Five-Year Outcomes Following Regionalization of Upper Extremity Devascularization/Amputation Injuries

Introduction:

Improvement in survival and patient outcomes following regionalization of trauma care services has been demonstrated by strong evidence. The implementation of integrated regional trauma care systems has involved changes aimed at combining all services within a region in a coordinated network assuring that patients are treated at the most appropriate facilities and by the most experienced personnel. This has led to the development of specialized trauma centres within regional trauma systems.

Purpose:

The purpose of the study was to measure i) short-term survival, ii) post-operative complications, and iii) immediate re-intervention rates of digital replantation surgeries following the implementation of a regionalized program aimed at covering the Quebec population.

Methods:

Prospective cohort study including all digital amputated and/or devascularized patients in the province of Quebec, over a 5-year period. Inclusion criteria included all patients surgically managed by the microsurgeons of the Quebec Replantation Program team.

Results:

From April 2004 to March 2009, the incidence rate of amputation-devascularization injuries was estimated to 1.8 per 100,000 active inhabitants per year, in Quebec. Four hundred and twelve patients with 785 fingers with suspected vascular compromise were surgically treated. There were 410 amputated and 346 devascularized digits managed surgically.  There were twenty four (11 amputations and 13 devascularizations) major upper extremity injuries (proximal to the wrist). Approximately half of all injuries were work related. The short-term success, complications and re-intervention rates of reimplanted digits were 81%, 25.4%, and 28% respectively. The short-term success, complications and re-intervention rates of revascularized digits were 93%, 25%, and 13% respectively. High success rates were identified in thumb and in avulsion injury categories.  Time to definitive care was decreased when following regionalization.

Conclusion:

Immediate outcomes are comparable to the literature and sustained over a 5-year period. Thumb and avulsion injuries had better outcomes than what has been reported in the literature, although complication rates as well as need for re-operation were similar to other centres of excellence. Regionalization of microsurgical cases is paramount in providing medically optimal care in replantation surgery.

References:

Trunkey DD, Trunkey DD. Regionalization of trauma care. Top Emerg Med 1981; 3(2):91-96.

Pederson WC, Pederson WC. Replantation. [Review] [194 refs]. Plast Reconstr Surg 2001; 107(3):823-841.

Wang H, Wang H. Secondary surgery after digit replantation: its incidence and sequence. Microsurgery 2002; 22(2):57-61.