The most dreaded phone call an orthopaedic surgeon can get while on call has to be a finger amputation. Few surgeons would attempt to replant an amputated finger because of the special expertise, ICU monitoring, and equipment needed. Even worse, when a surgeon tries to transfer the patient to the regional replant center, the receiving center often balks at or refuses the transfer request, leaving the patient with few options.
It's not too surprising that no one wants to take care of these injuries. These patients rarely show up at convenient times and the surgery can entail several hours of delicate surgery sewing microscopic blood vessels back together. Results vary widely but this author reported a 30.6% failure rate. Chung reported that the costs to repair the finger averaged $20,330 with average hospitalization of 5.5 days. Faced with these discouraging prospects, many on-call doctors push patients to simply shorten the bone of the finger so it can be covered with the remaining skin.
This article from the Journal of Hand Surgery offers an alternative solution. Why not schedule these replantations to be fixed in the morning? It presents the results of an overnight refrigeration protocol for the replantation of amputated fingers. They report on 597 finger replantations, of which 185 were replanted the following day. In patients admitted after 6pm, the amputated finger was kept in a refrigerator over night and the surgery was scheduled to begin the following morning. In some cases where the finger was hanging on by a tendon or a nerve, the amputation was completed so the finger could be refrigerated overnight at 4-6 degrees C. Fingers were replanted within 24 hours of the injury.
Astoundingly, the delayed replantation fingers had a 93% survival rate compared to 91% in the immediate repair group. The difference was not statistically significant. The authors offer this insight:
"The overnight-delayed replantation approach offers several advantages. It relieves the working pressure of overnight surgeries on the members of the team and reduces the overall cost per case. It allows the surgeries to be performed under optimal conditions, with a rested surgical team and a fully staffed operating room. This may, in part, explain the good results obtained in the delayed replantation group, in keeping with others reporting better survival of replants performed during daylight time".
This idea of replanting fingers at convenient hours is not totally new. This article was published in 2015 on a similar group of patients. Although the sample size was much smaller, the results were similar to this more recent large study.
Comment:
Amputated fingers never happen at convenient times. Perhaps with this new approach, replant center teams will be able to better accommodate transfers. Surgeons will be able to treat patients during daylight hours when they and their teams are well rested. While this is convenient for the treating teams, the patient results are as good or better when treated the following morning. Overall, this is a win-win scenario.
