Proximal interphalangeal replantation with arthrodesis facilitates favorable esthetics and functional outcome
© Fujioka and Hayashida. 2015
Received: 8 November 2014
Accepted: 20 October 2015
Published: 27 October 2015
Management of finger amputations of the proximal interphalangeal (PIP) joint is still controversial. Regrettably, injured PIP joints seldom regain normal active motion; thus, many investigators recommend revision amputation with skeletal injury at or proximal to the PIP joint. We report the functional outcome of patients with replantation or revascularization following complete or incomplete amputations of the PIP joint.
A total of 15 digital replantations or revascularization were performed on 11 patients (9 males and 2 females, age, 26–69 years) with severe finger injuries at the PIP joint at our Medical Center from 2010 through 2012. Seven patients with 10 complete amputations underwent replantations, and 4 with 5 incomplete avulsion amputations underwent revascularization. PIP arthrodesis was performed in all cases. Routine postoperative evaluation was performed in 13 successfully treated patients.
The 13 successfully treated cases were tracked over a follow-up of 12 to 55 months. Arthrodesis of PIP caused significantly lower total active range of motion (TAM; 85–120°). The mean DASH score was 37/100 (range: 10–64 points). Although mobility is poorer in PIP replantations, adequate PIP joint fixation improves DASH score and hand function.
PIP replantation along with arthrodesis at a functional position for a finger amputation should be performed when the patient wishes to undergo replantation, which facilitates patient satisfaction.
KeywordsFinger amputation Finger avulsion Hand surgery outcomes Replantation Revascularization
Regrettably, injured PIP joints seldom regain normal active motion. A total of 15 digital replantations or revascularization were performed for the severe finger injuries at the PIP joint, and 13 successfully treated cases were evaluated. Although mobility is poorer in PIP replantations, adequate PIP joint fixation improves DASH score and hand function. PIP replantation along with arthrodesis at a functional position for a finger amputation facilitates patient satisfaction.
Eighty to ninety percent survival rate of the replantation of amputated fingers is reported in the literature [1, 2]. However, avulsion injuries are commonly cited as having poor functional outcomes after replantation, especially in the case of complete amputation or when there is damage to the proximal phalanx or the proximal interphalangeal (PIP) joint [3–5]. Thus, many investigators recommend revision amputation with skeletal injury at or proximal to the PIP joint . However, a large number of patients desire the replantation of their amputated fingers, and recent functional outcomes of sensibility and range of motion after replantation of finger avulsion injuries are better than what is historical data .
We report the functional outcome of patients with replantation or revascularization following complete or incomplete avulsion amputations at the PIP joint.
Patients and methods
Patient who underwent digital replantations or revascularization with severe finger injuries at the PIP joint. PIP arthrodesis at angle of 45° was performed in all cases
Total Active Motion
index, middle, right, little
Index 60, middle 60, ring 60, little 60
Index 80, middle 80
The mean active flexion of the PIP joint was 0° (arthrodesis), mean total active arc of motion (TAM) was 92 (range: 32–152) degrees and the mean DASH score was 37/100 (range: 10–64 points).
The salvage of amputated fingers has become a common procedure owing to advances in microsurgical technique. When the amputation occurred at the level of the DIP joint, replantation showed advantages including a one-stage procedure, adequate sensibility without painful neuroma, good metacarpophalangeal and PIP joint motion, and a cosmetically pleasing outcome compared with conventional stamp plasty . However, it is still difficult to achieve satisfactory functional results in cases of replantation or revascularization at the level of the PIP joint. Avulsion amputations at the PIP joint are likely to result in permanent disability of the hand . Thus, many investigators considered that replantation of a single finger amputated proximal to the flexor digitorum superficialis insertion was seldom indicated . Soucacos et al. evaluated the functional outcome of 67 successfully replanted single-digit amputations, and concluded that the indications for replantation of a single-digit amputation should be as follows: 1) amputation distal to the insertion of the flexor digitorum superficialis; 2) ring injuries type II and IIIa; and 3) amputations at the level of or distal to the DIP joint . Davis and Chung recommended revision amputation with skeletal injury at or proximal to the PIP joint in patients who are unwilling to accept a poor functional result .
However, when a patient with finger amputation proximal to the PIP joint wants to undergo replantation surgery, what should we do? In our experience, most patients who visited our emergency unit with amputated fingers desired replantation, even though they were informed about the unsatisfactory postoperative hand function. Our study showed that, although mobility is poorer in PIP replantations, patients can acquire a pinch function when the finger can be fixed in a functional position. Adequate PIP joint fixation improves DASH score and hand function. Hattori et al. studied 46 distal amputations in which 20 out of 23 patients in the replantation group always used the replanted finger for activities of daily living, whereas only 9 out of 23 patients in the amputation closure group always used the affected fingers. The replantation group also had less pain and a better DASH score. They concluded that replantation not only facilitated more favorable esthetics, but also a better functional outcome .
Of course, most hand surgeons would expect preservation of the PIP joint. However, as we showed in Case 1, a destroyed joint seldom regains normal activity, which would cause a significant disadvantage for the functional recovery of a hand. Thus, we recommend primary arthrodesis at a functional position following replantation, which would provide the best functional result along with shortening the treatment period.
We believe that PIP replantation along with arthrodesis at a functional position should be performed when the patient wishes to undergo replantation. This method provides both favorable esthetics and an acceptable functional outcome, facilitating patient satisfaction.
The authors herewith certifies that they are responsible for the contents of the manuscript. They have complied with the guidelines for conducting research in human subjects. The procedures are in accordance with the ethical standards of institutional committee on human experimentation of National Hospital Organization Nagasaki Medical Center.
The procedures followed were in accordance with the ethical standards of the National Institutes of Health, our institutional committee on human experimentation, and with the Helsinki Declaration of 1975, as revised in 1983.
Financial disclosure and products
There were no external sources of funding in the form of grants supporting the work presented in this manuscript.
This manuscript has not previously been presented at any meeting.
This article is original and has not previously been published.
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