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A Review of Troubled Replantations
Dawn Chia, MBBS, MRCS, MMed1; Shian Chao Tay, MBBS, FRCS, FAMS2
1Tan Tock Seng Hospital, Singapore; 2Singapore General Hospital, Singapore

Introduction: Majority of digital replantations enjoy a successful outcome. However, a proportion of replantations encounter an eventful period post critical revascularisation. We introduce the term ‘troubled replantation' to describe a replantation that manifests a period of questionable viability, presenting as either failing to revascularise immediately despite a patent microsurgical anastomosis, or a replantation that subsequently fails to remain viable after an initial period of successful revascularisation. Limited literature is available on the phenomenon of postoperative troubled replantations. This study reviews our centre's experience with troubled replantations and their management.
Materials and Methods: Data was collected retrospectively from patients who underwent replantations over a ten year period. We identified 113 patients who experienced a troubled postoperative period, and compared the characteristics and factors of troubled replantations against the non troubled replantations, and the measures taken to enhance their survival.
Results: A total of 137 troubled digits in 113 patients were identified. The number of troubled replantations were significantly higher in crush and avulsion type injuries, as well as in amputations with moderate to severe contamination . The use of regional nerve blocks was significantly associated with a lower incidence of troubled replantations. Arterial flow manifestations were more common than venous flow problems. Seventy (50% ) of troubled digits did not respond to any form of treatment including re-explorations and ultimately failed. 53 digits responded to non surgical measures such as dressing change and bedside bleeding procedures. 26 digits required re-exploration surgery, of which 14 digits survived. Majority of re-explorations were due to arterial failures.
Conclusion: From our experience, one third of replantations are troubled, and half of these eventually fail. The success of troubled replantations are significantly influenced by the pre-operative factors rather than intraoperative or postoperative management. We discuss the phenomena of troubled replantations and its management.


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