PURPOSE: Adults with traumatic digital amputation of the hand may be surgically managed with replantation or revision amputation. Preferences between treatment options vary between North American and Asian populations. This study aims to determine whether replantation compared to revision amputation yields superior patient-reported outcomes (PROs) and other outcomes. To date, there is no systematic review evaluating PROs in this population to suggest the optimal treatment approach depending on digital involvement (ie, thumb versus nonthumb) and the level of injury.
METHODS: Three databases (MEDLINE, Embase, and PubMed) were systematically searched from database inception until June 13, 2019 independently and in duplicate by 2 reviewers. Primary randomized and observational studies comparing replantation and revision amputation for isolated traumatic digital amputation in human subjects were considered for inclusion. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Data were pooled in a random-effects meta-analysis model with subgroups based on level of injury and the digit(s) involved. The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.
RESULTS: Of 4,350 studies identified, 12 retrospective cohort studies met inclusion criteria and compared outcomes of traumatic digital amputation treated with replantation (n = 717; 82.9% male; mean age, 40.3) versus revision amputation (n = 1,046; 79.8% male; mean age, 41.7). The overall replantation survival rate was 85.3%. The average MINORS score for included studies was 13.75/24 (57%; range, 10–18). Three studies reported sufficient PRO data for meta-analysis using the Michigan Hand Questionnaire (MHQ) and Disability of Arm, Shoulder and Hand (DASH) tool. Replantation of the thumb had a superior MHQ score (+12.01; 95% CI, 7.96–16.07; I2 = 18%) compared to revision amputation, whether the injury was proximal or distal to the interphalangeal joint. Replantation of single nonthumb digits had a superior MHQ score (+5.32; 95% CI, 3.11–7.53; I2 = 67%) and DASH score (−3.40; 95% CI, −6.72 to −0.09; I2 = 0%) compared to revision amputation. Only 12.1% of patients in the meta-analysis subgroup were from North American populations, whereas the remainder were from Asian populations.
CONCLUSION: There is significant heterogeneity in the reporting of outcome measures for traumatic digital amputation treatment and in the methods of stratifying levels of injury. There is low-quality evidence that replantation of the thumb achieves superior MHQ PROs compared to revision amputation, which may be clinically meaningful to patients based on existing estimates of the minimally important difference. Although replantation also demonstrated superior PROs (ie, MHQ and DASH) for single nonthumb digits, the magnitude of effect is likely not clinically important and is based on very low-quality evidence. Future prospective studies that evaluate PROs with stratification based on level of injury and digital involvement are needed to provide more specific treatment recommendations. In particular, more data from North American populations are required to determine if PROs vary based on cultural differences toward digital amputation treatment.