Advertisement

Postoperative Interventions in Pediatric Digital Replantation: A Tertiary Referral Center Case Review

Published:August 16, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.06.016

      Purpose

      Although a few case series have been published describing the excellent outcomes of replantation and revascularization operations in children, there has been limited study of the hospital course that these patients experience and the number of potentially harmful interventions and treatments that occur. The purpose of this study was to detail the results of various postoperative interventions, including anticoagulation, transfusion, leeching, sedation, and additional anesthetic exposures.

      Methods

      Twenty-nine patients aged less than 18 years had 34 digital revascularizations or replantations performed between January 2000 and May 2020. The details of each patient’s presentation, surgery, and postoperative care were analyzed.

      Results

      Nine of 29 children underwent repeat anesthetics, including 6 revision amputations. No demographic, surgical, or postoperative variables consistently preceded revision amputation or additional anesthetic procedures. Only 5 patients had >1 hemoglobin (Hb) measurement. Two patients received blood transfusions; the average drop in Hb was 3.5 g/dL from before surgery to the lowest after surgery. Four patients underwent leech therapy. Only patients receiving leech therapy required postoperative transfusions. Anticoagulation regimens were prescribed on the basis of demographic and surgical factors, although no medication or regimen seemed to affect outcomes.

      Conclusions

      Although the experience of digital replantation is essentially the same in pediatric patients as adults, there may be different ramifications for children. Specifically, postoperative management of pediatric digital replantation or revascularization can involve multiple interventions that carry their risks. Parents should be counseled about the risks of anticoagulants, transfusions, and repeat anesthetics, and clinicians should monitor Hb closely when using leech therapy.

      Type of study/level of evidence

      Case series, Therapeutic IV.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Barbary S.
        • Dap F.
        • Dautel G.
        Finger replantation: surgical technique and indications.
        Chir Main. 2013; 32: 363-372
        • Faivre S.
        • Lim A.
        • Dautel G.
        • Duteille F.
        • Merle M.
        Adjacent and spontaneous neurotization after distal digital replantation in children.
        Plast Reconstr Surg. 2003; 111 (discussion 166): 159-165
        • Mohan R.
        • Panthaki Z.
        • Armstrong M.B.
        Replantation in the pediatric hand.
        J Craniofac Surg. 2009; 20: 996-998
        • Squitieri L.
        • Reichert H.
        • Kim H.M.
        • Steggerda J.
        • Chung K.C.
        Patterns of surgical care and health disparities of treating pediatric finger amputation injuries in the United States.
        J Am Coll Surg. 2011; 213: 475-485
        • Cheng G.L.
        • Pan D.D.
        • Zhang N.P.
        • Fang G.R.
        Digital replantation in children: a long-term follow-up study.
        J Hand Surg Am. 1998; 23: 635-646
        • Ikeda K.
        • Yamauchi S.
        • Hashimoto F.
        • Tomita K.
        • Yoshimura M.
        Digital replantation in children: a long-term follow-up study.
        Microsurgery. 1990; 11: 261-264
        • Saies A.D.
        • Urbaniak J.R.
        • Nunley J.A.
        • Taras J.S.
        • Goldner R.D.
        • Fitch R.D.
        Results after replantation and revascularization in the upper extremity in children.
        J Bone Joint Surg Am. 1994; 76: 1766-1776
        • Dautel G.
        Fingertip replantation in children.
        Hand Clin. 2000; 16: 541-546
        • Cheng G.L.
        • Pan D.D.
        • Yang Z.X.
        • Fang G.R.
        • Gong X.S.
        Digital replantation in children.
        Ann Plast Surg. 1985; 15: 325-331
        • Kim J.Y.
        • Brown R.J.
        • Jones N.F.
        Pediatric upper extremity replantation.
        Clin Plast Surg. 2005; 32 (vii): 1-10
        • Michalko K.B.
        • Bentz M.L.
        Digital replantation in children.
        Crit Care Med. 2002; 30: S444-S447
        • Taghinia A.H.
        Pediatric replantation and revascularization.
        Hand Clin. 2019; 35: 155-178
        • Berlin N.L.
        • Tuggle C.T.
        • Thomson J.G.
        • Au A.
        Digit replantation in children: a nationwide analysis of outcomes and trends of 455 pediatric patients.
        Hand (N Y). 2014; 9: 244-252
        • Friedrich J.B.
        • Poppler L.H.
        • Mack C.D.
        • Rivara F.P.
        • Levin L.S.
        • Klein M.B.
        Epidemiology of upper extremity replantation surgery in the United States.
        J Hand Surg Am. 2011; 36: 1835-1840
        • Baker G.L.
        • Kleinert J.M.
        Digit replantation in infants and young children: determinants of survival.
        Plast Reconstr Surg. 1994; 94: 139-145
        • Taras J.S.
        • Nunley J.A.
        • Urbaniak J.R.
        • Goldner R.D.
        • Fitch R.D.
        Replantation in children.
        Microsurgery. 1991; 12: 216-220
        • Lafosse T.
        • Jehanno P.
        • Fitoussi F.
        Complications and pitfalls after finger replantation in young children.
        J Hand Microsurg. 2018; 10: 74-78
        • Yildirim S.
        • Calikapan G.T.
        • Akoz T.
        Reconstructive microsurgery in pediatric population-a series of 25 patients.
        Microsurgery. 2008; 28: 99-107
        • Tan A.B.
        • Teoh L.C.
        Upper limb digital replantation and revascularisation in children.
        Ann Acad Med Singapore. 1995; 24: 32-36
        • Lindfors N.
        • Marttila I.
        Replantation or revascularisation injuries in children: incidence, epidemiology, and outcome.
        J Plast Surg Hand Surg. 2012; 46: 359-363
        • Zhu Z.W.
        • Zou X.Y.
        • Huang Y.J.
        • et al.
        Evaluation of sensory function and recovery after replantation of fingertips at Zone I in children.
        Neural Regen Res. 2017; 12: 1911-1917
        • Wen G.
        • Xu J.
        • Chai Y.M.
        Fingertip replantation with palmar venous anastomoses in children.
        Ann Plast Surg. 2017; 78: 692-696
        • Yildiz M.
        • Sener M.
        • Baki C.
        Replantation in children.
        Microsurgery. 1998; 18: 410-413
        • Li N.Y.
        • Kleiner J.E.
        • Harris A.P.
        • Goodman A.D.
        • Katarincic J.A.
        Pediatric digit replantation following traumatic amputation: nationwide analysis of patient selection, outcomes, and cost.
        Hand (N Y). 2021; 16: 612-618.25
        • Patel K.
        • Goldman J.L.
        Safety concerns surrounding quinolone use in children.
        J Clin Pharmacol. 2016; 56: 1060-1075
        • Milone M.T.
        • Klifto C.S.
        • Lee Z.H.
        • Thanik V.
        • Hacquebord J.H.
        Relationships between vein repairs, postoperative transfusions, and survival in single digit replantation.
        Hand (N Y). 2020 Jul; 15: 488-494
        • Lee Z.H.
        • Cohen J.M.
        • Daar D.
        • Anzai L.
        • Hacquebord J.
        • Thanik V.
        Quantifying outcomes for leech therapy in digit revascularization and replantation.
        J Hand Surg Eur Vol. 2019; 44: 414-418
        • Josephson C.D.
        • Mondoro T.H.
        • Ambruso D.R.
        • et al.
        One size will never fit all: the future of research in pediatric transfusion medicine.
        Pediatr Res. 2014; 76: 425-431
        • Tyrrell C.T.
        • Bateman S.T.
        Critically ill children: to transfuse or not to transfuse packed red blood cells, that is the question.
        Pediatr Crit Care Med. 2012; 13: 204-209
        • Ing C.
        • Ma X.
        • Sun M.
        • et al.
        Exposure to surgery and anesthesia in early childhood and subsequent use of attention deficit hyperactivity disorder medications.
        Anesth Analg. 2020; 131: 723-733
        • Wilder R.T.
        • Flick R.P.
        • Sprung J.
        • et al.
        Early exposure to anesthesia and learning disabilities in a population-based birth cohort.
        Anesthesiology. 2009; 110: 796-804
        • Brody G.A.
        • Maloney W.J.
        • Hentz V.R.
        Digit replantation applying the leech Hirudo medicinalis.
        Clin Orthop Relat Res. 1989; : 133-137
        • Kotick J.D.
        • Taghinia A.
        Prolonged bleeding after a single leech application in pediatric hand surgery.
        J Hand Microsurg. 2017; 9: 98-100
        • Whitaker I.S.
        • Oboumarzouk O.
        • Rozen W.M.
        • et al.
        The efficacy of medicinal leeches in plastic and reconstructive surgery: a systematic review of 277 reported clinical cases.
        Microsurgery. 2012; 32: 240-250
        • Young G.
        • Male C.
        • van Ommen C.H.
        Anticoagulation in children: making the most of little patients and little evidence.
        Blood Cells Mol Dis. 2017; 67: 48-53
        • Saini S.
        • Folta A.N.
        • Harsh K.L.
        • et al.
        Anti-factor Xa-based monitoring of unfractionated heparin: clinical outcomes in a pediatric cohort.
        J Pediatr. 2019; 209: 212-219.e1
        • Cigna E.
        • Lo Torto F.
        • Maruccia M.
        • et al.
        Postoperative care in finger replantation: our case-load and review of the literature.
        Eur Rev Med Pharmacol Sci. 2015; 19: 2552-2561