Department of Hand Surgery, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, PR China.
Clin Orthop Relat Res. 2023 Aug 1;481(8):1583-1594. doi: 10.1097/CORR.0000000000002578. Epub 2023 Feb 16.
Ensuring the patency of repaired vessels is pivotal in improving the success rate of digit replantation. There is no consensus on how to best approach postoperative treatment for digit replantation. The influence of postoperative treatment on the risk of failure of revascularization or replantation remains unclear.
QUESTIONS/PURPOSES: (1) Is there an increased risk of postoperative infection with early discontinuation of antibiotic prophylaxis? (2) How are anxiety and depression affected by a treatment protocol consisting of prolonged antibiotic prophylaxis and administration of antithrombotic and antispasmodic drugs and by the failure of a revascularization or replantation procedure? (3) Are there differences in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins? (4) What factors are associated with failure of revascularization or replantation?
This retrospective study was conducted between July 1, 2018, and March 31, 2022. Initially, 1045 patients were identified. One hundred two patients chose revision of amputation. In all, 556 were excluded because of contraindications. We included all patients in whom the anatomic structures of the amputated part of the digit were well preserved, and those with an ischemia time for the amputated part that did not exceed 6 hours. Patients in good health without any other serious associated injuries or systemic diseases and those without a history of smoking were eligible for inclusion. The patients underwent procedures that were performed or supervised by one of four study surgeons. Patients were treated with antibiotic prophylaxis (1 week); patients treated with antithrombotic and antispasmodic drugs were categorized into the prolonged antibiotic prophylaxis group. The remaining patients treated with antibiotic prophylaxis for less than 48 hours and no antithrombotic and no antispasmodic drugs were categorized into the nonprolonged antibiotic prophylaxis group. Postoperative follow-up was for a minimum of 1 month. Based on the inclusion criteria, 387 participants with 465 digits were selected for an analysis of postoperative infection. Twenty-five participants with a postoperative infection (six digits) and other complications (19 digits) were excluded from the next stage of the study, in which we assessed factors associated with the risk of failure of revascularization or replantation. A total of 362 participants with 440 digits were examined, including the postoperative survival rate, variation in Hospital Anxiety and Depression Scale scores, the association between the survival rate and Hospital Anxiety and Depression Scale scores, and the survival rate based on the number of anastomosed vessels. Postoperative infection was defined as swelling, erythema, pain, purulent discharge, or a positive bacterial culture result. Patients were followed for 1 month. The differences in anxiety and depression scores between the two treatment groups and the differences in anxiety and depression scores based on failure of revascularization or replantation were determined. The difference in the risk of revascularization or replantation failure based on the number of anastomosed arteries and veins was assessed. Except for statistically significant variables (injury type and procedure), we thought that the number of arteries, number of veins, Tamai level, treatment protocol, and surgeons would be important. A multivariable logistic regression analysis was used to perform an adjusted analysis of risk factors such as postoperative protocol, injury type, procedure, number of arteries, number of veins, Tamai level, and surgeon.
Postoperative infection did not appear to increase without prolonged use of antibiotic prophylaxis beyond 48 hours (1% [3 of 327] versus 2% [3 of 138]; OR 2.4 [95% confidence interval (CI) 0.5 to 12.0]; p = 0.37). Intervention with antithrombotic and antispasmodic therapy increased the Hospital Anxiety and Depression Scale scores for anxiety (11.2 ± 3.0 versus 6.7 ± 2.9, mean difference 4.5 [95% CI 4.0 to 5.2]; p < 0.01) and depression (7.9 ± 3.2 versus 5.2 ± 2.7, mean difference 2.7 [95% CI 2.1 to 3.4]; p < 0.01). In the analysis based on the failure of revascularization or replantation, the Hospital Anxiety and Depression Scale scores for anxiety (11.4 ± 4.4 versus 9.7 ± 3.5, mean difference 1.7 [95% CI 0.6 to 2.8]; p < 0.01) and depression (8.5 ± 4.6 versus 7.0 ± 3.1, mean difference 1.5 [95% CI 0.5 to 2.5]; p < 0.01) were higher in the failed revascularization or replantation group than in the successful revascularization or replantation group. There was no increase in the artery-related risk of failure (one versus two anastomosed arteries: 91% versus 89%, OR 1.3 [95% CI 0.6 to 2.6]; p = 0.53). For patients with anastomosed veins, a similar outcome was observed for the two vein-related risk of failure (two versus one anastomosed vein: 90% versus 89%, OR 1.0 [95% CI 0.2 to 3.8]; p = 0.95) and three vein-related risk of failure (three versus one vein anastomosed: 96% versus 89%, OR 0.4 [95% CI 0.1 to 2.4]; p = 0.29). Factors associated with failure of revascularization or replantation included the mechanism of injury (crush: OR 4.2 [95% CI 1.6 to 11.2]; p < 0.01, avulsion: OR 10.2 [95% CI 3.4 to 30.7]; p < 0.01). Revascularization had a lower risk of failure than replantation (OR 0.4 [95% CI 0.2 to 1.0]; p = 0.04). Treatment with a protocol of prolonged antibiotics, antithrombotics, and antispasmodics was not associated with a lower risk of failure (OR 1.2 [95% CI 0.6 to 2.3]; p = 0.63).
With proper wound debridement and patency of repaired vessels, prolonged use of antibiotic prophylaxis and regular antithrombotic and antispasmodic treatment may not be necessary for successful digit replantation. However, it may be associated with higher Hospital Anxiety and Depression Scale scores. Postoperative mental status is associated with digit survival. Well-repaired vessels, instead of the number of anastomosed vessels, could be critical to survival and decrease the influence of risk factors. Further research on consensus guidelines that compare postoperative treatment and the surgeon's level of expertise after digit replantation should be conducted at multiple institutions.
Level III, therapeutic study.
确保修复后的血管通畅是提高断指再植成功率的关键。对于断指再植术后的治疗方法尚未达成共识。术后治疗对再植或再血管化失败风险的影响尚不清楚。
问题/目的：（1）早期停止预防性使用抗生素是否会增加术后感染的风险？（2）治疗方案包括延长抗生素预防、使用抗血栓和抗痉挛药物以及再植或再血管化失败，焦虑和抑郁会受到怎样的影响？（3）吻合的动静脉数量是否会影响再植或再血管化的失败风险？（4）哪些因素与再植或再血管化失败有关？
本回顾性研究于 2018 年 7 月 1 日至 2022 年 3 月 31 日进行。最初，有 1045 名患者入选。102 名患者选择了修改截肢。共有 556 名患者因禁忌证被排除。我们纳入了所有指体断离部位解剖结构保存良好的患者，以及指体缺血时间不超过 6 小时的患者。纳入身体健康、无其他严重合并伤或系统性疾病、无吸烟史的患者。患者接受由四位研究医生之一进行的手术或监督。患者接受抗生素预防治疗（1 周）；接受抗血栓和抗痉挛药物治疗的患者被分为延长抗生素预防组。其余接受少于 48 小时抗生素预防且未接受抗血栓和抗痉挛药物治疗的患者被分为非延长抗生素预防组。术后随访至少 1 个月。根据纳入标准，387 名参与者的 465 个指体被纳入术后感染的分析。25 名参与者（6 个指体）发生术后感染和其他并发症（19 个指体），被排除在下一阶段研究中，在此阶段，我们评估了与再植或再血管化失败风险相关的因素。共有 362 名参与者的 440 个指体接受了检查，包括术后存活率、医院焦虑和抑郁量表评分的变化、存活率与医院焦虑和抑郁量表评分的关系，以及基于吻合血管数量的存活率。术后感染定义为肿胀、红斑、疼痛、脓性分泌物或细菌培养阳性。患者随访 1 个月。比较两组之间的焦虑和抑郁评分差异，以及再植或再血管化失败的焦虑和抑郁评分差异。评估吻合动脉数量与再植或再血管化失败风险之间的差异。除了统计学上显著的变量（损伤类型和手术）外，我们认为动脉数量、静脉数量、Tamai 分级、治疗方案和外科医生是重要的。采用多变量逻辑回归分析对术后方案、损伤类型、手术、动脉数量、静脉数量、Tamai 分级和外科医生等危险因素进行调整分析。
术后感染似乎不会因超过 48 小时而延长使用抗生素预防而增加（1%[3/327]与 2%[3/138]；比值比 2.4[95%置信区间（CI）0.5 至 12.0]；p=0.37）。使用抗血栓和抗痉挛药物治疗会增加医院焦虑和抑郁量表的焦虑评分（11.2±3.0 与 6.7±2.9，平均差异 4.5[95%CI 4.0 至 5.2]；p<0.01）和抑郁评分（7.9±3.2 与 5.2±2.7，平均差异 2.7[95%CI 2.1 至 3.4]；p<0.01）。基于再植或再血管化失败的分析中，焦虑评分（11.4±4.4 与 9.7±3.5，平均差异 1.7[95%CI 0.6 至 2.8]；p<0.01）和抑郁评分（8.5±4.6 与 7.0±3.1，平均差异 1.5[95%CI 0.5 至 2.5]；p<0.01）在再植或再血管化失败组中较高。动脉相关的失败风险没有增加（1 个与 2 个吻合动脉：91%与 89%，比值比 1.3[95%CI 0.6 至 2.6]；p=0.53）。对于吻合静脉的患者，两种静脉相关的失败风险（2 个与 1 个吻合静脉：90%与 89%，比值比 1.0[95%CI 0.2 至 3.8]；p=0.95）和三种静脉相关的失败风险（3 个与 1 个吻合静脉：96%与 89%，比值比 0.4[95%CI 0.1 至 2.4]；p=0.29）也观察到类似的结果。与再植或再血管化失败相关的因素包括损伤机制（挤压伤：比值比 4.2[95%CI 1.6 至 11.2]；p<0.01，撕脱伤：比值比 10.2[95%CI 3.4 至 30.7]；p<0.01）。再植的失败风险低于再血管化（比值比 0.4[95%CI 0.2 至 1.0]；p=0.04）。使用延长抗生素、抗血栓和抗痉挛药物的方案治疗与失败风险降低无关（比值比 1.2[95%CI 0.6 至 2.3]；p=0.63）。
在适当的伤口清创和修复血管通畅的情况下，成功的断指再植可能不需要延长使用抗生素预防和定期使用抗血栓和抗痉挛药物。然而，这可能与更高的医院焦虑和抑郁量表评分相关。术后心理状态与指体存活率相关。吻合良好的血管，而不是吻合的静脉数量，可能是存活的关键，并降低危险因素的影响。应该在多个机构进行比较术后治疗和外科医生水平的共识指南的进一步研究。
III 级，治疗研究。
