Finger Replantation Optimization Study (FRONT): Update on National Trends

Abstract

Purpose: Traumatic digit amputations have an adverse impact on patients’ daily living. Despite experts advocating for digit replantation, studies have shown a continued decrease in rate of replantation. We performed a national-level investigation to examine the recent trend of practice for digital replantation. Methods: We used the National Inpatient Sample database under the Healthcare Cost and Utilization Project to select adult patients with traumatic digit amputation from 2001 to 2014.We calculated the rate of attempted and rate of successful digit replantation per year, subcategorizing for digit type (thumb or finger) and for hospital type (rural, urban non-teaching, or urban teaching). We also analyzed the pattern of distribution of case volume to each hospital type per year. We used two multivariable logistic regression models to investigate patient demographic and hospital characteristics associated with the odds of replantation attempt and success. Results: Among the 14,872 adult patients with a single digit amputation from 2001 to 2014, only 1,670 (11.2%) underwent replantation. The rate of replantation attempt trended down over the years for both thumb and finger injuries at all hospital types, despite increasing proportions of cases being sent to urban teaching hospitals where they were more than twice as likely to undergo replantation. The rate of successful replantation stayed stable for thumb at 82.9% and increased for fingers from 76.1% to 82.4% over the years. Patients were more likely to undergo replantation if they had private insurance or had a higher level of income. Neither hospital case volume nor hospital type were predictive of successful replantation. Conclusions: Although more single digit amputations were treated by urban teaching hospitals with higher likelihood to replant, the downward trend in rate of attempt regardless of hospital type demonstrates that concentration of case volume is not the solution to reverse the declining trend.

50+ years of replantation surgery experience: are we progressing or regressing?

“…An interesting finding in the Cho et al [2] study was that patients with private insurance were twice as likely to receive replantation in comparison to patients with Medicare or Medicaid. As payer status directly influences reimbursement, they suggested that financial incentive may play a role.…”

“…Their proposed solution was centralization of replantations. In distinction to this, Cho et al [2] found that "neither hospital case volume nor hospital type was predictive of successful replantation". Replantation attempts decreased at all hospital types: rural or urban, teaching or non-teaching.…”

“…Studies have demonstrated that replantation may be more desirable: a 2019 study reported significantly better functional outcomes in patients with successful replantation than revision outcomes, as measured by nine-hole peg test times, Semmes-Weinstein monofilament test, and three-point pinch test. Patientreported outcomes -the Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System upper-extremity module scores and functional outcomes -were significantly higher as well [2] . While successful replantation appears to be superior to revision amputation, there has been an alarming decrease in attempts to replant amputated digits.…”

Recomendaciones para optimizar el éxito en reimplante de dedos

“…Los mecanismos de amputación contusivos y avulsivos son los más frecuentes, siendo el mecanismo por aplastamiento menos frecuente. 3 El mecanismo de guillotina, a pesar de ser la técnica más favorable y funcional, apenas ocurre. El mecanismo lesional por sí solo no contraindica la cirugía, pero nos informa sobre la dificultad técnica del reimplante, las posibles complicaciones y futuro resultado funcional (►Tabla 2).…”

“…1 La atención en centros de referencia para esas lesiones presenta mayor tasa de indicación del reimplante, mayor éxito en la cirugía reparadora, disminución de los tiempos de ingreso hospitalario, menor coste económico y mayor planificación de procedimientos secundarios. [2][3][4] El dominio de las técnicas microquirúrgicas permite indicar el reimplante disminuyendo de forma notable las secuelas por amputación, a la vez que aumenta la satisfacción de los pacientes con el tratamiento recibido. [5][6][7] Es fundamental no confundir el éxito de las anastomosis vasculares con el éxito del resultado funcional.…”