A NEW SURGICAL CLASSIFICATION AND POST-OPERATIVE PROTOCOL FOLLOWING VERY DISTAL REPLANTATION

Abstract

OBJECTIVE: The purpose of this study were to present a new surgical classification, based on types of injuries, and to evaluate significance of our post-operative protocol for fingertip replantation, especially crush-avulsion cases.

METHODS:Twenty fingertip amputations in 20 consecutive patients were replanted at our institute for recent 5 years. There were 17 male patients and 3 female patients, ranging in age from 19 to 62 years(mean,45.3years). All cases were classified as crush and avulsion according to Yamano. There were 13 amputations in Zone I and 7 in Zone II according to Tamai’s classification for the level of amputation. Also, we classified our cases based on the type of injury. [New Classification] Type IA: Distal transverse palm arterial arch (DTPA) is remained in the proximal part Type IB: DTPA is remained in the amputated part Type II : Loss of DTPA There were 4 cases in Type IA, 4 in Type IB, and 12 in Type II. Postoperatively, 12000–24000U of urokinase and 500 ml of low molecular-weight dextran were given intravenously for 7 consecutive days. In very severe crush/avulsion cases, 10000–15000 U of heparin were given intravenously for 5 days additionally.

RESULTS: The overall survival rate of the 20 replantations was 90.0% (zone I:83.3%, Zone II:100%). The survival rate was 100% in type IA, 100% in type IB, and 83.3% in type II. For arterial repair, vein grafts were necessary in 1 of 4 type IA(25%), 1 of 4 type IB(25%), and 11 of 12 type II(91.7%). In 3 of 4 type IA, end to end anastomosis were possible by the technique of transpositioning DTPA. In 3 of 4 type IB, proper digital artery was anastomosed to central artery of the pulp. Regarding functional outcomes with a follow-up period greater than 6mons, excellent cases were 87.0% (according to Tamai’s functional classification). The mean range of motion of the distal interphalangeal joint was 40 degrees. All patients achieved protective sensation of replanted fingertips. Other complications were cold intolerance(22.2%), nail deformity(66.6%), and pulp atrophy (33.3%). Blood transfusions were not necessary in all cases.

CONCLUSIONS: Our new classification of fingertip amputation based on DTPA was available for strategy of arterial repair, because if DTPA is lost, most cases (91.7%) need vein grafts. Also, in crush/avulsion fingertip amputation, our clinical protocol was very useful and raised success rate of fingertip replantation (90.0%) for crush-avulsion cases.