |
| No | 45 (22.8%) |
| Not sure | 28 (14.2%) |
| Yes | 124 (62.9%) |
| Insufficient hospital infrastructure (e.g., surgical rooms, recovery facilities). | |
| No | 75 (38.1%) |
| Not sure | 37 (18.8%) |
| Yes | 85 (43.1%) |
| Lack of a specialized surgical team (e.g., microsurgeons, experienced staff). | |
| No | 19 (9.6%) |
| Not sure | 35 (17.8%) |
| Yes | 143 (72.6%) |
| Financial constraints or lack of resources for performing advanced surgeries. | |
| No | 39 (19.8%) |
| Not sure | 36 (18.3%) |
| Yes | 122 (61.9%) |
| Lack of patient cooperation or late presentation of amputations (beyond the ideal reattachment time). | |
| No | 45 (22.8%) |
| Not sure | 31 (15.7%) |
| Yes | 121 (61.4%) |
| Cultural or societal factors (e.g., stigma associated with reattachment procedures). | |
| No | 95 (48.2%) |
| Not sure | 43 (21.8%) |
| Yes | 59 (29.9%) |
| I do not see any significant barriers in performing finger replantation. | |
| No | 133 (67.5%) |
| Yes | 64 (32.5%) |
3.6. Comparison analysis between different professions
A comparison was made between three groups: medical students (N = 61), specialists/consultants (N = 99), and surgical/ER residents (N = 37). The analysis focused on several factors deemed important for the success of finger replantation.
Time to reattachment was deemed critical by 83.6% of medical students, 89.9% of specialists/consultants, and 91.9% of residents (p = 0.4). Proper surgical technique was also deemed crucial by 80.3% of medical students, 88.9% of specialists/consultants, and 81.1% of residents (p = 0.3). A significant difference was observed in patient age perception across professions, with 69.7% of specialists/consultants and 51.4% of residents agreeing (p = 0.01). The preservation of the amputated part was also deemed important by 68.9% of medical students, 84.8% of specialists/consultants, and 83.8% of residents (p = 0.04). A strong association was found between the presence of a microsurgeon and successful replantation, with 70.7% of specialists/consultants and 70.3% of residents stating this factor is crucial (<0.001) with the largest effect size observed (Cramer’s V = 0.36, 95% CI [0.23, 0.48])). The availability of advanced surgical tools was also deemed important by 50.8% of medical students, 74.7% of specialists/consultants, and 75.7% of residents. A significant difference was observed between the groups, with specialists/consultants and residents more likely to emphasize the importance of these tools compared to medical students (p = 0.004) (Table 5).
Table 5.
Factors are important for the success of finger replantation among different specialists.
| Medical student (N = 61) | Specialist/consultant (general surgery, orthopedics, plastic, emergency) (N = 99) | Surgical or ER resident (N = 37) | Total (N = 197) | P value* | Effect size** [95% CI] | |
|---|---|---|---|---|---|---|
| Time to reattachment | 0.37 | |||||
| No | 10.0 (16.4%) | 10.0 (10.1%) | 3.0 (8.1%) | 23.0 (11.7%) | ||
| Yes | 51.0 (83.6%) | 89.0 (89.9%) | 34.0 (91.9%) | 174.0 (88.3%) | ||
| Proper surgical technique | 0.27 | |||||
| No | 12.0 (19.7%) | 11.0 (11.1%) | 7.0 (18.9%) | 30.0 (15.2%) | ||
| Yes | 49.0 (80.3%) | 88.0 (88.9%) | 30.0 (81.1%) | 167.0 (84.8%) | ||
| Age of the patient | 0.01 | 0.21 [0.08, 0.35]. | ||||
| No | 32.0 (52.5%) | 30.0 (30.3%) | 18.0 (48.6%) | 80.0 (40.6%) | ||
| Yes | 29.0 (47.5%) | 69.0 (69.7%) | 19.0 (51.4%) | 117.0 (59.4%) | ||
| Preservation of the amputated part (e.g., temperature, condition) | 0.04 | 0.18 [0.05, 0.32]. | ||||
| No | 19.0 (31.1%) | 15.0 (15.2%) | 6.0 (16.2%) | 40.0 (20.3%) | ||
| Yes | 42.0 (68.9%) | 84.0 (84.8%) | 31.0 (83.8%) | 157.0 (79.7%) | ||
| Presence of a microsurgeon | < 0.001 | 0.36 [0.23, 0.48]. | ||||
| No | 41.0 (67.2%) | 29.0 (29.3%) | 11.0 (29.7%) | 81.0 (41.1%) | ||
| Yes | 20.0 (32.8%) | 70.0 (70.7%) | 26.0 (70.3%) | 116.0 (58.9%) | ||
| Availability of advanced surgical tools (e.g., microsurgical instruments) | 0.004 | 0.24 [0.11, 0.37] | ||||
| No | 30.0 (49.2%) | 25.0 (25.3%) | 9.0 (24.3%) | 64.0 (32.5%) | ||
| Yes | 31.0 (50.8%) | 74.0 (74.7%) | 28.0 (75.7%) | 133.0 (67.5%) |
P value calculated using Chi-square test.
Effect size calculated using Cramér’s V.
The analysis of barriers to successful finger replantation revealed several significant differences between the three professional groups. A majority of specialists/consultants (78.8%) and residents (83.8%) identified a lack of training or expertise in replantation techniques as a barrier, compared to 73.8% of medical students. There was a significant difference between groups in this regard (p = 0.0231). Similarly, specialists/consultants (72.7%) and residents (70.3%) were more likely to report limited access to specialized surgical instruments as a barrier compared to medical students (54.1%), with statistical significance (p = 0.0061). While delays in patient arrival were recognized by the majority of participants across all groups, no significant difference was found (p = 0.3941). Insufficient hospital infrastructure was another key barrier, with a higher proportion of medical students (49.2%) and specialists/consultants (45.5%) emphasizing this issue compared to residents (37.8%), and a significant difference was observed (p = 0.0121). The lack of a specialized surgical team was notably highlighted by specialists/consultants (80.8%) and residents (73.0%), compared to medical students (59.0%) (p = 0.0171). Financial constraints also emerged as a major concern, particularly among specialists/consultants (64.6%) and medical students (59.0%), with significant differences between groups (p < 0.001), with the largest effect size observed (Cramér’s V=0.24, 95% CI [0.11, 0.37]). Cultural or societal factors were identified as a barrier by a greater proportion of specialists/consultants (58.6%) and medical students (39.3%), compared to residents (24.3%) (p = 0.0181). Lastly, specialists/consultants (70.7%) and residents (78.4%) were more likely to report that no significant barriers existed, whereas 44.3% of medical students expressed the same sentiment (p = 0.0431). These findings underscore the diverse perceptions of barriers across different professional groups, highlighting areas where targeted interventions could improve outcomes in finger replantation procedures (Table 6).
Table 6.
Barriers to successful finger replantation between the three professional groups.
| Medical student (N = 61) | Specialist/consultant (general surgery, orthopedics, plastic, other) (N = 99) | Surgical or ER resident (N = 37) | Total (N = 197) | p value* | Effect size**
[95% CI] |
|
|---|---|---|---|---|---|---|
| 1. Lack of training or expertise in replantation techniques. | 0.02 | 0.17 [0.03, 0.31]. | ||||
| No | 0.0 (0.0%) | 9.0 (9.1%) | 2.0 (5.4%) | 11.0 (5.6%) | ||
| Not sure | 16.0 (26.2%) | 12.0 (12.1%) | 4.0 (10.8%) | 32.0 (16.2%) | ||
| Yes | 45.0 (73.8%) | 78.0 (78.8%) | 31.0 (83.8%) | 154.0 (78.2%) | ||
| Limited access to specialized surgical instruments (e.g., microsurgical tools). | 0.006 | 0.19 [0.06, 0.33]. | ||||
| No | 4.0 (6.6%) | 13.0 (13.1%) | 4.0 (10.8%) | 21.0 (10.7%) | ||
| Not sure | 24.0 (39.3%) | 14.0 (14.1%) | 7.0 (18.9%) | 45.0 (22.8%) | ||
| Yes | 33.0 (54.1%) | 72.0 (72.7%) | 26.0 (70.3%) | 131.0 (66.5%) | ||
| Delay in the patients arrival to the hospital or trauma center. | 0.39 | |||||
| No | 10.0 (16.4%) | 27.0 (27.3%) | 8.0 (21.6%) | 45.0 (22.8%) | ||
| Not sure | 12.0 (19.7%) | 12.0 (12.1%) | 4.0 (10.8%) | 28.0 (14.2%) | ||
| Yes | 39.0 (63.9%) | 60.0 (60.6%) | 25.0 (67.6%) | 124.0 (62.9%) | ||
| Insufficient hospital infrastructure (e.g., surgical rooms, recovery facilities). | 0.012 | 0.18 [0.05, 0.32]. | ||||
| No | 13.0 (21.3%) | 45.0 (45.5%) | 17.0 (45.9%) | 75.0 (38.1%) | ||
| Not sure | 18.0 (29.5%) | 13.0 (13.1%) | 6.0 (16.2%) | 37.0 (18.8%) | ||
| Yes | 30.0 (49.2%) | 41.0 (41.4%) | 14.0 (37.8%) | 85.0 (43.1%) | ||
| Lack of a specialized surgical team (e.g., microsurgeons, experienced staff). | 0.017 | 0.17 [0.04, 0.31]. | ||||
| No | 6.0 (9.8%) | 9.0 (9.1%) | 4.0 (10.8%) | 19.0 (9.6%) | ||
| Not sure | 19.0 (31.1%) | 10.0 (10.1%) | 6.0 (16.2%) | 35.0 (17.8%) | ||
| Yes | 36.0 (59.0%) | 80.0 (80.8%) | 27.0 (73.0%) | 143.0 (72.6%) | ||
| Financial constraints or lack of resources for performing advanced surgeries. | <0.001 | 0.24 [0.11, 0.37]. | ||||
| No | 5.0 (8.2%) | 28.0 (28.3%) | 6.0 (16.2%) | 39.0 (19.8%) | ||
| Not sure | 20.0 (32.8%) | 7.0 (7.1%) | 9.0 (24.3%) | 36.0 (18.3%) | ||
| Yes | 36.0 (59.0%) | 64.0 (64.6%) | 22.0 (59.5%) | 122.0 (61.9%) | ||
| Lack of patient cooperation or late presentation of amputations (beyond the ideal reattachment time). | 0.19 | |||||
| No | 8.0 (13.1%) | 28.0 (28.3%) | 9.0 (24.3%) | 45.0 (22.8%) | ||
| Not sure | 13.0 (21.3%) | 12.0 (12.1%) | 6.0 (16.2%) | 31.0 (15.7%) | ||
| Yes | 40.0 (65.6%) | 59.0 (59.6%) | 22.0 (59.5%) | 121.0 (61.4%) | ||
| Cultural or societal factors (e.g., stigma associated with reattachment procedures). | 0.02 | 0.17 [0.04, 0.31]. | ||||
| No | 21.0 (34.4%) | 58.0 (58.6%) | 16.0 (43.2%) | 95.0 (48.2%) | ||
| Not sure | 16.0 (26.2%) | 15.0 (15.2%) | 12.0 (32.4%) | 43.0 (21.8%) | ||
| Yes | 24.0 (39.3%) | 26.0 (26.3%) | 9.0 (24.3%) | 59.0 (29.9%) | ||
| I do not see any significant barriers in performing finger replantation. | 0.04 | 0.18 [0.04, 0.31]. | ||||
| No | 34.0 (55.7%) | 70.0 (70.7%) | 29.0 (78.4%) | 133.0 (67.5%) | ||
| Yes | 27.0 (44.3%) | 29.0 (29.3%) | 8.0 (21.6%) | 64.0 (32.5%) |
P value calculated using Chi-square test.
Effect size calculated using Cramér’s V.
4. Discussion
This study aimed to assess the knowledge, attitudes, practices, and perceived barriers related to finger replantation among Jordanian medical students, specialists/consultants, and surgical/ER residents. The findings on knowledge regarding finger replantation reveal a generally high level of awareness among respondents, with 81.2% correctly identifying it as a surgical procedure to reattach a severed finger. This suggests that the majority have a fundamental understanding of the procedure, which is crucial for timely and appropriate management of such cases. Similar to Vietnam, where advances in hand surgery coexist with gaps in nationwide coordination and challenges in building unified professional societies [11], our setting also faces obstacles in establishing standardized protocols and ensuring equitable access to specialized care. Lessons from Vietnam’s development—including the role of national societies, surgical education reforms, and rural outreach—could inform capacity-building strategies for Jordan and other countries with comparable healthcare landscapes.
Societal and professional perceptions play an important role in shaping decisions about finger replantation. Nishizuka et al. conducted a comparative study analyzing societal preferences for digit replantation in the United States and Japan, finding that the majority of respondents in both countries favored replantation over wound closure for finger amputations. Their study also revealed that treatment preference was significantly influenced by factors such as appearance, recovery time, and the likelihood of survival of the replanted digit, whereas attitudes on body integrity and perceived stigma toward finger amputees did not have a significant impact. Additionally, Japanese participants placed greater emphasis on appearance, sensation, and the survival of the replanted finger compared to their American counterparts. Our study aligns with these findings by reinforcing the importance of key factors that influence the success of finger replantation. Similar to Nishizuka et al., our results highlight the critical role of timely reattachment, with 88.32% of respondents identifying it as the most crucial factor. Furthermore, proper surgical technique, preservation of the amputated part, and access to advanced surgical tools were widely recognized as essential components for successful outcomes. These findings suggest that while patient preference may not be driving the decline in replantation rates, both public perception and surgical feasibility play important roles in shaping treatment decisions. By understanding these perspectives, healthcare providers can work toward improving awareness, accessibility, and outcomes of finger replantation procedures [12].
Perceptions of barriers to finger replantation varied significantly across different professional groups, reflecting variations in training, experience, and clinical exposure. Similar challenges have been documented in other resource-limited regions. For example, reports from Yamen highlight the critical role of targeted microsurgery training programs and regional referral systems in improving replantation success rates [7]. Similarly, in sub-Saharan Africa, innovative training initiatives and the establishment of dedicated microsurgical units have been shown to bridge gaps in access to specialized care [13]. These parallel experiences further support the need for structured training programs and infrastructure development in our setting. In contrast, studies from high-income countries highlight that while training and infrastructure are generally available, challenges often relate to timely referral, patient preference, and system-level coordination [1,14]. These comparisons indicate that although the nature of barriers differs between settings, improving training, resource allocation, and referral processes is critical globally to optimize replantation outcomes.
A major barrier highlighted by most participants was the lack of specialized training or expertise in replantation techniques. These findings align with existing literature, which underscores the importance of adequate training in complex surgical procedures such as finger replantation [7,15]. While this barrier was recognized by all groups, it was more prominent among residents, which may reflect their greater exposure to surgical procedures and, consequently, a more critical view of their preparedness. Medical students, having less clinical experience, may not yet fully grasp the level of expertise required, which could explain their lower recognition of this barrier. This highlights the importance of structured educational programs and skill development opportunities for residents and medical students, as hands-on experience and simulation-based training have been shown to significantly improve surgical outcomes in similar fields [16,17].
Access to specialized surgical instruments, including microsurgical tools, was another prominent barrier, with 72.7% of specialists/consultants and 70.3% of residents highlighting this issue, compared to 54.1% of medical students. This disparity can be attributed to the greater awareness of resource limitations experienced by those more embedded in clinical practice. The scarcity of microsurgical tools, which are essential for the precision required in replantation surgery, can significantly impact the outcome of such procedures. Specialists/consultants, who often have decision-making authority regarding surgical resources, may be more attuned to these shortages and their potential consequences [18,19]. This finding suggests that improving access to advanced surgical tools should be a priority in hospital settings to enhance the success of complex surgeries like replantation.
Interestingly, the delay in patient arrival to the hospital did not emerge as a statistically significant barrier, despite being recognized by the majority of participants. This finding is consistent with previous studies indicating that while delays in replantation can lead to poorer outcomes, it may not be perceived as a substantial barrier by healthcare professionals once the patient arrives [20]. Possible explanations include effective triage protocols, pre-hospital referral practices, and early stabilization measures, which may mitigate the impact of delayed presentation on replantation outcomes. However, efforts to improve pre-hospital care and patient education regarding the importance of timely replantation should continue to be emphasized, as earlier intervention has been correlated with improved replantation success [21].
Insufficient hospital infrastructure was another important factor, with 49.2% of medical students, 45.5% of specialists/consultants, and 37.8% of residents identifying it as a barrier. The statistical significance reflects the growing concern about resource constraints in healthcare settings, which can compromise the quality of care delivered. These findings are particularly concerning in low-resource settings, where hospital infrastructure may not meet the needs of high-complexity surgeries like finger replantation [22]. Addressing infrastructure limitations, including surgical room availability and recovery facilities, is crucial to ensuring that patients have access to the necessary resources for successful replantation.
The lack of a specialized surgical team, including microsurgeons, was also identified as a major barrier, especially by specialists/consultants (80.8%) and residents (73.0%), compared to 59.0% of medical students. This is in line with existing research that has demonstrated the importance of a skilled multidisciplinary team for successful replantation procedures [23]. The findings suggest that surgical teams with specialized training in microsurgery can significantly impact patient outcomes. Hospitals and healthcare systems should prioritize the recruitment and retention of microsurgeons to ensure that a dedicated team is available for these high-stakes procedures.
Financial constraints were reported as a barrier by a significant number of participants. Limited resources, including funding for advanced surgical tools and training, can undermine the ability to provide high-quality care. This highlights the need for healthcare institutions to secure adequate funding for the purchase of microsurgical equipment and the development of specialized training programs for medical staff [24]. Furthermore, public health policies should consider providing financial support for hospitals to ensure they can adequately manage complex surgical cases like replantation.
Finally, the perception of no significant barriers to finger replantation was more prevalent among specialists/consultants and residents, compared to medical students. This reflects the increased confidence and experience that these professionals gain as they advance in their careers. It is encouraging that these groups feel more equipped to perform replantation surgeries, suggesting that training and experience play a crucial role in overcoming perceived barriers to complex procedures.
This study offers several strengths, including its focus on healthcare professionals’ perceptions of finger replantation and the identification of key factors influencing successful outcomes, such as timely reattachment, surgical expertise, and access to advanced technology. These insights help clarify professional priorities in resource-constrained settings. However, the study is not without limitations. Reliance on self-reported survey data may introduce response bias, and the sample—though diverse in clinical roles—was drawn from professional networks within Jordan, including convenience sampling via institutional networks and WhatsApp groups, which may introduce selection bias and limit generalizability. Additionally, the relatively small sample size and confinement to a single country may further restrict the applicability of the findings to other settings. Finally, the study did not fully account for variations in healthcare infrastructure or availability of microsurgical services, which could significantly affect outcomes.
Future research should incorporate broader, possibly multinational samples, and include real-world clinical data to better examine how preferences and systemic capacity influence surgical success. Longitudinal studies comparing functional and psychological outcomes between replantation and amputation could further inform evidence-based decision-making and patient counseling. Further research is also needed to evaluate institutional capacities, patient awareness, and national outcomes related to finger replantation surgeries, to inform strategic planning and capacity-building efforts in hand surgery services.
5. Conclusion
The findings of this study offer valuable insights into the perceived barriers to successful finger replantation among healthcare professionals in Jordan. Key obstacles identified include limited training, inadequate access to specialized instruments, and insufficient infrastructure. Notably, the variation in responses across professional groups underscores the need for targeted interventions tailored to different stages of clinical training and practice. In a resource-constrained setting like Jordan, where microsurgical services are not uniformly available and delays in care may adversely affect outcomes, understanding healthcare professionals’ knowledge and attitudes is critical. Improving triage decisions, referral patterns, and educational efforts can enhance the quality and timeliness of care. Future research should evaluate the impact of structured interventions—such as regional microsurgical training programs (e.g., initiatives in Saudi Arabia under the Saudi Commission for Health Specialties), multidisciplinary team approaches, and infrastructure development—on overcoming these barriers and improving replantation outcomes.
Acknowledgments
We would like to extend our heartfelt gratitude to all individuals who have contributed to the successful completion of this research endeavor. Their unwavering support, expertise, and dedication have been crucial in advancing our understanding of Knowledge, Attitudes, Practices, and Barriers towards finger replantation in Jordan. We express our deepest appreciation to the Institutional Review Board (IRB) at Istiklal Hospital for their meticulous review and invaluable feedback, ensuring the ethical conduct of the study and safeguarding the safety of our participants. Our sincere thanks are also extended to all who participated in this study. Their willingness to share their experiences and insights has been invaluable and has greatly enriched the findings of our research.
Ethics approval
This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Istiklal Hospital.
Consent to participate
The requirement for written informed consent was waived for this study, as it poses no more than minimal risk to participants. Instead, voluntary participation was ensured by including an approval statement at the beginning of the questionnaire. By proceeding with the survey, participants acknowledge that they have read and understood the study’s purpose, confidentiality measures, and their right to withdraw at any time without consequences. This approach aligns with ethical research guidelines for minimal-risk studies.
Authors’ contributions
Saleh Abualhaj contributed to the conceptualization and design of the study, data collection, analysis, manuscript drafting, and final approval. Mosleh M. Abualhaj was involved in data interpretation, critical revision of the manuscript, and provided significant intellectual input. Lina Alshadfan participated in survey development, coordinated data collection, and conducted literature review. Anas As’ad contributed to statistical analysis and assisted in interpreting the results. Mohamad Kharashgah supported data acquisition and participant recruitment. Tayseer A. Al-tawarah contributed to the clinical interpretation of findings and manuscript editing. Abed Alazeez Alkhatib was responsible for data visualization, preparation of tables and figures, and drafting parts of the discussion. Mohammad Aljaidi supported manuscript revision, reference management, and final review. All authors read and approved the final version of the manuscript and agree to be accountable for its contents.
Disclosure statement
The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Data availability statement
The data underlying this article are available in the article.
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Papers of special note have been highlighted as either of interest (•) or of considerable interest (••) to readers.
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Data Availability Statement
The data underlying this article are available in the article.