Department| Volume 19, ISSUE 4, P434-435, October 2006

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A Retrospective Study of Functional Outcomes after Successful Replantation versus Amputation Closure for Single Fingertip Amputations

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      There is controversy concerning the indications for replantation of a single amputated digit. Although high success rates have been reported, these reports focused on survival rates versus functional results.
      Purpose: To compare the functional outcome of successful microsurgical replantation versus amputation closure for single fingertip amputations.
      Method: A retrospective analysis on 46 patients with single finger amputations was performed (23 successful replant, 23 amputation closure). Thumb amputations were excluded. Minimal postoperative follow-up period was 24 months after successful replantation and 12 months after amputation revision. Post-treatment evaluation included: the Disability of Arm, Shoulder, and Hand questionnaire (DASH), patient satisfaction, grip strength, AROM of the proximal interphalangeal (PIP) joint, pain, paresthesia, and cold intolerance. Hospitalization time and time out off work were also reviewed. Statistical testing was performed with the Mann-Whitney U test or the chi-square test for comparison of two-scaled variables.
      Results: AROM of the PIP was greater in the replantation group. The existence of paresthesia and cold intolerance was not statistically different between the two groups; pain in the affected fingers was more frequent in the amputation closure group. The average DASH score of the successful replantation group was statistically better. All 23 patients in the successful replantation group were highly or fairly satisfied with their surgical results, only 14 patients in the amputation closure group were highly or fairly satisfied. The successful replantation group experienced longer hospitalization and out of work time.
      Conclusion: Successful replantation of single fingertip amputations can result in minimal pain, better functional outcome, better appearance, and higher patient satisfaction. The authors recommend replantation to obtain better appearance and better functional outcome. Should the patient desire a simple procedure and quicker return to work, amputation closure is an accepted method despite the disadvantage of digital shortening and the risk for a painful stump.
      Discussion: This study was performed in Japan, where aesthetics are especially important. Confucian moral values predominate. Maintaining one's bodily integrity and physical appearance is stressed as much as function. The most important indication for replantation should be improved hand function when in compliance with the patient's value system. While replantation may be the ideal method to treat finger amputation, one must consider the risks and needs. This would include the possibility of replantation failure, the need for highly skilled microsurgery, longer recovery time, longer time out of work, and higher cost.
      Limitations: This was a retrospective study with a small number of subjects and not a prospective randomized study. The patients chose their preferred surgical intervention when both were an option. This created an inevitable bias. The results of pain assessment may have been influenced by the timing of the assessment. A shorter follow-up period was used for the amputation closure group because they were discharged earlier. The two groups would be better compared at the same postoperative time. Another limitation of this study is that it did not include the postoperative rehabilitation program after either successful replantation or amputation closure. For example, use of the affected finger was encouraged; however, specialized desensitization was not applied.
      Commentary: There would be value to conducting a randomized, prospective study in multiple cultures to compare the functional outcome of successful finger replantation versus amputation closure.
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