Cooling Composite Graft for Distal Finger Amputation: A Reliable Alternative to Microsurgery Implantation

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1 Cooling Composite Graft for Distal Finger Amputation: A Reliable Alternative to Microsurgery Implantation FRANCESCO IDONE 1, ANDREA SISTI 2, JURI TASSINARI 2 and GIUSEPPE NISI 2 1 Jalisco Plastic and Reconstructive Institute, University of Guadalajara, Guadalajara, Mexico; 2 Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy Abstract. Background: Finger amputations are the most common injuries to the upper limb. There are many options in the management of fingertip or finger amputations. We report our experience using cooling composite graft (Hirase technique) for distal finger amputation, as alternative to microsurgery implantation. Patients and Methods: We collected a case series of eight patients and report on the clinical outcomes after a 10-month follow-up period. Results: The amputated part survived almost completely in six patients; in these cases, the fingertip amputations were classified, according to the Allen classification, as level I in two cases, level II in three cases and level III in one case. Conclusion: Re-implantation of an amputated finger with the Hirase technique is possible and can provide good distal soft-tissue coverage and recovery of sensory and motor functions. We believe that re-attachment of the amputated portion as a composite graft represents an important alternative to microsurgery. Fingertip amputations are one of the most common injuries presenting at the Emergency Department. The management of very distal amputation in case of good preservation of the amputated part is still a controversial issue (1, 2). The fingertip is defined as the part of the digit distal to the insertion of the flexor and extensor tendons into the distal phalanx. Many authors have classified fingertip amputations. According to the Allen classification (3), fingertip amputations are divided into four zones: in zone I, the amputated part does not include any bone fragment and no Correspondence to: Andrea Sisti, MD, Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Viale Bracci 11, 53100, Siena, Italy. Tel: , Fax: , asisti6@gmail.com Key Words: Amputation, traumatic surgery, finger injuries, replantation methods, treatment outcome. suitable vessel for anastomosis is available. Zone II includes amputation through the nail bed, preserving at least one-half of the nail bed and the matrix, no dorsal vein is available at this level, venous drainage of the replanted part is achieved by controlled bleeding (heparinized saline solution or leeches). Zone III is similar to zone II, but the remaining nail bed is shorter, and a hooked nail deformity is likely to occur if replantation fails; zone IV is proximal to the nail fold; a dorsal vein usually can be dissected and repaired to ensure venous drainage of the replanted part. Replantation of the fingertip, when successful, provides excellent cosmetic outcomes by maintaining the digit's length, preserving the nail and improving function. It can also provide a high degree of patient satisfaction (4). Although replantation of a fingertip is technically possible, this is not commonly performed due to the presumed complexity of the procedure and to the doubts about the outcome, because of the poor venous drainage of the fingertip. The reattachment of the amputated portion as a composite graft in the adult population also carries a high risk of failure (5, 6). Hirase described a replantation model without vascular anastomosis; he used ice and aluminum foil in order to keep the graft cool until neovascularization occurs, ensuring the survival of the composite graft (7-10). The purpose of this study was to evaluate the results achieved after re-attaching the amputated part following the Hirase technique. Patients and Methods Between March 2014 and April 2015, the Hirase technique was used to treat eight patients with fingertip amputation distal to the lunula, seven were men and one was a woman (age range=24-45 years). F.I. performed all the procedures, using local anesthesia. Details of patients are summarized in Table I. The cause of injury was work accident in three cases and domestic injuries in five cases. The traumatized finger was the index of the non dominant hand in three cases, the middle finger of the dominant hand in two, the ring finger of the non dominant hand in one, the thumb of the non X/2016 $

2 Table I. Demographic data of the patients. No complications were experienced in any case. Patient no. Age (years)/gender Affected finger Affected hand Cause of amputation Percentage reattachment 1 29/M I Left Sliding door 100% 2 35/M II Left Knife 95% 3 39/M II Right Saw 95% 4 24/M IV Left Sliding door 95% 5 41/M II Right Sliding door 90% 6 29/F V Left Crush 80% 7 45/M III Left Saw 80% 8 32/M III Left Crush 100% dominant hand in one, and the little finger of the dominant hand in the remaining case. Crush amputations in a slamming door and other forms of crush injury were the most frequent cause of injury. The amputation level, according to the Allen classification, was level I in two cases, level II in three cases, and level III in three cases. All patients were treated in our emergency setting, and no hospitalization was required. The technique of cooling the composite graft was used to treat all these cases of amputated finger. Surgical technique. Firstly, the amputated part and the digit were debrided and irrigated with physiological solution in order to remove all the debris (Figure 1). Particularly for the amputated part, accurate debridement of wound margins was performed. When a fragment of bone was found in the amputated part, it was fixed with a longitudinal Kirschner to obtain good stability of the finger. Attention was paid to achieving perfect bone fixation in order to avoid irregularity of the nail bed once the healing of the finger is complete. Under loupe magnification, meticulous suturing of the nail bed was then performed with fine resorbable suture, usually with an 8/0 caliber suture. Finally the amputated part was reattached to the original site with a 4/0 nylon suture (Figure 2). At the end of the procedure, the finger was wrapped in aluminum foil and a bag with ice was immediately put all around the amputated part, as described by Hirase, in order to retard cellular degeneration (Figure 3). The aluminum foil used to wrap the finger was useful to the maintenance of a sufficiently low temperature. The patient was then instructed to keep their finger cool for about 72 h. The patients were seen 3 days after this treatment and each week to check their progress. Results Figure 1. Preoperative view of patients number 1 (a), 2 (b), 4 (c) and 5 (d). The patients were seen 3 days after treatment and the aluminum foil was removed. In the first stage (3 days after the amputation), the amputated part looked pale. Then the patients were visited each week for the next month and during this time superficial areas of necrosis were observed on the top of the amputated part; however, we usually waited one month before performing debridement of any of these areas. All the debridement procedures were performed in an outpatient setting, they were painless and no anesthetic was used (Figure 4). Three months after the operation, the previously described necrotic areas had spontaneously reepithelized and the fingers looked almost well-defined and normal (Figure 5). The amputated part survived almost completely in six patients; in these cases, the fingertip amputations was of Allen classification level I in two cases, level II in three cases and level III in one case. The two remaining cases, 502

3 Idone et al: Cooling Composite Graft for Distal Finger Amputation Figure 4. Aspect of the fingers after debridement (one month postoperatively) in patients number 2 (a) and 5 (b). Figure 2. Reattachment of the amputated part of the finger is complete (patient number 5). Figure 3. Cooling the composite graft using aluminum foil and ice: treatment should be continued for 72 h. classified as level III, resulted in partial survival of about 80%. In these cases, by direct admission of the patients, the treatment indicated with aluminum foil and ice bag was not correctly performed, especially during the night. Sensitivity was also evaluated by the static two-point discrimination test (11), and a good recovery of sensitivity was observed in all patients. The two-point discrimination testing of the volar fingertip pulp was less than 5 mm in all patients and no patient complained of dysesthesia or cold Figure 5. Postoperative view of patient number 1 (a), 2 (b), 4 (c) and 5 (d). After three months, the aspect of the finger is almost normal and well-defined. 503

4 intolerance. Partial nail deformity was observed in three fingers with zone III amputation with the injury very close to the nail matrix. In the other five fingers, normal nail growth was observed, with a good cosmetic result of the lamina. At the last follow-up visit (3 months after the operation), all patients were able to normally use their digits also for pinching and picking up small objects. Discussion Distal amputations of the fingertip always represents a challenge for hand surgeons and plastic surgeons. Hirase in his classification divided the distal fingertip amputation into four zones according to the level of amputation. Distal phalanx (DP)-I represents the most distal zone, where it is almost impossible to suture arterial and venous vessels; DP- II is the zone extending between the base of the nail and the distal ends of arterial vessels and is divided into two levels, DP-IIA and DP-IIB, depending on the level of injury to the artery (A: distal, B: proximal). The last level of amputation, DP-III, indicates the zone proximal to the base of the nail. While for treatment of a DP-III amputation many authors have reported success in replantation procedures, the ideal treatment for a more distally located amputation such as DP- II is still controversial. At this level of amputation, venous anastomosis is not always feasible because of the difficulty in finding a vein in such a distal level of finger and because of the great microsurgical skills that a vein anastomosis with a very small caliber requires. To achieve sufficient drainage from the amputated part is challenging and the feared complication is congestion, with loss of the distal finger and the necessity for a second surgical procedure. However, several cases of successful replantation with only arterial anastomosis have been reported (12-14); in these cases, drainage from the amputated part were obtained by the use of leeches or heparin solution to obtain controlled bleeding in order to avoid venous congestion. In our experience, the technique of cooling the amputated part of the finger and its management as a composite graft is a reliable alternative to microsurgery replantation. Conley and Vonfraenkel introduced this technique for the treatment of composite graft in nose reconstruction (15). Hirase first used the cooling composite graft technique for the treatment of fingertip amputations (8). He recommended the use of cooling of the amputated part for DP-I level of amputation, however, we found that this technique can also obtain optimal results for DP-II level of amputation, as we have demonstrated in our study here. In our series of eight cases, all grafts survived almost completely. Only in two cases was there partial necrosis due to incorrect following of treatment by the patients, i.e. noncontinuous cooling of the amputated part for the period indicated. After 72 h of cooling of the amputated part, Hirase suggested the use of prostaglandin E1, intravenously for 3 days. The administration of prostaglandins seems to enhance angiogenesis since they are responsible for increased blood flow and subsequent improvement in microcirculation. However, in our study, this protocol was not followed due to the impossibility of offering an intravenous treatment to all the patients. Conclusion We believe that re-attachment of the amputated portion as a composite graft not only represents an alternative to microsurgery replant, but could also be considered as a candidate for gold-standard treatment, even for DP-II level amputation. However, larger cases series and prospective studies are needed to confirm the superiority of the cooling technique over microsurgery. In conclusion, the cooling composite graft method was shown here to be a simple and reliable surgical technique for fingertip re-attachment. Funding None. Conflicts of Interest None. References 1 Woo SH, Kim YW, Cheon HJ, Nam HJ, Kang DH, Kim JM and Ahn HC: Management of complications relating to finger amputation and replantation. Hand Clin 31(2): , Miller AJ, Rivlin M, Kirkpatrick W, Abboudi J and Jones C: Fingertip amputation treatment: a survey study. Am J Orthop 44(9): E , Allen MJ: Conservative management of finger tip injuries in adults. Hand 12(3): , Bueno RA Jr., Battiston B, Ciclamini D, Titolo P, Panero B and Tos P: Replantation: current concepts and outcomes. Clin Plast Surg 41(3): , Choo J, Sparks B, Kasdan M and Wilhelmi B: Composite grafting of a distal thumb amputation: a case report and review of literature. Eplasty 15: e5, Kiuchi T, Shimizu Y, Nagasao T, Ohnishi F, Minabe T and Kishi K: Composite grafting for distal digital amputation with respect to injury type and amputation level. J Plast Surg Hand Surg 49(4): , Adani R, Marcoccio I and Tarallo L: Treatment of fingertip amputation using the Hirase technique. Hand Surg 8(2): , Hirase Y: Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction. Br J Plast Surg 46(8): ,

5 Idone et al: Cooling Composite Graft for Distal Finger Amputation 9 Hirase Y: Salvage of fingertip amputated at nail level: new surgical principles and treatments. Ann Plast Surg 38(2): , Hirase Y: Free composite graft to claw nail deformity using the ice water cooling method. Tech Hand Up Extrem Surg 2(1): 47-49, Tong J, Mao O and Goldreich D: Two-point orientation discrimination versus the traditional two-point test for tactile spatial acuity assessment. Front Hum Neurosci 7: 579, Jung SN, Yoon S, Kwon H and Yim YM: Successful replantation of an amputated earlobe by microvascular anastomosis. J Craniofac Surg 20(3): , Nakamura J, Kinoshita Y, Hama H, Ishimori Y and Kasai S: Successful replantation of four fingers by a single common digital artery anastomosis. J Microsurg 2(1): 53-57, Kim SW, Han HH and Jung SN: Use of the mechanical leech for successful zone I replantation. Sci World J 2014: , Conley JJ and Vonfraenkel PH: The principle of cooling as applied to the composite graft in the nose. Plast Reconstr Surg (1946) 17(6): , Received April 17, 2016 Revised May 23, 2016 Accepted May 25,