Challenges in measuring outcomes following digital replantation.
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ABSTRACT:
SUBMITTER: Sebastin SJ
PROVIDER: S-EPMC3842343 | biostudies-other | 2013 Nov
REPOSITORIES: biostudies-other
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Project description:Introduction There is a lack of consensus on what the critical outcomes in replantation are and how best to measure them. This review aims to identify all reported outcomes and respective outcome measures used in digital replantation. Materials and Methods Randomized controlled trials, cohort studies, and single-arm observational studies of adults undergoing replantation with at least one well-described outcome or outcome measure were identified. Primary outcomes were classified into six domains, and outcome measures were classified into eight domains. The clinimetric properties were identified and reported. A total of 56 observational studies met the inclusion criteria. Results In total, 29 continuous and 29 categorical outcomes were identified, and 87 scales and instruments were identified. The most frequently used outcomes were survival of replanted digit, sensation, and time in hospital. Outcomes and measures were most variable in domains of viability, quality of life, and motor function. Only eight measures used across these domains were validated and proven reliable. Conclusion Lack of consensus creates an obstacle to reporting, understanding, and comparing the effectiveness of various replantation strategies.
| S-EPMC7735551 | biostudies-literature
Project description:Fingertip amputation is a challenging injury to manage. Among various reconstructive procedures, replantation results in superior outcome, but is seldom considered in many institutions. From the identification of vessel ends to reanastomosis of the submillimeter vessels, fingertip's highly specialized anatomy requires technical excellence. By addressing these anatomic challenges, fingertip replantation can be a routine reconstructive option for microvascular surgeons.
| S-EPMC3842354 | biostudies-other
Project description:BackgroundDigital replantation attempt and success rates have been declining in the United States. Regionalization of digit replantation has been proposed as a solution to improve both attempt and success rates of these procedures. There is limited information about which criteria could establish a hospital as a center specialized for digit replantation. The authors analyzed hospital replantation volume and patient factors associated with successful thumb/finger replantation.MethodsA retrospective study using data from the 2008 to 2012 State Inpatient Databases of the Health Care Cost and Utilization Project from five states (New York, California, North Carolina, Utah, and Florida) was performed. The generalized estimating equation method was used to examine the association between patient characteristics and hospital volume and success of thumb/finger replantation. A receiver operating characteristic curve and Youden's J statistic were used to determine annual hospital replantation volume cutoff levels for success rates.ResultsThere were 3417 digit amputation injuries, with 631 replantation attempts (18 percent) and with an overall thumb/finger replantation success rate of 70 percent. The hospital annual replantation volume increased the odds of success (OR, 1.06; 95 percent CI, 1.02 to 1.10). The annual hospital volume of three replantations was needed to achieve a success rate of 70 percent.ConclusionsPractice patterns demonstrate that hospitals with higher annual volume have greater success. Identifying high-volume centers and regionalization of digit replantation should be considered a priority.Clinical question/level of evidenceTherapeutic, III.
| S-EPMC5327819 | biostudies-literature
Project description:There is no international consensus on the use of perioperative thromboprophylaxis in digital replantation. Suboptimal perioperative management may lead to replant failure, which compromises extremity function, worsens psychosocial outcomes for patients, and incurs significant cost. This systematic review evaluates and compares the efficacy and safety of perioperative antithrombotic protocols used in digital replantation.MethodsA Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)--compliant prospectively registered (PROSPERO, CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE, and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by 2 independent reviewers. All comparative studies that examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion.ResultsCollectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% men, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%), with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications among patients treated with systemic heparin.ConclusionsThe clinical efficacy and safety of perioperative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available.
| S-EPMC7605889 | biostudies-literature
Project description:Surgical ingenuity has resulted in continuing microsurgical innovation in replantation. In this article, the authors define complex amputations as those that stretch the boundaries or fall outside traditionally defined indications for replantation. They discuss management of difficult situations involving multiple digit amputations, multiple-level amputations, prolonged ischemia, and multiple trauma. The role of transpositional and ectopic replantation, as well as the requirement for secondary procedures in replantation is also discussed. Although technically challenging, microsurgical management of complex amputations ultimately results in far superior outcomes.
| S-EPMC3842345 | biostudies-other
Project description:IntroductionThere is much controversy regarding the current indications and contraindications for digital replantation.Presentation of caseThree patients with absolute contraindications for digital replantation according to classical criteria are presented (Case 1: multilevel amputation of the hand and fingers; Case 3: avulsion of the thumb; Case 4: index amputation proximal to the insertion of the flexor digitorum superficialis). In addition a patient with a very distal digital amputation (Case 2), whose indication for replantation is controversial is also presented. In all cases, the patients were replanted and showed good functional and aesthetical results.DiscussionMost authors advocate that the classical indications for replantation have been validated by experience, are predicated on the potential for long-term function, and should be followed in most if not all cases. However, some surgeons have been adopting a more liberal attitude with good results.ConclusionThe clinical cases presented in this paper suggest that the standard criteria for digital replantation should not be followed rigidly but instead should be regarded as a general guide.
| S-EPMC3679422 | biostudies-literature
Project description:Penile amputations are uncommon injuries, therefore, the management and outcome of these patients have been compiled from solitary case studies or short reviews. Accidental trauma during circumcision, injury inflicted by a partner following marital discord, and genital self-mutilation observed in patients with deep psychosis, account for a majority of the presentations. Initially, patients with total penile amputations were managed by resuturing the penile structures without repairing the vessels. A high incidence of skin and glans necrosis, urethral strictures, and a failure of sensory recovery were observed, though the penile shaft sometimes survived. Presently, microsurgical replantation has markedly improved the results, though issues of skin loss and urethral stricture still persist. A series of three patients with penile amputation is presented (complete = 2, partial = 1); the technical considerations and outcomes are discussed.
| S-EPMC3842340 | biostudies-other
Project description:Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.
| S-EPMC7818032 | biostudies-literature
Project description:ImportanceRisk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes.ObjectiveTo assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes.Design, setting, and participantsThis case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure.ExposuresDigit replantation and revascularization.Main outcomes and measuresDigit survival at 1-month follow up (case success) and number of complications.ResultsA total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93.Conclusions and relevanceOperative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.
| S-EPMC8548947 | biostudies-literature
Project description:The versatility of a pedicled groin flap can be further increased by raising it in a bilobed fashion. This allows the flap to cover both the volar and dorsal surfaces of a hand or forearm defect. A 48-year-old man sustained an avulsion amputation of his right forearm by a rolling machine in a workplace accident. Replantation of the right forearm was performed, and the postoperative course was uneventful. Unfortunately, the wound healing was complicated by circumferential marginal skin necrosis, which was confined to the distal forearm. A bilobed pedicled groin flap was performed for the wound coverage because reconstruction with a free flap would be very risky as the vessels were avulsed from the proximal part of the forearm. A good functional recovery of the hand and fingers was noted at 12 months' follow-up. The advantages of a bilobed pedicle groin flap are that it allows coverage of both the volar and dorsal surfaces at one setting and primary closure of the donor site is possible. Furthermore, a long tube-shaped pedicle in this flap can reduce the patient discomfort and prevent finger stiffness by allowing a range of motion exercise. In conclusion, the bilobed pedicled groin flap is a useful option to cover soft tissue defects involving both the volar and dorsal surfaces over the mid- to distal forearm, especially when the free flap is contraindicated.
| S-EPMC7253286 | biostudies-literature