Initial Management of Traumatic Digit Amputation: A Retrospective Study on Functional Outcomes
Ledibabari Mildred Ngaage, BA (Hons) Cantab. MB BChir1, Georgette Oni, MD PhD FRCS Plast2, Rudolf Buntic, MD, FACS3, Charles M Malata, BSc (HB), LRCP MRCS, FRCS (Glasg), FRCS (Plast) 2,4 Gregory M Buncke, MD
1University of Cambridge, Cambridge, United Kingdom; 2Addenbrooke's Hospital, Cambridge, United Kingdom; 3The Buncke Clinic, San Francisco, CA; 4Postgraduate Medical Institute, Cambridge & Chelmsfold, United Kingdom
Background: Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings. Successful replantation can help to mitigate these deficits if good functional return occurs. Little has been recorded on the preoperative management before replantation and how that affects the function and survival of the replanted digit.
Methods: A retrospective cohort study was conducted and data was collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice, and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data collected included gender, age, hand dominance, smoking status, mechanism of injury, digit injured, and injury level. Function was defined by sensation, range of movement, and strength. Secondary endpoints included number of digits that survived, secondary operations, and complication rate. Data was tabulated and analysed using IBM SPSS software.
Results: Over the 18-month period, 74 of 177 digits were replanted with an overall survival rate of 86.5%. This did not vary considerably for preoperative factors, with the exception of avulsion injuries (69%). The survival rate did not differ greatly between the protocols (minimal, incomplete and complete protocols were 95%, 87%, and 91%, respectively, p=0.6149). However, the complication rate was significantly different between the complete Buncke (20%) and the minimal (60%) protocols (p=0.0484), and was particularly noteworthy for soft tissue complications (p=0.0472). Additionally, significance was found between the number of surgeries for the incomplete protocol and the complete Buncke protocol (1.6 vs 2.7, p=0.0872). Differences in sensation and grip strength were statistically significant between protocols (p=0.0465 and p=0.0430, respectively) but no significance was found for the other modalities of function.
Conclusion: Preoperative management was found to have no significant effect on survival. However, the complete Buncke protocol was found to significantly reduce the complication rate which suggests that the protocol prevents compromise of tissue integrity. Additionally, statistical significance was found between all protocols for sensation and grip strength. A higher-powered study is needed to further investigate the effects of preoperative management on complication rates and functional outcomes.
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