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Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis
Asian Journal of Surgery xxx (xxxx) xxx
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ORIGINAL ARTICLE
Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis Minghui Liu a, Chunhe Hu b, * a b
Department of Trauma, Tianjin Union Medical Center, Tianjin, 300191, China Department of Hand Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050017, China
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 September 2019 Received in revised form 7 December 2019 Accepted 24 December 2019 Available online xxx
Background/Objectives: The advance in the microvascular surgeries has made successful replantation of amputee fingertip or toe. Anterograde palm venous anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is technically challenging. The retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries. The purposes of the analysis were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgery. Methods: Digits were replanted by retrograde palm venous anastomosis (n ¼ 130, RPVA cohort) or anterograde palm venous anastomosis (n ¼ 220, APVA cohort). The data regarding the survival of transplanted tissues, analgesia, 2-points discrimination, and total active movement after 2-years of surgeries were collected and analyzed. Results: A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (p ¼ 0.004). 2-points discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p ¼ 0.014). The pain was fewer in the RPVA cohort than the APVA cohort (p ¼ 0.041). A total active motion was higher in the RPVA cohort than the APVA cohort (p ¼ 0.025). Anterograde palm venous anastomosis (p ¼ 0.021) were associated with the failure of transplanted digits tissues. Conclusions: Retrograde palm venous anastomosis had better functional and therapeutic outcomes than anterograde palm venous anastomosis in avulsion distal fingertip trauma. Level of evidence: III. © 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: 2-Points discrimination Anterograde palm venous anastomosis Avulsion distal hand trauma Microvascular surgery Retrograde palm venous anastomosis
1. Introduction Amputations and fingertip injuries of distal from the nail matrix are common in the emergency department of any general hospital.1 In upper extremities amputations, fingers pruning occurs frequently than proximal amputations.2 The replantation of the fingertip is technically feasible but is not routinely performed because of the risk of unsatisfactory outcomes and the complex microvascular surgical procedure.3,4 There are several treatment options, for example, conservative managements, local flaps to
* Corresponding author. Department of Hand Surgery, The Third Hospital of Hebei Medical University, No 139 Ziqiang Road, Shijiazhuang, Hebei, 050017, China. E-mail addresses: [email protected] (M. Liu), [email protected] (C. Hu).
replantation of the amputated part, etc.3 Also, these treatments provide excellent outcomes including patients' satisfaction. The successful replantation of the fingertip or thumb by maintaining the digital length, improving functions, and preserving the nail provides excellent cosmetic outcomes with patient's satisfaction5 but the amputated portion replacement microvascular surgery is difficult if arteries are not suitable and/or not available for anastomosis.6,7 The veins (palmar and lateral) are often available while the arteries are difficult to find in avulsions because the arteries are thick and get avulsed more easily than thin veins.7,8 When distal arteries are not available for anastomosis in digital replantation microvascular surgeries, the revascularization of the amputated fingertip by an afferent palm arteriovenous anastomosis is a preferred surgical procedure.7 Anterograde palm venous
https://doi.org/10.1016/j.asjsur.2019.12.010 1015-9584/© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
Fig. 1. Flow diagram of analysis.
anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is challenging replantation procedures.9 Retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries.10
Amputations and fingertip injuries are common in China.11 Such injuries are associated with disabilities, psychological impact, and financial burdens.3 However, advance in the microvascular surgeries has made successful replantation of amputee digit(s) in
Fig. 2. A schematic presentation of palm venous anastomosis. A: Retrograde palm venous anastomosis (vein to artery anastomosed) B. Anterograde palm venous anastomosis (artery to artery anastomosed). C. Anterograde palm venous anastomosis (vein to vein anastomosed).
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
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China.12 The objectives of the retrospective study of prospectively collected data were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgeries. 2. Patients and methods 2.1. Ethics approval and consent to participate The designed protocol (PMU/CL/26/19 dated 15 Jun 2019) of the established study was approved by the third Hospital of Hebei Medical University review board. The study reporting adheres to the law of China, strengthening the reporting of observational studies in epidemiology (STROBE) statement: A cohort study, and the V2008 Helsinki Declaration. An informed consent form was signed by all the participating patients regarding anesthesia, replantation surgery, radiology (if required), pathology, and the publication of the study in all formats of the publication house irrespective of time and language including personal data and image(s) during hospitalization. 2.2. Study population From 17 January 2015 to 1 Jun 2017, a total of 315 patients (age 18 years and above) with avulsion distal fingertip and thumb
Fig. 3. Analysis of digits with survived transplanted tissues. Data are expressed as frequencies (percentage). Numbers of digits subjected to anastomosed for RPVA cohort 130 and for APVA cohort 220. Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant. *Significantly higher percentage of digits.
trauma due to mechanical injuries were available at the department of emergency of the third Hospital of Hebei Medical University, China and the Tianjin Union Medical Center, China. Microvascular surgeries of anastomosis were performed in a total of 350 avulsion distal fingertips and thumb. A total of 130 digits were replanted by retrograde palm venous anastomosis (RPVA cohort) and 220 digits were replanted by anterograde palm venous anastomosis (APVA cohort). The study chart is shown in Fig. 1.
Table 1 Demographical, arthrological, and clinical characteristics of patients with avulsion distal fingertip trauma. Characters
Cohorts
Type of anastomosis performed
Comparisons between cohorts
RPVA
APVA
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of patients with trauma
114
201
Numbers of digits subjected to anastomosed
130
220
p-value
Age (years) Ethnicity
36.67 ± 8.58 104(91) 8(7) 1(1) 1(1) 81(71) 33(29) 5(4) 12(11) 15(13) 7(6) 15(13) 12(11) 25(22) 23(20) 18(14) 33(25) 42(32) 25(19) 12(10) 13(11) 14(12) 57(50) 45(39) 12(11) 42(32) 56(43) 32(25) 105.52 ± 22.25
38.59 ± 8.56 182(91) 15(7) 2(1) 2(1) 161(80) 40(20) 7(4) 23(12) 28(14) 9(4) 32(16) 27(13) 38(19) 37(18) 30(14) 52(24) 71(32) 47(21) 20(9) 21(10) 22(11) 86(43) 92(46) 23(11) 58(26) 107(49) 55(25) 101.92 ± 20.15
0.057 0.998
Gender Cause for Injury
Digit
Diabetes Hypertension Smoking
a
Amputation level
Operation time (min)
Han Chinese Tibetan Mongolian North Korean refuge Male Female Pipe Card door Door Saw Knife Exercise bike Gym equipment Motor vehicle accident Thumb Index finger Long finger Ring finger Little finger
No Previous Current Guillotine Crush Crush avulsion
0.072 0.962
0.991
0.851 0.716 0.460
0.459
0.180
Categorial data are expressed as frequencies (percentage) and continuous data are expressed as mean ± SD. The Fischer's exact test was performed for categorial data and the Mann-Whitney U test was performed for continuous data. A p-value of less than 0.05 was considered significant. a Guillotine: A clean-cut amputation, crush: moderate amputation with the crush, crush avulsion: Avulsion injuries with the severe crush.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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Table 2 Factors associated with the risks for failure of transplanted digits tissues. Numbers of digits with failure transplanted tissues included in analysis
68
Characteristics
Risk ratio
95% CI
p-value
1.2 29.45 0.42 0.98 1.24 1.35 1.28 1.19 1.22 0.52 26.25 1.12 2.45 7.24
0.15e5.45 2.15e37.45 0.04e0.98 0.17e6.41 0.14e5.11 0.21e3.22 0.31e3.99 0.35e4.01 0.45e3.68 0.45e1.12 3.12e35.13 0.41e2.45 1.49e3.21 1.23e6.44
0.81 0.041 1.37 0.62 0.053 0.062 0.071 0.069 0.073 1.38 0.049 0.082 0.054 0.021
Age (years) Ethnicity Gender Cause for Injury Digit Diabetes Hypertension Smoking Amputation levela Operation time (min) Type of anastomosis performed
50 >50a Male Female
Retrograde palm venous anastomosis Anterograde palm venous anastomosisa
Digits with survived transplanted tissues were considered as reference standard. The risk ratio >1 and p-value of less than 0.05 was considered significant. a Significant risk factor associated with failure of transplanted digits tissues.
Fig. 4. Retrograde palm venous anastomosis performed in the left index finger. A: Before microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
2.3. Data collection Patients were observed for 2 years after the reconstructive operation. The data regarding the survival of transplanted tissues, the cosmetic appearance of digits, digits growth situation, analgesia, 2-points discrimination, and total active movement after 2years of operations were collected from the records of the institutes.
2.4. Surgeries Open wounds of patients were irrigated with normal saline in the operation theater. All patients had received Cefoperazone 1 g þ Sulbactam 500 mg injection before the operation. Patients were subjected to local anesthesia for the purpose of the reconstructive surgeries, 4.0 propylene suture was passed through amputee digits, so as to carry. The dissections and isolation of arteries and veins were performed under a microscope (Swift M10TMP Advanced Trinocular Microscope, Tanotis, Bangalore, India). The
Fig. 5. Anterograde palm venous anastomosis performed in the right index finger. A: Before microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
bones of amputee digits and figure tips were fixed, the proximal radial digital arteries and palmar cutaneous veins were anastomosed as arteriovenous shunts without veins graft.2 5000 IU/day low molecular weight heparin and 100 mg/day oral Aspirin were given to patients for 4-days.3 Also, patients received tetanus toxoid injection. In retrograde surgeries, the palmar cutaneous veins from proximal palm area were anastomosed to the proximal radial digital arteries of the amputated stump in order to re-establish arterial inflow (vein to artery anastomosed, Fig. 2A)10 and in anterograde surgeries, the proximal radial digital arteries from proximal palm area were anastomosed to the proximal radial digital arteries of the amputated stump (artery to artery anastomosed, Fig. 2B) and the palmar cutaneous veins from proximal palm area were anastomosed to the palmar cutaneous veins of the amputated stump (vein to vein anastomosed, Fig. 2C) in order to re-establish arterial and venous flows, respectively.9 Orthopedic surgeons (minimum 5-
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
Fig. 6. Retrograde palm venous anastomosis performed in the interphalangeal joint of left thumb. A: 10-days after microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
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Fig. 8. Analysis of 2-points discrimination. Data are expressed as mean ± SD. Numbers of digits subjected to anastomosed for RPVA cohort 130 and for APVA cohort 220. The Mann-Whitney U test was performed for statistical analysis. A p-value of less than 0.05 was considered significant. *Significantly higher 2-points discrimination.
2.7. 2-Points discrimination
Fig. 7. Anterograde palm venous anastomosis performed in the interphalangeal joint of left thumb. A: 10-days after microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
years of experience in hand reconstruction surgeries) of institutes performed all surgeries. After healing of digits, all patients were subjected to the rehabilitation program. 2.5. Personal satisfaction At the end of 2-years of follow-up, all the patients were asked for personal satisfaction by surgeons (who were not performed the surgeries) on a three-point scale (poor, moderate, and well) for reconstructive surgical satisfaction.13 2.6. Analgesia At the end of 2-years of follow-up, all the patients were asked for pain without touch to digits by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes on a three-point scale (sensitive, normal, and dull) for reconstructed digits.
At the end of 2-years of follow-up, it was measured by comparing reconstructed digits with the same digits of the other hands using a Touch-Test 2-Point Discriminator (Baseline® DISCRIM-A-GON, AliMed, Inc., Dedham, Massachusetts, USA).13 It was performed by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes. 2.8. Total active motion At the end of 2-years of follow-up, the total active motion was measured by surgeons (who were not performed the surgeries) as the sum of active motions of all joints of hands-on three-point scale (poor: < 75% activity, moderate: 50e75% activity, and well: 76e100% activity).14 2.9. Cold intolerance At the end of 2-years of follow-up, it was measured by the selfadministered Cold Intolerance Severity Score questionnaire. Less than 15 considered as absent, 15e25: mild, 26e50: moderate, 51e75: severe, 76e100: extreme.15 It was performed by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes. The other functional and therapeutic outcomes were evaluated at the end of 2-years of follow-up by medical staff (minimum 3-
Table 3 Evaluation of functional outcome after 2-years of surgeries. Characters
Cohorts
Comparisons between cohorts
RPVA
APVA
Type of anastomosis performed
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of patients with trauma
114
201
Numbers of digits subjected to anastomosed
130
220
p-value
Cosmetic appearance of digits
14(11) 116(89) 13(10) 117(90) 37(32) 45(39) 32(28)
42(19) 178(81) 41(19) 179(81) 46(23) 91(45) 64(32)
0.049
Digits growth situation Patients' satisfaction
Poor Well Poor Well Poor Moderate Well
0.033 0.180
Data are expressed as frequencies (percentage). Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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Table 4 Evaluation of therapeutic outcomes after 2-years of surgeries. Characters
Cohorts
Comparisons between cohorts
RPVA
APVA
Type of anastomosis performed
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of digits subjected to anastomosed
130
220
p-value
Touch
53(41) 45(35) 32(24) 37(29) 85(65) 8(6) 18(14) 48(37) 64(49)
123(56) 59(27) 38(17) 49(22) 139(63) 32(15) 54(25) 84(38) 82(37)
0.022
Analgesia
Total active motion
Poor Moderate Well Sensitive Normal Dull Poor Moderate Well
0.041
0.025
Data are expressed as frequencies (percentage). Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant.
years of experience who were not involved in the surgeries) of the institutes. 2.10. Statistical analysis For statistical analyses, InStat 3.1 (GraphPad, San Diego, CA, USA) was used. The Fischer exact test was performed for categorical data3 and the Mann-Whitney U test was performed for continuous data. Logistic regression analysis was performed for factors associated with the risks for the failure of transplanted digits tissues.16 All results of the study were considered significant at a 95% level of significance. 3. Results 3.1. Demographical and clinical characteristics of the enrolled patients There was no significant difference between demographical and clinical conditions, level of amputation, and the time of the surgeries between two cohorts (p > 0.05 for all, Table 1). 3.2. Functional outcomes Atrophic changes were not observed in any of the replanted digits during the follow-up period of 2-years. All digits were healed during 2-months after surgeries. A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (121 (93%) vs. 161 (73%), p ¼ 0.004, Fig. 3). Age (>50 years, p ¼ 0.041), level of amputation (p ¼ 0.049), and anterograde palm venous anastomosis (p ¼ 0.021) were associated with the failure of transplanted digits tissues (Table 2). The cosmetic appearance of digits was improved in the RPVA cohort (Fig. 4) than the APVA cohort (Fig. 5; p ¼ 0.049). Also, the digits' growth situation was sound in the RPVA cohort (Fig. 6) than the APVA cohort (Fig. 7, p ¼ 0.033). The personal satisfaction was the same between both cohorts (p ¼ 0.18). The detailed functional outcomes are presented in Table 3. 3.3. Therapeutic outcomes None of the patients had reported cold intolerance (the selfadministered Cold Intolerance Severity Score < 15 for all) or any neuropathic pain during the follow-up period. 2-points
discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p ¼ 0.014, Fig. 8). Touch was good in the RPVA cohort than the APVA cohort (p ¼ 0.022). The pain was fewer in the RPVA cohort than the APVA cohort (p ¼ 0.041). The total active motion was higher in the RPVA cohort than the APVA cohort (p ¼ 0.025). The detailed therapeutic outcomes are presented in Table 4.
4. Discussion Digits with survived transplanted tissues were higher in the RPVA cohort than the APVA cohort (93% vs. 73%) and anterograde palm venous anastomosis was associated with the failure of transplanted digits tissues. These results of the current study were parallel with the results of a retrospective analyses3,16 and case series.7,10,17 Venous anastomoses performed during avulsion distal fingertip trauma surgeries is a key factor affecting the survival of transplanted tissues because it achieves optimal nerve recovery.1 Avulsion distal fingertip microvascular surgery always has the risk of replantation failure.16 Anterograde palm venous anastomosis is the first choice among avulsion distal fingertip trauma surgeries9,18 but has an inferior recovery of the replanted digits due to necrosis7 and the other issues, e.g. need incision and dissection.9 Also, it is technically difficult.1 Failure of surgeries would lead to the high hospital stay and economic burden over patients’ heads.16 Retrograde palm venous anastomosis is recommended in avulsion distal fingertip microvascular surgery. Therapeutic efficacies of patients of the RPVA cohort were higher than the APVA cohort. These results of the current study were parallel with the results of retrospective analyses3,7,19 and case series.10 The adequate blood supply and recovery of the peripheral nerve are responsible for better therapeutic outcomes including analgesia and 2-points discrimination of retrograde palm venous anastomosis.13 Anterograde palm venous anastomosis is not a reliable microvascular surgery in avulsion distal fingertip trauma. The study reported no significant difference for patients' satisfaction (p ¼ 0.18) and a narrow range of significant difference for the cosmetic appearance of digits (p ¼ 0.049) between retrograde palm venous anastomosis surgical procedure and anterograde palm venous anastomosis surgical procedure. These results of the current study were parallel with the results of a retrospective analyses18,19 and case series.10 Patients concentered more on cosmetic appearance rather than pain, motion, and other functional outcomes. Apart from patients’ satisfaction functional and therapeutic
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
outcomes are required to achieve in avulsion distal fingertip microvascular surgery. The psychological characteristics of patients may have effects over functional outcomes of avulsion distal fingertip microvascular surgeries16 but the study did not perform multivariate analyses to show such effects. The substantial training and commitment of the surgeons also have effects over functional and therapeutic outcomes.16,20 There might be required to perform microvascular surgeries by more specialized and experienced surgeons. The surgeons’ technique level, which has great influence in survival rate of fingertip replantation but did not include in the study. Besides this, unlike anterograde palm venous anastomosis surgical procedure, retrograde palm venous anastomosis surgical procedure may have issues of venous valve physiological blockade the venous return problem. However, one hypothesis is also that bicuspid valves present in the digital veins may divert venous flow to reach revascularization.7 Further research is required in microsurgeries to consider such parameters. 5. Conclusions Retrograde palm venous anastomosis surgical procedure had better functional and therapeutic outcomes than anterograde palm venous anastomosis surgical procedure. The study recommended retrograde palm venous anastomosis surgical technic for avulsion distal fingertip microvascular surgeries when they prefer to do anterograde palm venous anastomosis. Availability of data and materials The datasets used and analyzed during the current study available from the corresponding author on reasonable request. Funding None. Authors’ contributions All authors read and approved the manuscript for publication. ML was project administrator, contributed to data curation, investigation, methodology, resources, software, validation and literature review of the study. CH contributed to conceptualization, formal analyses, resources, and literature review of the study and draft, review, and edited the manuscript for intellectual content. Both authors agree to be accountable for all aspects of work ensuring integrity and accuracy. Declaration of competing interest The authors declared that they have no conflict of interest or any other competing interest regarding results and/or discussion reported in the research.
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Acknowledgments The authors are thankful for the surgical, medical, and nonmedical staff of the third Hospital of Hebei Medical University, China and the Tianjin Union Medical Center, China. List of Abbreviations STROBE
Strengthening the reporting of observational studies in epidemiology
References 1. Purisa H, Ozturk MB, Kabakas F, Mersa B, Ozcelik IB, Sezer I. Intramedullary venous drainage system for distal fingertip replantations. Ann Plast Surg. 2017;79:166e173. 2. Venkatramani H, Sabapathy SR. Fingertip replantation: technical considerations and outcome analysis of 24 consecutive fingertip replantations. Indian J Plast Surg. 2011;44:237e245. 3. Tian Y, Li N, Wang L-C, Ma J, Wang B-S. A retrospective study of retrograde versus antegrade palm arteriovenous anastomosis in the distal fingertip replantation. Int J Clin Exp Med. 2017;10:5349e5352. 4. Yu H, Wei L, Liang B, Hou S, Wang J, Yang Y. Nonsurgical factors of digital replantation and survival rate: a metaanalysis. Indian J Orthop. 2015;49: 265e271. 5. Jazayeri L, Klausner JQ, Chang J. Distal digital replantation. Plast Reconstr Surg. 2013;132:1207e1217. 6. Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011;128:723e737. 7. Fakin R, Gazzola R, Calcagni M, Giovanoli P, Giesen T. Replantation by palmar arteriovenous anastomosis in complex finger amputations. Chir Main. 2015;34: 240e244. 8. Buntic RF, Brooks D. Standardized protocol for artery-only fingertip replantation. J Hand Surg Am. 2010;35:1491e1496. 9. Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair and reconstruction of thumb and finger tip injuries: a global view. Clin Plast Surg. 2014;41:325e359. 10. Giesen T, Forster N, Kunzi W, Giovanoli P, Calcagni M. Retrograde arterialized free venous flaps for the reconstruction of the hand: review of 14 cases. J Hand Surg Am. 2014;39:511e523. 11. Jin K, Lombardi DA, Courtney TK, et al. Patterns of work-related traumatic hand injury among hospitalised workers in the People's Republic of China. Inj Prev. 2010;16:42e49. 12. Kiuchi T, Shimizu Y, Nagasao T, Ohnishi F, Minabe T, Kishi K. Composite grafting for distal digital amputation with respect to injury type and amputation level. J Plast Surg Hand Surg. 2015;49:224e228. 13. Chen QZ, Sun YC, Chen J, Kong J, Gong YP, Mao T. Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair. J Hand Surg Eur. 2015;40: 935e943. 14. Zhu H, Bao B, Zheng X. A comparison of functional outcomes and therapeutic costs: single-digit replantation versus revision amputation. Plast Reconstr Surg. 2018;141:244ee249e. 15. Feng Y, Hu M, Yan H, Zhang X, Tao Z, Lv Z. Repair of dorsal defects over the middle phalanx and proximal interphalangeal joint with a transposition flap from the dorsum of the proximal phalanx. J Hand Surg Am. 2011;36:864e869. 16. Chang DH, Ye SY, Chien LC, Ma H. Epidemiology of digital amputation and replantation in Taiwan: a population-based study. J Chin Med Assoc. 2015;78: 597e602. 17. Hsu CC, Lin YT, Moran SL, Lin CH, Wei FC, Lin CH. Arterial and venous revascularization with bifurcation of a single central artery: a reliable strategy for Tamai Zone I replantation. Plast Reconstr Surg. 2010;126:2043e2051. 18. Wei CY, Orozco O, Vinagre G, Shafarenko M. Reverse distal transverse palmar arch in distal digital replantation. Ann Plast Surg. 2017;79:473e476. 19. Fakin RM, Calcagni M, Klein HJ, Giovanoli P. Long-term clinical outcome after epineural coaptation of digital nerves. J Hand Surg Eur. 2016;41:148e154. 20. Shale CM, Tidwell 3rd JE, Mulligan RP, Jupiter DC, Mahabir RC. A nationwide review of the treatment patterns of traumatic thumb amputations. Ann Plast Surg. 2013;70:647e651.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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ORIGINAL ARTICLE
Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis Minghui Liu a, Chunhe Hu b, * a b
Department of Trauma, Tianjin Union Medical Center, Tianjin, 300191, China Department of Hand Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050017, China
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 September 2019 Received in revised form 7 December 2019 Accepted 24 December 2019 Available online xxx
Background/Objectives: The advance in the microvascular surgeries has made successful replantation of amputee fingertip or toe. Anterograde palm venous anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is technically challenging. The retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries. The purposes of the analysis were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgery. Methods: Digits were replanted by retrograde palm venous anastomosis (n ¼ 130, RPVA cohort) or anterograde palm venous anastomosis (n ¼ 220, APVA cohort). The data regarding the survival of transplanted tissues, analgesia, 2-points discrimination, and total active movement after 2-years of surgeries were collected and analyzed. Results: A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (p ¼ 0.004). 2-points discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p ¼ 0.014). The pain was fewer in the RPVA cohort than the APVA cohort (p ¼ 0.041). A total active motion was higher in the RPVA cohort than the APVA cohort (p ¼ 0.025). Anterograde palm venous anastomosis (p ¼ 0.021) were associated with the failure of transplanted digits tissues. Conclusions: Retrograde palm venous anastomosis had better functional and therapeutic outcomes than anterograde palm venous anastomosis in avulsion distal fingertip trauma. Level of evidence: III. © 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: 2-Points discrimination Anterograde palm venous anastomosis Avulsion distal hand trauma Microvascular surgery Retrograde palm venous anastomosis
1. Introduction Amputations and fingertip injuries of distal from the nail matrix are common in the emergency department of any general hospital.1 In upper extremities amputations, fingers pruning occurs frequently than proximal amputations.2 The replantation of the fingertip is technically feasible but is not routinely performed because of the risk of unsatisfactory outcomes and the complex microvascular surgical procedure.3,4 There are several treatment options, for example, conservative managements, local flaps to
* Corresponding author. Department of Hand Surgery, The Third Hospital of Hebei Medical University, No 139 Ziqiang Road, Shijiazhuang, Hebei, 050017, China. E-mail addresses: [email protected] (M. Liu), [email protected] (C. Hu).
replantation of the amputated part, etc.3 Also, these treatments provide excellent outcomes including patients' satisfaction. The successful replantation of the fingertip or thumb by maintaining the digital length, improving functions, and preserving the nail provides excellent cosmetic outcomes with patient's satisfaction5 but the amputated portion replacement microvascular surgery is difficult if arteries are not suitable and/or not available for anastomosis.6,7 The veins (palmar and lateral) are often available while the arteries are difficult to find in avulsions because the arteries are thick and get avulsed more easily than thin veins.7,8 When distal arteries are not available for anastomosis in digital replantation microvascular surgeries, the revascularization of the amputated fingertip by an afferent palm arteriovenous anastomosis is a preferred surgical procedure.7 Anterograde palm venous
https://doi.org/10.1016/j.asjsur.2019.12.010 1015-9584/© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
Fig. 1. Flow diagram of analysis.
anastomosis is generally preferred in avulsion distal fingertip trauma surgeries but is challenging replantation procedures.9 Retrograde venous anastomosis is proved to be easy and effective in larger defects hand reconstruction surgeries.10
Amputations and fingertip injuries are common in China.11 Such injuries are associated with disabilities, psychological impact, and financial burdens.3 However, advance in the microvascular surgeries has made successful replantation of amputee digit(s) in
Fig. 2. A schematic presentation of palm venous anastomosis. A: Retrograde palm venous anastomosis (vein to artery anastomosed) B. Anterograde palm venous anastomosis (artery to artery anastomosed). C. Anterograde palm venous anastomosis (vein to vein anastomosed).
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
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China.12 The objectives of the retrospective study of prospectively collected data were to compare functional and therapeutic outcomes of retrograde palm venous anastomosis against anterograde palm venous anastomosis in the avulsion distal fingertip and thumb microvascular surgeries. 2. Patients and methods 2.1. Ethics approval and consent to participate The designed protocol (PMU/CL/26/19 dated 15 Jun 2019) of the established study was approved by the third Hospital of Hebei Medical University review board. The study reporting adheres to the law of China, strengthening the reporting of observational studies in epidemiology (STROBE) statement: A cohort study, and the V2008 Helsinki Declaration. An informed consent form was signed by all the participating patients regarding anesthesia, replantation surgery, radiology (if required), pathology, and the publication of the study in all formats of the publication house irrespective of time and language including personal data and image(s) during hospitalization. 2.2. Study population From 17 January 2015 to 1 Jun 2017, a total of 315 patients (age 18 years and above) with avulsion distal fingertip and thumb
Fig. 3. Analysis of digits with survived transplanted tissues. Data are expressed as frequencies (percentage). Numbers of digits subjected to anastomosed for RPVA cohort 130 and for APVA cohort 220. Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant. *Significantly higher percentage of digits.
trauma due to mechanical injuries were available at the department of emergency of the third Hospital of Hebei Medical University, China and the Tianjin Union Medical Center, China. Microvascular surgeries of anastomosis were performed in a total of 350 avulsion distal fingertips and thumb. A total of 130 digits were replanted by retrograde palm venous anastomosis (RPVA cohort) and 220 digits were replanted by anterograde palm venous anastomosis (APVA cohort). The study chart is shown in Fig. 1.
Table 1 Demographical, arthrological, and clinical characteristics of patients with avulsion distal fingertip trauma. Characters
Cohorts
Type of anastomosis performed
Comparisons between cohorts
RPVA
APVA
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of patients with trauma
114
201
Numbers of digits subjected to anastomosed
130
220
p-value
Age (years) Ethnicity
36.67 ± 8.58 104(91) 8(7) 1(1) 1(1) 81(71) 33(29) 5(4) 12(11) 15(13) 7(6) 15(13) 12(11) 25(22) 23(20) 18(14) 33(25) 42(32) 25(19) 12(10) 13(11) 14(12) 57(50) 45(39) 12(11) 42(32) 56(43) 32(25) 105.52 ± 22.25
38.59 ± 8.56 182(91) 15(7) 2(1) 2(1) 161(80) 40(20) 7(4) 23(12) 28(14) 9(4) 32(16) 27(13) 38(19) 37(18) 30(14) 52(24) 71(32) 47(21) 20(9) 21(10) 22(11) 86(43) 92(46) 23(11) 58(26) 107(49) 55(25) 101.92 ± 20.15
0.057 0.998
Gender Cause for Injury
Digit
Diabetes Hypertension Smoking
a
Amputation level
Operation time (min)
Han Chinese Tibetan Mongolian North Korean refuge Male Female Pipe Card door Door Saw Knife Exercise bike Gym equipment Motor vehicle accident Thumb Index finger Long finger Ring finger Little finger
No Previous Current Guillotine Crush Crush avulsion
0.072 0.962
0.991
0.851 0.716 0.460
0.459
0.180
Categorial data are expressed as frequencies (percentage) and continuous data are expressed as mean ± SD. The Fischer's exact test was performed for categorial data and the Mann-Whitney U test was performed for continuous data. A p-value of less than 0.05 was considered significant. a Guillotine: A clean-cut amputation, crush: moderate amputation with the crush, crush avulsion: Avulsion injuries with the severe crush.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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Table 2 Factors associated with the risks for failure of transplanted digits tissues. Numbers of digits with failure transplanted tissues included in analysis
68
Characteristics
Risk ratio
95% CI
p-value
1.2 29.45 0.42 0.98 1.24 1.35 1.28 1.19 1.22 0.52 26.25 1.12 2.45 7.24
0.15e5.45 2.15e37.45 0.04e0.98 0.17e6.41 0.14e5.11 0.21e3.22 0.31e3.99 0.35e4.01 0.45e3.68 0.45e1.12 3.12e35.13 0.41e2.45 1.49e3.21 1.23e6.44
0.81 0.041 1.37 0.62 0.053 0.062 0.071 0.069 0.073 1.38 0.049 0.082 0.054 0.021
Age (years) Ethnicity Gender Cause for Injury Digit Diabetes Hypertension Smoking Amputation levela Operation time (min) Type of anastomosis performed
50 >50a Male Female
Retrograde palm venous anastomosis Anterograde palm venous anastomosisa
Digits with survived transplanted tissues were considered as reference standard. The risk ratio >1 and p-value of less than 0.05 was considered significant. a Significant risk factor associated with failure of transplanted digits tissues.
Fig. 4. Retrograde palm venous anastomosis performed in the left index finger. A: Before microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
2.3. Data collection Patients were observed for 2 years after the reconstructive operation. The data regarding the survival of transplanted tissues, the cosmetic appearance of digits, digits growth situation, analgesia, 2-points discrimination, and total active movement after 2years of operations were collected from the records of the institutes.
2.4. Surgeries Open wounds of patients were irrigated with normal saline in the operation theater. All patients had received Cefoperazone 1 g þ Sulbactam 500 mg injection before the operation. Patients were subjected to local anesthesia for the purpose of the reconstructive surgeries, 4.0 propylene suture was passed through amputee digits, so as to carry. The dissections and isolation of arteries and veins were performed under a microscope (Swift M10TMP Advanced Trinocular Microscope, Tanotis, Bangalore, India). The
Fig. 5. Anterograde palm venous anastomosis performed in the right index finger. A: Before microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
bones of amputee digits and figure tips were fixed, the proximal radial digital arteries and palmar cutaneous veins were anastomosed as arteriovenous shunts without veins graft.2 5000 IU/day low molecular weight heparin and 100 mg/day oral Aspirin were given to patients for 4-days.3 Also, patients received tetanus toxoid injection. In retrograde surgeries, the palmar cutaneous veins from proximal palm area were anastomosed to the proximal radial digital arteries of the amputated stump in order to re-establish arterial inflow (vein to artery anastomosed, Fig. 2A)10 and in anterograde surgeries, the proximal radial digital arteries from proximal palm area were anastomosed to the proximal radial digital arteries of the amputated stump (artery to artery anastomosed, Fig. 2B) and the palmar cutaneous veins from proximal palm area were anastomosed to the palmar cutaneous veins of the amputated stump (vein to vein anastomosed, Fig. 2C) in order to re-establish arterial and venous flows, respectively.9 Orthopedic surgeons (minimum 5-
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
Fig. 6. Retrograde palm venous anastomosis performed in the interphalangeal joint of left thumb. A: 10-days after microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
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Fig. 8. Analysis of 2-points discrimination. Data are expressed as mean ± SD. Numbers of digits subjected to anastomosed for RPVA cohort 130 and for APVA cohort 220. The Mann-Whitney U test was performed for statistical analysis. A p-value of less than 0.05 was considered significant. *Significantly higher 2-points discrimination.
2.7. 2-Points discrimination
Fig. 7. Anterograde palm venous anastomosis performed in the interphalangeal joint of left thumb. A: 10-days after microvascular surgery. B: 2-years after microvascular surgery. Orthopedic surgeon (minimum 5-years of experience in hand reconstruction surgeries) of institute performed surgery.
years of experience in hand reconstruction surgeries) of institutes performed all surgeries. After healing of digits, all patients were subjected to the rehabilitation program. 2.5. Personal satisfaction At the end of 2-years of follow-up, all the patients were asked for personal satisfaction by surgeons (who were not performed the surgeries) on a three-point scale (poor, moderate, and well) for reconstructive surgical satisfaction.13 2.6. Analgesia At the end of 2-years of follow-up, all the patients were asked for pain without touch to digits by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes on a three-point scale (sensitive, normal, and dull) for reconstructed digits.
At the end of 2-years of follow-up, it was measured by comparing reconstructed digits with the same digits of the other hands using a Touch-Test 2-Point Discriminator (Baseline® DISCRIM-A-GON, AliMed, Inc., Dedham, Massachusetts, USA).13 It was performed by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes. 2.8. Total active motion At the end of 2-years of follow-up, the total active motion was measured by surgeons (who were not performed the surgeries) as the sum of active motions of all joints of hands-on three-point scale (poor: < 75% activity, moderate: 50e75% activity, and well: 76e100% activity).14 2.9. Cold intolerance At the end of 2-years of follow-up, it was measured by the selfadministered Cold Intolerance Severity Score questionnaire. Less than 15 considered as absent, 15e25: mild, 26e50: moderate, 51e75: severe, 76e100: extreme.15 It was performed by medical staff (minimum 3-years of experience who were not involved in the surgeries) of institutes. The other functional and therapeutic outcomes were evaluated at the end of 2-years of follow-up by medical staff (minimum 3-
Table 3 Evaluation of functional outcome after 2-years of surgeries. Characters
Cohorts
Comparisons between cohorts
RPVA
APVA
Type of anastomosis performed
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of patients with trauma
114
201
Numbers of digits subjected to anastomosed
130
220
p-value
Cosmetic appearance of digits
14(11) 116(89) 13(10) 117(90) 37(32) 45(39) 32(28)
42(19) 178(81) 41(19) 179(81) 46(23) 91(45) 64(32)
0.049
Digits growth situation Patients' satisfaction
Poor Well Poor Well Poor Moderate Well
0.033 0.180
Data are expressed as frequencies (percentage). Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
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M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
Table 4 Evaluation of therapeutic outcomes after 2-years of surgeries. Characters
Cohorts
Comparisons between cohorts
RPVA
APVA
Type of anastomosis performed
Retrograde palm venous anastomosis
Anterograde palm venous anastomosis
Numbers of digits subjected to anastomosed
130
220
p-value
Touch
53(41) 45(35) 32(24) 37(29) 85(65) 8(6) 18(14) 48(37) 64(49)
123(56) 59(27) 38(17) 49(22) 139(63) 32(15) 54(25) 84(38) 82(37)
0.022
Analgesia
Total active motion
Poor Moderate Well Sensitive Normal Dull Poor Moderate Well
0.041
0.025
Data are expressed as frequencies (percentage). Fischer's exact test was performed for statistical analysis. A p-value of less than 0.05 was considered significant.
years of experience who were not involved in the surgeries) of the institutes. 2.10. Statistical analysis For statistical analyses, InStat 3.1 (GraphPad, San Diego, CA, USA) was used. The Fischer exact test was performed for categorical data3 and the Mann-Whitney U test was performed for continuous data. Logistic regression analysis was performed for factors associated with the risks for the failure of transplanted digits tissues.16 All results of the study were considered significant at a 95% level of significance. 3. Results 3.1. Demographical and clinical characteristics of the enrolled patients There was no significant difference between demographical and clinical conditions, level of amputation, and the time of the surgeries between two cohorts (p > 0.05 for all, Table 1). 3.2. Functional outcomes Atrophic changes were not observed in any of the replanted digits during the follow-up period of 2-years. All digits were healed during 2-months after surgeries. A higher percentage of digits with survived transplanted tissues found in the RPVA cohort than the APVA cohort (121 (93%) vs. 161 (73%), p ¼ 0.004, Fig. 3). Age (>50 years, p ¼ 0.041), level of amputation (p ¼ 0.049), and anterograde palm venous anastomosis (p ¼ 0.021) were associated with the failure of transplanted digits tissues (Table 2). The cosmetic appearance of digits was improved in the RPVA cohort (Fig. 4) than the APVA cohort (Fig. 5; p ¼ 0.049). Also, the digits' growth situation was sound in the RPVA cohort (Fig. 6) than the APVA cohort (Fig. 7, p ¼ 0.033). The personal satisfaction was the same between both cohorts (p ¼ 0.18). The detailed functional outcomes are presented in Table 3. 3.3. Therapeutic outcomes None of the patients had reported cold intolerance (the selfadministered Cold Intolerance Severity Score < 15 for all) or any neuropathic pain during the follow-up period. 2-points
discrimination found higher in the APVA cohort than the RPVA cohort (5.22 ± 1.56 mm vs. 4.81 ± 1.39 mm, p ¼ 0.014, Fig. 8). Touch was good in the RPVA cohort than the APVA cohort (p ¼ 0.022). The pain was fewer in the RPVA cohort than the APVA cohort (p ¼ 0.041). The total active motion was higher in the RPVA cohort than the APVA cohort (p ¼ 0.025). The detailed therapeutic outcomes are presented in Table 4.
4. Discussion Digits with survived transplanted tissues were higher in the RPVA cohort than the APVA cohort (93% vs. 73%) and anterograde palm venous anastomosis was associated with the failure of transplanted digits tissues. These results of the current study were parallel with the results of a retrospective analyses3,16 and case series.7,10,17 Venous anastomoses performed during avulsion distal fingertip trauma surgeries is a key factor affecting the survival of transplanted tissues because it achieves optimal nerve recovery.1 Avulsion distal fingertip microvascular surgery always has the risk of replantation failure.16 Anterograde palm venous anastomosis is the first choice among avulsion distal fingertip trauma surgeries9,18 but has an inferior recovery of the replanted digits due to necrosis7 and the other issues, e.g. need incision and dissection.9 Also, it is technically difficult.1 Failure of surgeries would lead to the high hospital stay and economic burden over patients’ heads.16 Retrograde palm venous anastomosis is recommended in avulsion distal fingertip microvascular surgery. Therapeutic efficacies of patients of the RPVA cohort were higher than the APVA cohort. These results of the current study were parallel with the results of retrospective analyses3,7,19 and case series.10 The adequate blood supply and recovery of the peripheral nerve are responsible for better therapeutic outcomes including analgesia and 2-points discrimination of retrograde palm venous anastomosis.13 Anterograde palm venous anastomosis is not a reliable microvascular surgery in avulsion distal fingertip trauma. The study reported no significant difference for patients' satisfaction (p ¼ 0.18) and a narrow range of significant difference for the cosmetic appearance of digits (p ¼ 0.049) between retrograde palm venous anastomosis surgical procedure and anterograde palm venous anastomosis surgical procedure. These results of the current study were parallel with the results of a retrospective analyses18,19 and case series.10 Patients concentered more on cosmetic appearance rather than pain, motion, and other functional outcomes. Apart from patients’ satisfaction functional and therapeutic
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010
M. Liu, C. Hu / Asian Journal of Surgery xxx (xxxx) xxx
outcomes are required to achieve in avulsion distal fingertip microvascular surgery. The psychological characteristics of patients may have effects over functional outcomes of avulsion distal fingertip microvascular surgeries16 but the study did not perform multivariate analyses to show such effects. The substantial training and commitment of the surgeons also have effects over functional and therapeutic outcomes.16,20 There might be required to perform microvascular surgeries by more specialized and experienced surgeons. The surgeons’ technique level, which has great influence in survival rate of fingertip replantation but did not include in the study. Besides this, unlike anterograde palm venous anastomosis surgical procedure, retrograde palm venous anastomosis surgical procedure may have issues of venous valve physiological blockade the venous return problem. However, one hypothesis is also that bicuspid valves present in the digital veins may divert venous flow to reach revascularization.7 Further research is required in microsurgeries to consider such parameters. 5. Conclusions Retrograde palm venous anastomosis surgical procedure had better functional and therapeutic outcomes than anterograde palm venous anastomosis surgical procedure. The study recommended retrograde palm venous anastomosis surgical technic for avulsion distal fingertip microvascular surgeries when they prefer to do anterograde palm venous anastomosis. Availability of data and materials The datasets used and analyzed during the current study available from the corresponding author on reasonable request. Funding None. Authors’ contributions All authors read and approved the manuscript for publication. ML was project administrator, contributed to data curation, investigation, methodology, resources, software, validation and literature review of the study. CH contributed to conceptualization, formal analyses, resources, and literature review of the study and draft, review, and edited the manuscript for intellectual content. Both authors agree to be accountable for all aspects of work ensuring integrity and accuracy. Declaration of competing interest The authors declared that they have no conflict of interest or any other competing interest regarding results and/or discussion reported in the research.
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Acknowledgments The authors are thankful for the surgical, medical, and nonmedical staff of the third Hospital of Hebei Medical University, China and the Tianjin Union Medical Center, China. List of Abbreviations STROBE
Strengthening the reporting of observational studies in epidemiology
References 1. Purisa H, Ozturk MB, Kabakas F, Mersa B, Ozcelik IB, Sezer I. Intramedullary venous drainage system for distal fingertip replantations. Ann Plast Surg. 2017;79:166e173. 2. Venkatramani H, Sabapathy SR. Fingertip replantation: technical considerations and outcome analysis of 24 consecutive fingertip replantations. Indian J Plast Surg. 2011;44:237e245. 3. Tian Y, Li N, Wang L-C, Ma J, Wang B-S. A retrospective study of retrograde versus antegrade palm arteriovenous anastomosis in the distal fingertip replantation. Int J Clin Exp Med. 2017;10:5349e5352. 4. Yu H, Wei L, Liang B, Hou S, Wang J, Yang Y. Nonsurgical factors of digital replantation and survival rate: a metaanalysis. Indian J Orthop. 2015;49: 265e271. 5. Jazayeri L, Klausner JQ, Chang J. Distal digital replantation. Plast Reconstr Surg. 2013;132:1207e1217. 6. Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011;128:723e737. 7. Fakin R, Gazzola R, Calcagni M, Giovanoli P, Giesen T. Replantation by palmar arteriovenous anastomosis in complex finger amputations. Chir Main. 2015;34: 240e244. 8. Buntic RF, Brooks D. Standardized protocol for artery-only fingertip replantation. J Hand Surg Am. 2010;35:1491e1496. 9. Tang JB, Elliot D, Adani R, Saint-Cyr M, Stang F. Repair and reconstruction of thumb and finger tip injuries: a global view. Clin Plast Surg. 2014;41:325e359. 10. Giesen T, Forster N, Kunzi W, Giovanoli P, Calcagni M. Retrograde arterialized free venous flaps for the reconstruction of the hand: review of 14 cases. J Hand Surg Am. 2014;39:511e523. 11. Jin K, Lombardi DA, Courtney TK, et al. Patterns of work-related traumatic hand injury among hospitalised workers in the People's Republic of China. Inj Prev. 2010;16:42e49. 12. Kiuchi T, Shimizu Y, Nagasao T, Ohnishi F, Minabe T, Kishi K. Composite grafting for distal digital amputation with respect to injury type and amputation level. J Plast Surg Hand Surg. 2015;49:224e228. 13. Chen QZ, Sun YC, Chen J, Kong J, Gong YP, Mao T. Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair. J Hand Surg Eur. 2015;40: 935e943. 14. Zhu H, Bao B, Zheng X. A comparison of functional outcomes and therapeutic costs: single-digit replantation versus revision amputation. Plast Reconstr Surg. 2018;141:244ee249e. 15. Feng Y, Hu M, Yan H, Zhang X, Tao Z, Lv Z. Repair of dorsal defects over the middle phalanx and proximal interphalangeal joint with a transposition flap from the dorsum of the proximal phalanx. J Hand Surg Am. 2011;36:864e869. 16. Chang DH, Ye SY, Chien LC, Ma H. Epidemiology of digital amputation and replantation in Taiwan: a population-based study. J Chin Med Assoc. 2015;78: 597e602. 17. Hsu CC, Lin YT, Moran SL, Lin CH, Wei FC, Lin CH. Arterial and venous revascularization with bifurcation of a single central artery: a reliable strategy for Tamai Zone I replantation. Plast Reconstr Surg. 2010;126:2043e2051. 18. Wei CY, Orozco O, Vinagre G, Shafarenko M. Reverse distal transverse palmar arch in distal digital replantation. Ann Plast Surg. 2017;79:473e476. 19. Fakin RM, Calcagni M, Klein HJ, Giovanoli P. Long-term clinical outcome after epineural coaptation of digital nerves. J Hand Surg Eur. 2016;41:148e154. 20. Shale CM, Tidwell 3rd JE, Mulligan RP, Jupiter DC, Mahabir RC. A nationwide review of the treatment patterns of traumatic thumb amputations. Ann Plast Surg. 2013;70:647e651.
Please cite this article as: Liu M, Hu C, Retrograde palm venous anastomosis versus anterograde palm venous anastomosis in avulsion distal fingertip trauma: Functional and therapeutic outcomes (FTO) analysis, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.12.010