Distal Digit Replantation: Challenges and Strategies to Improve Outcomes

Abstract

Digit replantation has undergone significant advancements since the 1960s. Despite progress, distal digit replantation remains one of the most challenging microsurgical procedures due to technical and clinical complexities. This review examines current challenges, strategic solutions in distal digit replantation, grounded in clinical experience and literature review. Key obstacles include managing minute vessel structures, venous congestion, and the critical condition of no available vessels for revascularization. Advances in surgical techniques, including preosteosynthesis vein grafting, intravascular stent, solitary central pulp artery bifurcation division, subdermal pocketing method, and postoperative management, have enhanced outcomes.

Keywords

distal digit replantation - distal digit revascularization - microsurgical digit replantation - distal phalanx replantation - finger replantation

Publikationsverlauf

Artikel online veröffentlicht:
20. Juni 2025

• References

• 1 Shigeo K, Susumu T. Successful replantation of a complete cut-off thumb. Case report. Plast Reconstr Surg 1968; 42 (04) 374-377
• 2 Hattori Y, Doi K, Sakamoto S, Yamasaki H, Wahegaonkar A, Addosooki A. Fingertip replantation. J Hand Surg Am 2007; 32 (04) 548-555
• 3 Nam YS, Jun YJ, Kim IB, Cho SH, Han HH. Anatomical study of the fingertip artery in Tamai Zone I: Clinical significance in fingertip replantation. J Reconstr Microsurg 2017; 33 (01) 45-48
• 4 Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg Am 1990; 15 (01) 148-154
• 5 Aksoy A, Gungor M, Sir E. Fingertip replantation without and with palmar venous anastomosis: Analysis of the survival rates and vein distribution. Ann Plast Surg 2017; 78 (01) 62-66
• 6 Chen YC, Chan FC, Hsu CC, Lin YT, Chen CT, Lin CH. Fingertip replantation without venous anastomosis. Ann Plast Surg 2013; 70 (03) 284-288
• 7 Wang LH, Zhang GQ. Use of digital subtraction angiography for assessment of digital replantation. J Zhejiang Univ Sci B 2012; 13 (03) 209-212
• 8 Lin CH, Aydyn N, Lin YT, Hsu CT, Lin CH, Yeh JT. Hand and finger replantation after protracted ischemia (more than 24 hours). Ann Plast Surg 2010; 64 (03) 286-290
• 9 Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 1988; 82 (02) 346-350
• 10 Waikakul S, Sakkarnkosol S, Vanadurongwan V, Un-nanuntana A. Results of 1018 digital replantations in 552 patients. Injury 2000; 31 (01) 33-40
• 11 Safa B, Greyson MA, Eberlin KR. Efficiency in replantation/revascularization surgery. Hand Clin 2019; 35 (02) 131-141
• 12 Wang SH, Hsu CC, Tzou CH, Hu CH. Synchronous microsurgical anastomosis in complex replantation surgery. J Hand Surg Eur Vol 2018; 43 (10) 1044-1049
• 13 Innocenti M, Malzone G, Menichini G. First-in-human free flap tissue reconstruction using a dedicated microsurgical robotic platform. Plast Reconstr Surg 2023; 151 (05) 1078-1082
• 14 Narushima M, Koshima I, Mihara M, Uchida G, Gonda K. Intravascular stenting (IVaS) for safe and precise supermicrosurgery. Ann Plast Surg 2008; 60 (01) 41-44
• 15 Harris GD, Finseth F, Buncke HJ. Posterior-wall-first microvascular anastomotic technique. Br J Plast Surg 1981; 34 (01) 47-49
• 16 Suzuki Y, Ishikawa K, Isshiki N, Takami S. Fingertip replantation with an efferent A-V anastomosis for venous drainage: clinical reports. Br J Plast Surg 1993; 46 (03) 187-191
• 17 Tsumura T, Matsumoto T, Matsushita M, Kishimoto K, Shiode H. Examination of the dorsal finger vein anatomy using a vein visualization device. J Hand Surg Asian Pac Vol 2020; 25 (03) 291-295
• 18 Tsai TM, McCabe SJ, Maki Y. A technique for replantation of the finger tip. Microsurgery 1989; 10 (01) 1-4
• 19 Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa S, Yamasaki M. The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers. Plast Reconstr Surg 1992; 89 (04) 710-714
• 20 Koshima I, Yamashita S, Sugiyama N, Ushio S, Tsutsui T, Nanba Y. Successful delayed venous drainage in 16 consecutive distal phalangeal replantations. Plast Reconstr Surg 2005; 115 (01) 149-154
• 21 Zamfirescu D, Salman M, Lascar I. Delayed venous repair for distal phalanx replantation. J Reconstr Microsurg 2012; 28 (09) 603-606
• 22 Chen KT, Chen YC, Mardini S, Wei FC. Salvage of an avulsion amputated thumb at the interphalangeal joint level using afferent arteriovenous shunting. Br J Plast Surg 2005; 58 (06) 869-872
• 23 Hu CW, Chang TN, Chen YC, Hu CH. Negative-pressure wound therapy application in fingertip replantations and a systematic review. Plast Reconstr Surg 2022; 149 (01) 38e-47e
• 24 Han SK, Chung HS, Kim WK. The timing of neovascularization in fingertip replantation by external bleeding. Plast Reconstr Surg 2002; 110 (04) 1042-1046
• 25 Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am 2013; 38 (10) 2025-2028
• 26 Wong J, Lin CH, Chang NJ, Chen HC, Lin YT, Hsu CC. Digital revascularization and replantation using the wide-awake hand surgery technique. J Hand Surg Eur Vol 2017; 42 (06) 621-625
• 27 Heistein JB, Cook PA. Factors affecting composite graft survival in digital tip amputations. Ann Plast Surg 2003; 50 (03) 299-303
• 28 Lin TS, Jeng SF, Chiang YC. Fingertip replantation using the subdermal pocket procedure. Plast Reconstr Surg 2004; 113 (01) 247-253
• 29 Lin TS, Yang JC. Secondary subdermal pocket procedure for venous insufficiency after digital replantation/revascularization. Ann Plast Surg 2014; 73 (06) 662-667
• 30 Li YS, Chen CY, Yang SW, Tarng YW. Cross-finger subdermal pocketplasty as a salvage procedure for thumb tip replantation without vascular anastomosis: a case report. J Int Med Res 2018; 46 (09) 3717-3723
• 31 Su HH, Lui PW, Yu CL. et al. The effects of continuous axillary brachial plexus block with ropivacaine infusion on skin temperature and survival of crushed fingers after microsurgical replantation. Chang Gung Med J 2005; 28 (08) 567-574
• 32 Retrouvey H, Solaja O, Baltzer HL. Role of postoperative anticoagulation in predicting digit replantation and revascularization failure: A propensity-matched cohort study. Ann Plast Surg 2019; 83 (05) 542-547
• 33 Ramelli E, Durry A, Ruffenach L, Bruant-Rodier C, Bodin F. Decrease of thrombosis in microsurgical anastomoses: The use of intraoperative pure intraluminal unfractionated heparin. J Reconstr Microsurg 2020; 36 (01) 16-20
• 34 Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011; 128 (03) 723-737