JPRAS Open 6 (2015) 44e48. Contents lists available at ScienceDirect. JPRAS Open. journal homepage:

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JPRAS Open 6 (2015) 44e48 Contents lists available at ScienceDirect JPRAS Open journal homepage: http://www.journals.elsevier.

Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, Hong Kong article info abstract Article history: Received 7 January 2015 Accepted 10

1 JPRAS Open 6 (2015) 44e48 Contents lists available at ScienceDirect JPRAS Open journal homepage: jpras-open Case report A novel technique: Subatmospheric pressure wound therapy for treating venous congestion of replanted digits Margaret Woon Man Fok *, Boris Kwok Keung Fung Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, Hong Kong article info abstract Article history: Received 7 January 2015 Accepted 10 September 2015 Available online 9 October 2015 Keywords: Finger replantation Subatmospheric pressure wound therapy Venous congestion Finger amputation Venous congestion remains to be a major factor in causing digit replantation failures. The established solutions are: use of medical leech, local application of heparin gauze, and continuous nail bed massage. However, each method has its drawbacks. In theory, subatmospheric pressure wound therapy promotes continuous bleeding from the venules of the applied area, resulting in the relief of congestion. We applied subatmospheric pressure wound therapy to two replanted fingers of which venous congestion was noted shortly after the operation. The therapy was applied to each patient for one week. Both replanted fingers survived. No complication was noted The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license ( creativecommons.org/licenses/by-nc-nd/4.0/). Introduction Many treatments have been advocated for the management of venous congestion of finger replantation. However each option has its own drawbacks. In theory subatmospheric pressure wound therapy (SPWT) can promote continuous bleeding from the venules of the stump, relieving venous congestion. We propose the use of subatmospheric pressure wound therapy as a treatment option for venous congestion by presenting the outcome of our two cases. * Corresponding author. Department of Orthopaedics and Traumatology, 5/F, Professorial Block, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong. Tel.: þ ; fax: þ address: margaret_fok@yahoo.com (M.W.M. Fok) / 2015 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license (

2 M.W.M. Fok, B.K.K. Fung / JPRAS Open 6 (2015) 44e48 45 Cases In December 2012, a 33 years old gentleman was admitted for traumatic left thumb amputation at the inter-phalangeal joint level after being caught in a filing cabinet. Soft tissue contusion was noted at both stump ends. Emergency replantation was attempted with a cold ischaemic time of 6 hours. Interphalangeal joint fusion using Kirschner wire was performed. Only one artery and one very small vein (<2 mm) were anastomosed as additional vein with satisfactory quality at the distal stump could not be found. Signs of venous congestion were noted 1 hour post-operatively. As medical leech was not readily available, SPWT was applied to the stump after obtaining consent from the patient. SPWT was performed as follow: the replanted site, while keeping the stitches intact, was first dressed lightly with heparin saline gauze, and two layers of porous sponge. Catheter(s) with multiple side holes was then placed in-between the two layers of porous sponge, either at the dorsal or volar aspect of the finger, across the replanted site, away from the vascular anastomosis. The surrounding skin was dried and the entire dressing was sealed by adhesive plastic dressing to achieve a SPWT environment (Figure 1). The catheter was connected to the wall suction at a pressure of 120 mmhg. The finger tip, being covered by transparent adhesive dressing only, was used for circulation monitoring. Lamp therapy which was used to keep the replanted finger warm and to enhance the vasodilatation was applied for seven days and intra-venous Dextran was given for the initial three days. A course of broad spectrum antibiotic was given in order to prevent infection. Whenever a loss of SPWT seal was noted, dressing was changed by either the surgeon or designated nursing staff. The catheter was found to be blocked more easily in the early post-operative days and was changed daily for the first four days. It was then left intact. The circulation of the replanted digit was stable after seven days of SPWT. 50 ml of blood loss was noted intra-operatively and a total of 50 ml of blood was recorded in the suction bottle during the procedure of SPWT. The patient's vital signs remained stable. No blood transfusion was needed. The replanted Figure 1. Subatmospheric pressure wound therapy after replantation of left thumb.

3 46 M.W.M. Fok, B.K.K. Fung / JPRAS Open 6 (2015) 44e48 Figure 2. Left thumb one week later after removal of subatmospheric pressure wound therapy. digit survived and patient was discharged at the eighth day post-injury (Figure 2). No secondary surgery was needed up to six weeks, at which the patient left the country. A week later, a 30 years old gentleman was suffered from an amputation of his left index finger at the level of the distal inter-phalangeal joint level, by an electric saw. Emergency replantation was performed with a cold ischaemic time of 12 hours. Again distal inter-phalangeal joint fusion was performed with Kirchner wire. Only one artery and one vein could be found and were anastomosed. Post-operatively, venous congestion of the replanted fingers was noted at the fourth hour. SPWT was applied. Change of dressings was performed for a total of four times. Routine lamp therapy, Dextran infusion and a course of broad spectrum antibiotic were given. The SPWT was used for a total of seven days. 50 ml of blood loss was noted intra-operatively and 40 ml of blood was recorded at the suction bottle during the entire process of SPWT. No blood transfusion was needed. The replanted digit survived (Figure 3) and the patient was discharged on the eighth day post-injury. Up till the latest followup which was at 18 months post-replantation, no secondary surgery was required. Distal interphalangeal joint was fused at 5 flexion (Figure 4). The patient was satisfied with the outcome and resumed work 2.5 months post-operatively. Discussion For digital replantations, most centres recognized that there should be a 2:1 ratio of total venous outflow to arterial inflow vessel size diameter, in order to restore the normal capillary pressures and to decrease the likelihood of oedema establishment. 1 If this ratio is not met, venous congestion may develop. In fact, venous congestion was accounted for as many as 41% digit replantation failures. 2 This holds true especially for crushed traumatic amputations, as the associated injuries to the dorsal veins of the fingers make the re-anastomosis procedures on these vessels very difficult.

3 Based on this theory, use of medical leech, and external bleeding by creating a para-ungula stub, making a fish mouth incision or removal of nail plate, together with the local administration of

4 M.W.M. Fok, B.K.K. Fung / JPRAS Open 6 (2015) 44e48 47 Figure 3. Left index finger one week after removal of subatmospheric pressure wound therapy. Constant, slow, venous oozing is recognized to limit venous congestion until new venous channels are developed to provide venous drainage. 3 Based on this theory, use of medical leech, and external bleeding by creating a para-ungula stub, making a fish mouth incision or removal of nail plate, together with the local administration of heparin, are currently the established methods to treat venous congestion. 4e6 Unfortunately, each option has its associated disadvantages. Despite of its success rate, medical Leech could lead to infection of up to 20%, especially from Aeromonas hydrophilia, a potentially Figure 4. Left index finger 10 months post-replantation. a. Dorsal view, b. lateral view and c. when making a fist.

5 48 M.W.M. Fok, B.K.K. Fung / JPRAS Open 6 (2015) 44e48 harmful bacteria found in leeches. Excessive bleeding, allergic reaction, and psychological stress are some potential problems associated with this form of management. 6 Meanwhile, different methods of giving heparin locally to the replanted stump either via a small incision to the stump 3,5 or via nail bed after the nail plate removal 5 had been described. Heparin can promote the continuation of local bleeding and is more readily available than medical leech. However, frequent changes in the finger dressings are often necessary. Thus, these methods often require significant manpower for close monitoring of the finger. 7 The use of SPWT for the management of venous congestion in replanted digits is a technique which has not been reported in literature. In recent years, SPWT is a popular treatment option for wound care management, as it facilitates new blood vessels and granulation tissue formation. 8 Even when used in open finger tip injuries, a high success rate is observed. 9 Meanwhile, the rationale in using SPWT in venous congested replanted digit is, to some extent, different. The sustained suction exerts external pressure to the stump and encourages continuous bleeding from the venules of the distal stump. This, in turn, facilitates blood flow at the amputated part and prevents thrombosis at the venules. It may promote new blood vessels formation at the amputated stump. The use of 120 mmhg suction pressure in these cases is mainly in accordance to previous study of using SPWT in finger and hand injury. 10 In the meantime, the decision of using SPWT for seven days is based on the fact that the timing of neovascularization in finger tip replantation is between five and seven days. 4 A learning curve is observed in acquiring the technique of creating a SPWT seal. However as the popularity of using SPWT is increasing for wound management, more allied health staff have attained this expertise. SPWT may not be the most cost-effective method in resolving venous congestion. However apart from the manpower in detecting the loss of SPWT seal and in changing it, all the other materials used are readily available. Thus, SPWT is a viable option for the management of venous congestion with no observed complication. Conflicts of interest None. Funding N/A. References 1. Lee BI, Chung HY, Kim WK, et al. The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation. Ann Plast Surg. 2000;44:288e Weiland AJ, Villarreal-Rios A, Kleinert HE, et al. Replantation of digits and hands: analysis of surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg Am. 1977;2:1e Han SK, Chung HS, Kim WK. The timing of neovascularization in fingertip replantation by external bleeding. Plast Reconstr Surg. 2002;110:1042e Golden MA, Quinn JJ, Partington MT. Leech therapy in digital replantation. AORN J. 1995;62:364e366, 369, Pederson WC. Replantation. Plast Reconstr Surg. 2001;107:823e Wells MD, Manktelow RT, Boyd JB, Bowen V. The medical leech: an old treatment revisited. Microsurgery. 1993;14:183e Goldner RD, Stevanovic MV, Nunley JA, et al. Digital replantation at the level of the distal interphalangeal joint and the distal phalanx. J Hand Surg Am. 1989;14(2 Pt 1):214e Orgill DP, Bayer LR. Update on negative-pressure wound therapy. Plast Reconstr Surg. 2011;127(suppl 1):105Se115S. 9. Aydin U, Ozbek S, Akin S, Ozyurtlu M. Custom subatmospheric dressing for fingertip injuries. Tech Hand Up Extrem Surg. 2011;15:104e Matsushita Y, Fujiwara M, Nagata T, et al. Negative pressure therapy with irrigation for digits and hands: pressure measurement and clinical application. Hand Surg. 2012;17:71e75.

Interesting Case Series. Traumatic Thumb Amputation: Case and Review

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