Digit Replantation: Experience of two U.S. academic level-i trauma centers

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1 Washington University School of Meicine igital Open Access Publications 2013 igit Replantation: Experience of two U.S. acaemic level-i trauma centers uretti Fufa Washington University School of Meicine in St. Louis Ryan Calfee Washington University School of Meicine in St. Louis Linley Wall Washington University School of Meicine in St. Louis Wenjing Zeng Washington University School of Meicine in St. Louis Charles Golfarb Washington University School of Meicine in St. Louis Follow this an aitional works at: Recommene Citation Fufa, uretti; Calfee, Ryan; Wall, Linley; Zeng, Wenjing; an Golfarb, Charles,,"igit Replantation: Experience of two U.S. acaemic level-i trauma centers." The Journal of Bone an Joint Surgery.95, (2013). This Open Access Publication is brought to you for free an open access by igital It has been accepte for inclusion in Open Access Publications by an authorize aministrator of igital For more information, please contact

2 2127 COPYRIGHT Ó 2013 BY THE JOURNAL OF BONE AN JOINT SURGERY, INCORPORATE igit Replantation: Experience of Two U.S. Acaemic Level-I Trauma Centers uretti Fufa, M, Ryan Calfee, M, Linley Wall, M, Wenjing Zeng, M, an Charles Golfarb, M Investigation performe at Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, Missouri, an University of Cincinnati, Cincinnati, Ohio Backgroun: espite avances in microsurgery, igit replantation now is performe less frequently in the U.S. compare with fifteen years ago. There has been uncertainty regaring whether previously reporte U.S. replantation success rates an results reporte from other countries reflect the current experience in the U.S. We hypothesize that the success of igit replantation at two acaemic level-i referral hospitals in the U.S. woul be similar to previously publishe results. Methos: In this retrospective case series, we examine all cases of igit replantation that were performe from 1997 through 2010 at two institutions. The cumulative rate of viable igit replantations was etermine. Binary logistic regression moeling etermine the relative impact of patient, injury, an operative factors on replantation survival. Results: uring the stuy perio, 135 igit replantations were performe in 106 patients. Fourteen cases i not meet our inclusion criteria, yieling a cohort of 121 replantations. The thumb (n = 40) was the most commonly replanteigit, followe by the long finger (n = 31). The mechanism of injury was classifie as sharp in eighty-three igits, crush in nineteen igits, an avulsion in eighteen igits. The majority of replantations were performe following Tamai level-iii (n = 49) or level-iv (n = 56) amputations. Sixty-nine (57%) of the igit replantation proceures were successful. Logistic regression analysis ientifie replantation of the raial three igits an no history of tobacco use as significant inepenent preictors of replantation success. Conclusions: The rate of success of igit replantation (57%) at two acaemic level-i trauma hospitals was lower than previously publishe rates. Raial-igit involvement an no prior tobacco use were associate with replantation success. This moest success rate reflects a nee for aitional evaluation of our current benchmarks an clinical settings for replantation surgery. These ata help to better inform patients, families, an physicians who are consiering igit replantation. Level of Evience: Therapeutic Level IV. See Instructions for Authors for a complete escription of levels of evience. The fiel of replantation surgery has progresse markely since the first successful arm replantation by Malt in 1962, the report of successful microsurgical anastomoses in animals by Buncke in 1964, an the first successful thumb replantation by Tamai an Komatsu in Classically, igit survival rates following igit replantation have been reporte to be between 80% to 90%, epening on the inication 5-8. Waikakul et al. reporte on a series of 1018 total an subtotal replantations in which the igit survival rate was 92% 8. A review of the literature reveale that our currently accepte replantation survival rates have been generate from literature publishe before the 1990s an, more recently, from Asian centers. Whereas many early avances in microsurgical techniques were achieve in North America, in the last ecae Asia has become the leaer in microsurgery. Avances in Asia inclue a growing number of successful replantations following very istal fingertip amputations, of fingers with prolonge ischemic time, an of multiple amputateigits. Aitionally, the emerging fiel of supermicrosurgery, which involves isclosure: None of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of any aspect of this work. One or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. No author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete isclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. J Bone Joint Surg Am. 2013;95:

3 2128 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC microanastomoses ranging from 0.3 to 0.8 mm in iameter, was pioneere in Japan an has allowe extension of the classic inications for replantation surgery 5,9-11. Two recent reviews highlight the importance of the contributions from Asia to our unerstaning of igit replantation. In one, a systematic review regaring outcomes of istal igit replantation, Sebastin an Chung evaluate thirty stuies (2273 istal replantations), of which only two were from the U.S. 6.Intheother,ecevaluate the success rates of igit replantation in a meta-analysis of eight stuies, an, again, just two stuies were from U.S. institutions 12. We ientifie only a very few reports of igit replantation success from the U.S. in the last twenty years 5,13-15, with just two of these involving a cohort of greater than fifty patients 13,14. A growing boy of literature suggests that replantation is being performe less frequently in the U.S. toay compare with fifteen years ago. Payatakes et al. reporte that, in a survey regaring microsurgery in the U.S., only 56% of responing American Society for Surgery of the Han (ASSH) members inicate that they performe replantations. Of those, the majority performe fewer than five replantations per year 16. The literature on the epiemiology an availability of replantation surgery in the U.S. has confirme that replantations are increasingly being performe in smaller numbers an by fewer surgeons Several explanations for these trens have been offere, incluing a eclining number of amputations, eclining reimbursement, complexity of the cases, an increase selectivity for attempting replantation 3, Currently, a thorough unerstaning of these trens an their effect on outcomes of replantation surgery in the U.S. is lacking. Given these observations, the aim of the present stuy was to investigate the volume an moern success of igit replantation in a large series from two acaemic level-i trauma centers in the U.S. We hypothesize that igit survival rates following igit replantation woul be similar to those foun in the literature. Materials an Methos Stuy esign We performe a retrospective case series investigation after institutional review boar approval was obtaine at each participating center. Patients were ientifie for stuy inclusion on the basis of Current Proceural Terminology coes for igit replantation (20816, 20822, 20824, an 20827) in the perio from June 1997 through ecember 2010 at two institutions. We reviewe the meical recors, incluing emergency epartment summaries, operative reports, an raiographs, of all patients who unerwent replantation of at least one igit. Patients were exclue from our series if the primary emergency surgery resulte in amputation, regarless of whether replantation was attempte or consiere. We exclue all cases of incomplete amputation, as efine by Biemer 20, an any amputation proximal to the level of the metacarpal hea. Both institutions are large teaching hospitals (more than 700 bes) that are American College of Surgeons-certifie level-i trauma centers offering continuous microsurgical coverage for replantation. Barnes-Jewish Hospital has a general catchment area of 300 miles (483 km) an routinely treats patients from seven surrouning states. The University of Cincinnati has a general catchment area of 150 miles (241 km) an routinely treats patients from three surrouning states. All twenty-seven surgeons who performe TABLE I Tamai Classification of igit Amputation Level Level I II III IV V escription* istal to FP insertion istal interphalangeal joint to FP insertion Mile phalanx istal to FS insertion Proximal phalanx to mile phalanx FS insertion Metacarpophalangeal joint an proximal *FP = flexor igitorum profunus; FS = flexor igitorum superficialis. replantations were either plastic surgeons or fellowship-traine orthopaeic han surgeons. emographic patient ata were recore, incluing age, hanominance, mechanism of injury, occupation, Workers Compensation status, tobacco use, an evience of comorbiities known to affect small bloo vessels (iabetes, intravenous rug use, collagen vascular isorers, an coronary artery isease). Raiographs, together with emergency room an consultation notes, were use to etermine the igit(s) involve an the level(s) of injury (accoring to the Tamai classification as escribe by Yoshimura 21, Table I). We reviewe operative reports to recor operative etails that ha the potential to impact replant viability, incluing the number of arteries an veins repaire an the use of vein grafts. Finally, we examine surgeon experience as etermine by the number of years in practice at the time of the replantation surgery. Our primary outcome was survival of the replanteigit. Survival was efine as igit viability for a minimum of twenty-one ays. This efinition reflects the success of the revascularization proceure, an, for the purpose of analysis, revision amputations performe after this time point were consiere complications, not failures. Fourteen cases were exclue from analysis because of a follow-up perio of less than twenty-one ays. Cases of replantation that faile within twenty-one ays were inclue for the purposes of analysis. igit re-exploration was performe at the iscretion of each surgeon, an vessel revision was not consiere a failure. Cases requiring a return to the operating room for amputation or revision amputation within twenty-one ays following the inex surgery were consiere failures of replantation. Inications an Operative Technique The ecision to attempt replantation was base on the iscretion of the attening surgeon an inclue the following factors: amputation of the thumb, multiple-igit amputations, time from injury to arrival, appropriate transportation an conition of the amputate part (absence of a high egree of tissue amage, such as the ribbon sign 22 ), an meical stability to unergo replantation. The patient s age, igit(s) amputate, an hanominance were also taken into account in the ecision-making. Single-igit replantation (excluing the thumb) was attempte when the amputation was istal to the insertion of the flexor igitorum superficialis tenon, other igits were severely injure, an the patient agree with the physician that replantation woul offer improve function. The surgical technique inclue early arrival of the amputate part to the operating room for inspection an preparation of the igit uner the operating microscope. A two-team approach was use, when possible, to allow for simultaneous preparation of the amputate part an the injure han. At least one han fellow assiste the attening surgeon in all cases, an in fifteen cases, two primary attening surgeons participate in the replantation. All replantations were performe on the basis of the protocol of the attening surgeon but were similar overall. The repairs began with osseous stabilization (longituinal or crossing Kirschner wires, or a plate an screws). Tenon repairs were performe with nonabsorbable braie suture. With use of stanar

4 2129 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC Fig. 1 Percentages of replantations by igit. techniques (aventitial stripping an 9-0 or 10-0 nylon sutures), microsurgical repairs were performe with the use of an operating microscope, incluing the use of vasoilatory agents, such as liocaine an/or papaverine, an intraoperative antithrombotic supplementation with heparin. In cases in which it was not possible to perform a tension-free repair of the vessels or nerves, vein an nerve grafts, respectively, were use. Postoperative monitoring inclue hourly neurovascular checks for a minimum of twenty-four hours. Patients routinely receive anticoagulation therapy postoperatively with use of heparin, extran, an/or aspirin, on the basis of surgeon preference. Methos to treat venous congestion (heparin soaks an leech therapy) were employe as neee. Patient reainess for ischarge was etermine on a case-by-case basis, with ischarge eeme appropriate when hospital-base interventions no longer appeare to contribute to igit survival. Statistical Analysis We useescriptive statistics to etermine the success of igit replantation an ientify the emographics of replantation in our cohort. Univariate chi-square analysis an a Fisher exact test were use to etermine potential ifferences in replant survival rates accoring to categorical patient emographics, injury etails, an operative techniques, with significance set at p < Inepenent preictors of replantation survival inclue in this analysis were age, sex, hanominance, igit amputate, level of amputation, mechanism of injury, smoking status, evience of small-vessel comorbiity, number of veins an arteries repaire, use of vein graft, time from injury to surgery, an surgeon years in practice. Variables that coul influence the survival of the replante igit (p < 0.15 in the univariate analysis) were entere into a binary logistic regression analysis to preict the effect on replantation survival. Inepenent variables inclue in the final statistical moel were assesse on the basis of their regression coefficient, an are presente with os ratios with 95% confience intervals (CIs) to emonstrate their effect on replant survival. The inepenence of inepenent variables was confirme prior to their inclusion in the logistic moel (r < 0.3 for all). Moel performance was assesse on the basis of a nonsignificant result on the Hosmer-Lemeshow test, significant improvement with each block in aition to overall moel significance, an assessment of the moel s preictive ability regaring replantation success. Source of Funing No sources of funing were use in the preparation of this stuy. Results Epiemiology of Replantation (Table II) One hunre an thirty-five igits were replante at our institutions in 106 patients (five replantations per hospital per year on average). Fourteen cases were exclue from the final analysis because of a uration of replantation survival of less than twenty-one ays, yieling a final cohort of 121 igit replantations in ninety-three patients. The average uration of follow-up was thirteen months (range, eight ays to ten years). The average patient age in our cohort was thirty-nine years (range, seventeen to seventy-nine years). Four patients (seven igit replantations) in our cohort were women. The nonominant han was more commonly injure (sixty-one of 100 cases in which hanominance was clearly recore). Thirtyfive percent (forty-two) of the replantations were peforme in patients with a history of smoking or other tobacco use. The thumb was the most commonly replanteigit (33% of the cases) (Fig. 1), an a sharp mechanism of injury was the most common mechanism (Fig. 2). Eighty-seven percent of the

5 2130 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC TABLE II Univariate Associations Between igit Survival an Variables Variable No. (%) of igits that Survive No. (%) of Failures Total P Value Age 0.62 <30 yr 19 (53) 17 (47) yr 43 (57) 32 (43) yr 7 (70) 3 (30) 10 Sex Male 63 (55) 51 (45) 114 Female 6 (86) 1 (14) 7 ominant han* Yes 21 (54) 18 (46) 39 No 40 (66) 21 (34) 61 Total 100 igit Thumb 27 (68) 13 (33) 40 Inex 10 (63) 6 (38) 16 Long 20 (65) 11 (35) 31 Ring 8 (35) 15 (65) 23 Small 4 (36) 7 (64) 11 Tamai level 0.43 II 4 (67) 2 (33) 6 III 26 (53) 23 (47) 49 IV 31 (55) 25 (45) 56 V 8 (80) 2 (20) 10 Time from injury to surgery* <6 hr 22 (51) 21 (49) hr 10 (56) 8 (44) 18 >10 hr 3 (50) 3 (50) 6 Total 67 Mechanism of injury* Sharp 46 (55) 37 (45) 83 Crush 13 (68) 6 (32) 19 Avulsion 10 (56) 8 (44) 18 Total 120 Tobacco use* Yes 19 (45) 23 (55) 42 No 47 (65) 25 (35) 72 Total 114 Artery repair* artery 49 (58) 35 (42) 84 2 arteries 19 (54) 16 (46) 35 Total 119 Vein repair* or 1 vein 21 (46) 25 (54) 46 Multiple veins 48 (64) 27 (36) 75

6 2131 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC TABLE II (continue) Variable No. (%) of igits that Survive No. (%) of Failures Total P Value Vein graft* Yes 17 (55) 14 (45) 31 No 52 (58) 38 (42) 90 Small-vessel comorbiity Yes 7 (39) 11 (61) 18 No 62 (60) 41 (40) 103 Surgeon years in practice <5 25 (49) 26 (51) (57) 13 (43) (68) 8 (32) (67) 5 (33) 15 *Hanominance, mechanism of injury, tobacco use, time from injury to surgery, artery repair, vein repair, an vein graft are base on the subset of cases for which these ata were available. A significant variable. replantations were performe following amputations at Tamai level III (forty-nine replantations) or level IV (fifty-six replantations) (Fig. 3). Of the ninety-three patients, seventy-three unerwent single-igit replantation an twenty unerwent multiple-igit replantation. Forty of the single-igit replantations involve the thumb. Inications to perform single-igit replantation in the remaining cases inclue amputation istal to the flexor igitorum superficialis tenon (n = 3), mutilating injury to other igits (n = 24), an surgeon iscretion or no absolute inication ientifie in the chart (n = 6). The time from injury to the start of the surgical proceure, which was note in the meical recor for sixty-seven cases (Table II), average six hours (range, two to twelve hours). The average number of ays spent in the intensive care unit an the average number of ays until hospital ischarge were five an eight ays, respectively. Fig. 2 Percentages of replantations by mechanism.

7 2132 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC TABLE III Final Logistic Moel of Factors Associate with Replantation Survival Variable B Os Ratio (Ajuste) 95% CI Wal x2 Test P Value Thumb, inex, or long igit * Small-vessel comorbiity No tobacco use history * *A significant variable (p < 0.05). Success of igit Replantation Sixty-nine (57%) of the 121 replanteigits survive. The average time to failure was eight ays (range, one to nineteen ays). Eight (15%) of the failures occurre in the immeiate postoperative perio, between one an three ays following replantation. Twenty-six (50%) of the failures occurre within the first week following replantation. In just two cases, a seconary proceure aime at revascularization was attempte; one ha arterial revision anastomosis an the other, venous revision anastomosis. Both of these cases ultimately haigit amputation, one on ay six an one on ay nine following secon-look surgery. We began by testing thirteen inepenent variables for univariate association with replantation survival. Age, sex, ominant han, mechanism of injury, time from injury to start of surgery, number of arteries repaire, use of vein grafts, an surgeon years in practice were not associate with igit survival (Table II). Inepenent variables that were foun to be potentially correlate with each other mechanism of injury an level of amputation, smoking an small-vessel comorbiity were examine an were verifie not to be highly correlate (r s = 0.16 an r s = 0.07, respectively). The association of igit replante, Tamai level V (yes/no), history of tobacco use, repair of multiple veins, an small-vessel comorbiity with replantation success approache significance (set at p < 0.15). Therefore, these variables were inclue in a binary logistic moel that assesse for their impact on replantation survival. Two factors foun to preict replantation success were replantation of raial-sieigits (p = 0.001) an no Fig. 3 Percentages of replantations by Tamai level. smoking history (p = 0.013) (Table III). The final moel correctly preicte the outcome of replantation in 71% of the cases. Seconary Proceures Fifty-nine percent of the igits that unerwent replantation require at least one seconary proceure. One hunre an twenty-one seconary reconstructive proceures were performe in seventy-one igits. The most common seconary proceure was revision amputation (n = 56), followe by tenolysis (n = 15) an contracture release (n = 10). Seven cases require seconary soft-tissue-coverage proceures, incluing split-thickness or full-thickness skin grafting (n = 3), local flaps (n = 3), or a peicle groin flap (n = 1). iscussion The aim of the present stuy was to report the current success of igit replantation in a large series treate in the U.S. We stuie 121 igit replantations an foun a 57% igit survival rate. This survival rate is substantially lower than the rates reporte in the last fifteen years, which have range from 80% to 90% 5-8. A review of the literature reveale that the vast majority of recent stuies of large numbers of igit replantations were performe in centers outsie of the U.S. 1,6,12,23. The largest series from the U.S. (more than 300 igit replantations) showe a 76% survival rate but was publishe in Other large series from the U.S. have shown a 56% rate of success of istaltip replantation (in a stuy of fifty-three igits) 13 an a 91% rate of success of thumb replantation (in a stuy of 103 cases) 15, but we i not fin any stuies of series of greater than fifty igit replantations in the last ten years. In orer to report on our large series, we use the combine experience of multiple surgeons over a 12.5-year perio at two acaemic level-i trauma centers that provie twenty-four-hour microsurgical coverage but are not eicate microsurgical centers. Whereas this volume of igit replantations (an average of five replantations per institution per year) is low, recent U.S. trens in replantation surgery suggest that large teaching hospitals such as ours are managing the majority of amputation injuries 24,25.Using the Nationwie Inpatient Sample, Barzin et al. emonstrate a significant ecrease in the number of replantations performe uring the years 1998 to , a time perio overlapping with that in our cohort. An epiemiological stuy of igit replantation in U.S. hospitals in 1996 emonstrate that igit replantation was performe in only 15% of the hospitals inclue in the investigation. Of those, 60% performe only one replantation in 1996

8 2133 IGIT R EPLANTATION:EXPERIENCE OF T WO U.S. ACAEMIC an only 2% (eighteen hospitals) performe more than ten that year 27. In light of these trens, we believe that our moest volume an success rate offer an accurate epiction of the current practice ofigitreplantationintheu.s. The moest success following igit replantation at our institutions may justify the concern that limite volume has anegativeimpactonreplantationsurvival.weilanetal. were among the first to show that replantation survival rates increase with surgeon experience 28. Several authors have expresse concern that the eclining number of igit replantations performe in the U.S. may result in iminishe confience an experience with microsurgery among han surgeons 3,16,25.To better manage the ecreasing volume of replantation cases, some have suggeste that specialize microsurgical teams shoul be create at regional specialty centers in the U.S., as has been one in other countries Currently, such eicate microvascular staff an teams o not exist at either of our participating centers. In this investigation, we i not fin that the surgeon s number of years in practice significantly affecte replantation survival. However, specific ata on the total number of replantations performe by each surgeon woul likely have provie a more accurate gauge of surgeon experience. Another explanation for the seemingly low igit survival rate following igit replantation in the present stuy may be publication bias in the existing literature, with surgeons eciing not to report results when they fall unfavorably outsie the accepte range. We analyze several other factors to etermine their effect on the outcome of igit replantation. Positive preictors of replantation success inclue raial-igit replantation (thumb, inex, or long finger) an no history of tobacco use (Table III). In an analysis of factors influencing survival following igit replantation, ec foun that the male sex, thumb replantation, a nonsharp mechanism of injury, aniabetes were associate with replantation failure 12.Inthatstuy,tobaccousefailetoreach significance. Li et al. foun that a non-sharp injury mechanism, tobacco use, an use of vein grafts were significantly preictive of replantation failure in 211 patients 23. Similarly, Waikakul et al. foun that a non-sharp mechanism of injury an tobacco use negatively affecteigit survival 8. We i not fin the mechanism of injury (sharp, crush, or avulsion) or ischemia time to influence igit survival significantly. However, our stuy was likely unerpowere to etect these previously establisheifferences, an selection bias may also be a factor. Beris et al. suggeste that iseases affecting peripheral circulation incluing atherosclerosis, isease of connective tissue, autoimmune isease, aniabetes may reuce igit survival rates 24. Heistein an Cook suggeste iabetes as a preictor of failure, but the numbers in their cohort were insufficient to emonstrate significance (six of their fiftythree patients haiabetes) 13. In our stuy, we categorize patients with iseases known to affect peripheral circulation into a small-vessel-comorbiity group. Small-vessel comorbiity approache, but i not reach, significance as a preictor of igit replantation failure. To our knowlege, a similar comorbiity category has not been use in a previously publishe stuy an was evelope a hoc for this investigation, but the specific comorbiities that we consiere were base on consensus meical evience inicating an effect on small peripheral vasculature. There were several limitations of the present stuy, which are common to any retrospective review. Patients may have been lost to follow-up an then receive a subsequent surgical proceure at another institution following the inex proceure. However, given that our institutions are the primary replantation centers for our regions an because of the complexity of igit replantation, we believe that this is unlikely. Notably, a large number of surgeons performe the replantations in this series, an a small number of replantations were performe by each surgeon. Our experience is consistent with the recently reporte observation that 62% of surgeons who perform replantations perform fewer than five per year 16.Theuseof the combine experience of multiple surgeons at two institutions inherently introuce variability in the treatment provie (e.g., microsurgical expertise, operative techniques, anticoagulation, anecision-making for re-exploration). However, this limitation reflects the current practice of replantation surgery in the U.S., where eicate replantation teams an microsurgical specialty centers are rare. We believe, therefore, that these limitations make our results generalizable to other level-i trauma centers in the U.S. Our specific aim was to etermine the success of igit replantation at our institutions; however, we also assesse factors that may have affecteigit survival. Our igit replantation survival rate of 57% is substantially lower than preicte on the basis of ata presente in the existing literature. These ata help to more accurately inform patients an surgeons of realistic expectations an reinforce the nee to carefully select patients for igit replantation. Our results reflect current practice an highlight the importance of a system-wie assessment of our replantation practices in the U.S. We believe that we must reassess inications for replantation, current microsurgical training, coing an reimbursement, an the concept of specialize microsurgical centers in orer to optimize surgical outcomes. n uretti Fufa, M Ryan Calfee, M Linley Wall, M Wenjing Zeng, M Charles Golfarb, M Washington University School of Meicine, 660 South Eucli Avenue, Campus Box 8233, St. Louis, MO aress for. Fufa: fufa@hss.eu References 1. Unglaub F, emir E, Von Reim R, Van Schoonhoven J, Hahn P. Long-term functional an subjective results of thumb replantation. Microsurgery. 2006;26(8): Hanel P, Chin SH. Wrist level an proximal-upper extremity replantation. Han Clin Feb;23(1):13-21.

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