BACKGROUND Replantation is an established treatment for traumatic upper extremity amputation. Only a few studies, however, have assessed the patient-reported outcomes of replantation, and the findings of these studies have been conflicting. QUESTIONS/PURPOSES (1) Is replantation associated with better hand function than revision amputation? (2) Is replantation associated with better health-related quality of life, less painful cold intolerance, and more pleasing hand esthetics than revision amputation after a traumatic hand amputation? METHODS In this retrospective, comparative study, we collected the details of all patients who sustained a traumatic upper extremity amputation and were treated at the study hospital. Between 2009 and 2019, we treated 2250 patients, and we considered all patients who sustained a traumatic amputation of two or more digital rays or a thumb as potentially eligible. Based on that, 15% (334 of 2250) were eligible; a further 2% (8 of 334) were excluded because of a subsequent new traumatic amputation or bilateral amputation, and another 22% (72 of 334) refused participation, leaving 76% (254 of 334) for analysis here. The primary outcome was the DASH score. Secondary outcomes included health-related quality of life (EuroQOL-5D [EQ-5D-5L] Index), painful cold intolerance (the Cold Intolerance Symptom Severity score), and hand esthetics (the Michigan Hand Questionnaire aesthetic domain score). The minimum follow-up time for inclusion was 18 months. Patients were classified into two treatment groups: replantation (67% [171 of 254], including successful replantation in 84% [144 of 171] and partially successful replantation in 16% [27 of 171], in which some but not all of the replanted tissue survived), and revision (complete) amputation (33% [83 of 254], including primary revision amputation in 70% [58 of 83] and unsuccessful replantation followed by secondary amputation in 30% [25 of 83]). In this cohort, replantation was performed if possible, and the reason for choosing primary revision amputation over replantation was usually an amputated part that was too severely damaged (15% [39 of 254]) or was unattainable (2% [4 of 254]). Some patients (3% [8 of 254]) refused to undergo replantation, or their health status did not allow replantation surgery and postoperative rehabilitation (3% [7 of 254]). Gender, age (mean 48 ± 17 years in the replantation group versus 50 ± 23 years in the revision amputation group; p = 0.41), follow-up time (8 ± 4 years in the replantation group versus 7 ± 4 years in the revision amputation group; p = 0.18), amputation of the dominant hand, smoking, extent of tissue loss, or presence of arterial hypertension did not differ between the groups. Patients in the replantation group less frequently had diabetes mellitus (5% [8 of 171] versus 12% [10 of 83]; p = 0.03) and dyslipidemia (4% [7 of 171] versus 11% [9 of 83]; p = 0.04) than those in the revision group and more often had cut-type injuries (75% [129 of 171] versus 60% [50 of 83]; p = 0.02). RESULTS After controlling for potential confounding variables such as age, injury type, extent of tissue loss before treatment, and accident of the dominant hand, replantation was not associated with better DASH scores than revision amputation (OR 0.82 [95% confidence interval (CI) 0.50 to 1.33]; p = 0.42). After controlling for potential cofounding variables, replantation was not associated with better EQ-5D-5L Index scores (OR 0.93 [95% CI 0.56 to 1.55]; p = 0.55), differences in Cold Intolerance Symptom Severity scores (OR 0.85 [95% CI 0.51 to 1.44]; p = 0.79), or superior Michigan Hand Questionnaire esthetic domain scores (OR 0.73 [95% CI 0.43 to 1.26]; p = 0.26) compared with revision amputation. CONCLUSION Replantation surgery was conducted, if feasible, in a homogenous cohort of patients who underwent amputation. If the amputated tissue was too severely damaged or replantation surgery was unsuccessful, the treatment resulted in revision (complete) amputation, which was not associated with worse patient-reported outcomes than successful replantation. These results contradict the assumed benefits of replantation surgery and indicate the need for credible evidence to better guide the care of these patients. LEVEL OF EVIDENCE Level III, therapeutic study.

中文翻译：

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与修正性截肢相比，创伤性截肢后的再植与更好的手部功能相关吗？

背景技术再植是创伤性上肢截肢的一种既定治疗方法。然而，只有少数研究评估了患者报告的再植结果，并且这些研究的结果相互矛盾。问题/目的 (1) 再植与修正截肢相比是否能带来更好的手部功能？(2) 与创伤性手部截肢后的修正截肢相比，再植是否会带来更好的健康相关生活质量、更少的寒冷不耐受疼痛以及更令人愉悦的手部美观？方法 在这项回顾性比较研究中，我们收集了所有遭受创伤性上肢截肢并在研究医院接受治疗的患者的详细信息。2009 年至 2019 年间，我们治疗了 2250 名患者，我们认为所有遭受两根或多根手指或拇指创伤性截肢的患者都可能符合资格。据此，15%（2250 人中的 334 人）符合资格；另外 2%（334 人中的 8 人）因随后发生新的创伤性截肢或双侧截肢而被排除，另外 22%（334 人中的 72 人）拒绝参与，留下 76%（334 人中的 254 人）在此进行分析。主要结果是 DASH 评分。次要结局包括健康相关的生活质量（EuroQOL-5D [EQ-5D-5L]指数）、疼痛的寒冷不耐受（寒冷不耐受症状严重程度评分）和手部美学（密歇根手部问卷美学领域评分）。纳入的最短随访时间为 18 个月。患者被分为两个治疗组：再植（67％[254 人中的 171 人]，其中 84％[171 人中的 144 人]成功再植，16％[171 人中的 27 人]部分成功再植，其中部分但不是全部再植组织存活）和翻修（完全）截肢（33% [254 人中的 83 人]，包括 70% 的初次翻修截肢 [83 人中的 58 人]，以及 30% 的再植失败后进行二次截肢 [83 人中的 25 人]）。在这个队列中，如果可能的话就进行再植，选择初次翻修截肢而不是再植的原因通常是截肢部位损坏太严重（15% [254 中的 39]）或无法实现（2% [254 中的 4]） ）。一些患者（3%[254人中的8人]）拒绝接受再植，或者他们的健康状况不允许进行再植手术和术后康复（3%[254人中的7人]）。性别、年龄（再植组平均 48 ± 17 岁，翻修截肢组平均 50 ± 23 岁；p = 0.41）、随访时间（再植组平均 8 ± 4 年，翻修组平均 7 ± 4 年）截肢组；p = 0.18），优势手截肢、吸烟、组织损失程度或动脉高血压的存在在各组之间没有差异。再植组患者患糖尿病的频率较低（5% [171 人中的 8 人] 对比 12% [83 人中的 10 人]；p = 0.03）和血脂异常（4% [171 人中的 7人] 对比 11% [83 人中的 9人]； p = 0。04）比翻修组的患者更常见，且更常发生割伤（75% [171 人中的 129 人] vs 60% [83 人中的 50 人]；p = 0.02）。结果 在控制了年龄、损伤类型、治疗前组织损失程度以及惯用手意外等潜在混杂变量后，与翻修截肢相比，再植与更好的 DASH 评分无关（OR 0.82 [95% 置信区间 (CI)） 0.50 至 1.33]；p = 0.42）。控制潜在的共同变量后，再植与更好的 EQ-5D-5L 指数评分（OR 0.93 [95% CI 0.56 至 1.55]；p = 0.55）、寒冷不耐受症状严重程度评分的差异（OR 0.85 [95%]）无关。与修正截肢相比，CI 0.51 至 1.44]；p = 0.79），或优于密歇根手问卷美学领域评分（OR 0.73 [95% CI 0.43 至 1.26]；p = 0.26）。结论 如果可行，再植手术是在接受截肢的同质患者队列中进行的。如果截肢组织损伤太严重或再植手术不成功，则治疗会导致修正（完全）截肢，这与患者报告的比成功再植更差的结果无关。这些结果与再植手术的假定益处相矛盾，并表明需要可靠的证据来更好地指导这些患者的护理。证据级别 III 级，治疗研究。