Functional Outcomes of Single Digit Replantation Versus Revision Amputation

Functional Outcomes of Single Digit Replantation Versus Revision Amputation, a Prospective Study

The purpose of this study is to compare functional outcomes in single digit replantation subjects compared with revision amputation. Functional outcomes will be assessed by DASH (disabilities of the arm, shoulder and hand) score and with Purdue Pegboard Test by the subject's respective hand therapist at their last visit. Results will contribute to generating a preoperative decision algorithm for single digit amputation injuries.

Study Overview

• Status: Recruiting
• Conditions: Amputation; Traumatic, Hand
• Intervention / Treatment: Procedure: Replantation; Procedure: Primary wound closure

Detailed Description

Research design: Prospective observational cohort study

Study population, enrollment, and duration of participation:

Collaborating institutions Revision amputation cohort: CHUM, Santa Cabrini Hospital and Maisonneuve Rosemont Hospital Replantation cohort: CEVARMU/CHUM

Inclusion Criteria: All replantation and revision amputation of single digits who are treated at the collaborating hospital centres Exclusion Criteria: Thumb amputation, Multiple digit amputation, Failure to follow-up with an occupational therapist

Enrollment:

Database encompassing regional plastic surgery interventions will be reviewed to target patients who underwent single digit replantation and revision amputation in the last year, up until the first patient that is not scheduled to come back for evaluation with his hand therapist (as not to introduce a selection bias). Going forward we will run prospectively until we have sufficient data to yield significant results, as the rarity of single digit replantation will be the limiting factor. On call plastic surgery residents at our institution will also be advised to contact the research personnel when they encounter possible candidates at the participating hospitals. The research personnel will in no instance intervene nor influence the decision-making process leading to either revision amputation or replantation of the single digit. Post-operatively, the research personnel will review the patient files to select participants meeting the selection criteria.

Participants will be classified to the following groups according to the intervention performed:

• Replantation group
• Revision amputation group
• Crossover group (initially replanted, then underwent revision amputation) Subgroups
• Injured digit (index, middle, ring, little)

• Injury level: Tamai classification

  • Zone 1 (distal to FDP insertion)
  • Zone 2 (distal to interphalangeal joint until FDP insertion)
  • Zone 3 (middle phalanx distal to FDS insertion)
  • Zone 4 (proximal phalanx until middle phalanx FDS insertion) o Zone 5 (metacarpophalangeal joint and proximal)

• Mechanism of injury o Guillotine

  • Minor crush
  • Major crush o Avulsion

The following data will be retrieved from the patients filles:

Demographic variables/Patient characteristics

• Age
• Gender
• Smoking status: cigarette and cannabis

• Patient comorbidity:

  • Diabetes mellitus
  • Hypertension
• Hand dominance
• Patient preference: cultural beliefs Variables possibly influencing outcome
• Ischemia time
• Workers' compensation
• Revision surgery

• Acute post-op complications o Infection

  • Bleeding
  • Vascular thrombosis o Other

• Chronic complications o Tendon rupture

  • Tendon adhesions
  • Bony malunion
  • Bony non-union
  • Painful neuroma formation o CRPS
  • Other

Evaluation phase and follow-up Each patient's respective hand therapist will then be contacted to be introduced to the research protocol. Instructions regarding patient consent and evaluation tools will be explained. Hand therapists who have the necessary materials and tools to administer the tests and who are willing to participate in the study will receive a copy of the research protocol, detailed instructions regarding their participation and the consent form.

End-of-hand therapy is defined as the last or second-to-last follow-up appointment with the collaborating hand therapist. At this moment, the hand therapist will introduce the patient to the research protocol and will obtain their informed written consent. The DASH score (appendix 1) will then be administered by the occupational therapist in a standardized manner to all participants. Lastly, a quantitative hand function test will be conducted using the Purdue Pegboard according to the standardized procedure described in the user manual by Lafayette Instrument Company, Inc. Both the injured and the non-injured hand will be tested.

A secured online excel sheet will be shared amongst all the collaborating occupational therapists to record the test results.

Statistical Methods:

In order to detect a significant difference in average functional outcome between the two study groups, we will conduct a two-sided t-test using the SPSS software (IBM SPSS, V26, NY). By choosing our cut-off to be 0.05 and a beta of 0.1, we gained 90% power (1 - beta), accordingly we will deem a p-value of ≤ 0.05 as statistically significant. Continuous data will be expressed as mean and standard deviation or median and range, and assessed with t test. Categorical (nominal) data will be summarized as the frequency (%) and we will utilize Pearson Chi-Square and Fisher's exact tests for analysis. We then will analyze the outcomes by logistic regression model comprising two study groups, sex, patient's comorbidities and habit of smoking, and the mechanism of injury. Multiple linear regression analysis will be performed to measure and control confounding variables.

Results obtained from the study will then be used to generate a preoperative decision algorithm for single digit replantation vs. revision amputation. This could help guide clinicians from peripheral centres with questions about medico-legal issues.

Safety Management:

Since the study procedures are not greater than minimal risk, serious adverse events (SAE) are not expected. If any unanticipated problems related to the research involving risks to subjects or others happen during the course of this study (including SAEs) these will be reported to the IRB in accordance with the procedure described in the Mode opératoire normalisé-10: Gestion des évènements indésirables. Adverse events (AEs) that are not serious but that are notable and could involve risks to subjects will be summarized in narrative or other format and submitted to the CÉR at the time of continuing review.

• Study Type: Observational
• Enrollment (Anticipated): 30

Contacts and Locations

• Study Contact: Name: Ophelie Doucet; Phone Number: 5148908000; Email: [email protected]

Study Locations

• Canada
  • Quebec
    • Montréal-Est, Quebec, Canada, H1T2M4
      • Recruiting
      • Maisonneuve-Rosemont Hospital
      • Contact: Ophelie Doucet, MD; Phone Number: 438-882-9681; Email: [email protected]

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 99 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

All subjects who have suffered a single digit amputation who are treated at the collaborating hospital centres

Description

Inclusion Criteria:

• Replantation of single digits treated at collaborating hospital centres
• Revision amputation of single digits treated at collaborating hospital centres

Exclusion Criteria:

• Thumb amputation
• Multiple digit amputation
• Failure to follow-up with hand therapist

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Replantation; This group will include subjects who suffered a single digit non-thumb amputation, and whose finger was replanted.	Procedure: Replantation; Surgical reattachment of a severed body part
Revision Amputation; This group will include subjects who suffered a single digit non-thumb amputation, and whose finger was not replanted.	Procedure: Primary wound closure; Primary wound closure with removal of exposed bone

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Functional outcome by DASH score	Measured by DASH score (higher scores indicate a greater level of disability, score range from 0 to 100)	Immediately following patient discharge from hand therapy
Functional outcome by Purdue Pegboard Test	Measured by Purdue Pegboard Test (higher scores indicate a greater level of dexterity and functionality and are typically compared with normative data stratified on the basis of age, score range depends on how the test is administered)	Immediately following patient discharge from hand therapy
Functional outcome by Michigan Hand Questionnaire	Measured by Michigan Hand Questionnaire (higher scores indicate a greater level of functionality, score range from 0 to 100)	Immediately following patient discharge from hand therapy

Collaborators and Investigators

• Sponsor: Centre hospitalier de l'Université de Montréal (CHUM)
• Investigators: Principal Investigator: Bruno Mastropasqua, MD, Université de Montréal

Publications and helpful links

General Publications

• Stone N, Shah A, Chin B, McKinnon V, McRae M. Comparing digital replantation versus revision amputation patient reported outcomes for traumatic digital amputations of the hand: A systematic review and meta-analysis. Microsurgery. 2021 Jul;41(5):488-497. doi: 10.1002/micr.30738. Epub 2021 Apr 3.
• Kaplan FT, Raskin KB. Indications and surgical techniques for digit replantation. Bull Hosp Jt Dis. 2001-2002;60(3-4):179-88.
• Tejedor Navarro A, Vendrell Jorda M, Puente Alonso C. Digital replantation/revascularization: predictive factors to microsurgery success-a single-center study. Eur J Trauma Emerg Surg. 2021 Feb;47(1):225-232. doi: 10.1007/s00068-019-01226-x. Epub 2019 Sep 24.
• Zhu H, Bao B, Zheng X. A Comparison of Functional Outcomes and Therapeutic Costs: Single-Digit Replantation versus Revision Amputation. Plast Reconstr Surg. 2018 Feb;141(2):244e-249e. doi: 10.1097/PRS.0000000000004024.
• Shaterian A, Sayadi LR, Tiourin E, Gardner DJ, Evans GRD, Leis A. Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis. Hand (N Y). 2021 Jan;16(1):11-17. doi: 10.1177/1558944719834658. Epub 2019 Apr 2.

Study record dates

Study Major Dates

• Study Start (Actual): January 17, 2023
• Primary Completion (Anticipated): May 15, 2024
• Study Completion (Anticipated): November 15, 2024

Study Registration Dates

• First Submitted: November 1, 2021
• First Submitted That Met QC Criteria: November 30, 2021
• First Posted (Actual): December 14, 2021

Study Record Updates

• Last Update Posted (Actual): January 23, 2023
• Last Update Submitted That Met QC Criteria: January 19, 2023
• Last Verified: January 1, 2023

More Information

Terms related to this study

• Keywords: function; DASH; Replantation; Single digit
• Additional Relevant MeSH Terms: Wounds and Injuries; Amputation, Traumatic
• Other Study ID Numbers: 2022-10233

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No