EDITOR’S CHOICE

Immediate Versus Overnight-Delayed

Digital Replantation: Comparative
Retrospective Cohort Study of Survival
Outcomes
Pedro C. Cavadas, MD, PhD,* Carlos Rubí, MD,† Alessandro Thione, MD, PhD,*
Alberto Pérez-Espadero, MD†

Purpose Ischemia time has been traditionally considered a critical factor in replantation sur-
vival rate. The objective of this study was to compare the survival rate between immediate and
overnight-delayed digital replantation.
Methods We performed a retrospective cohort study of all digital replantations performed at
our clinic between 2005 and 2016. The survival rate was compared between the immediate
digital replantation group (immediate replantation group) and those that were replanted the
morning after they were admitted to the hospital (overnight-delayed replantation group). The
decision to delay the replant was made in cases admitted in the evening with less than 12
hours of previous ischemia time and without farm-related contamination.
Results Five hundred ninety-seven digital replantations (456 patients) were analyzed. One
hundred eighty-five (31%) digital replantations were performed the following day (delayed
replantation group) and 412 (69%) digital replantations were performed the same day that
they were admitted to the hospital (immediate replantation group). The overall survival rate
was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2%
(376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185).
There were no statistically significant differences between the immediate and the delayed
replantation groups with respect to age, zone of amputation, or presence of multiple
amputations.
Conclusions Our study suggests that overnight delay is a safe approach for digital replantation
when performed by experienced microsurgeons. (J Hand Surg Am. 2018;-(-):-e-.
Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic IV.
Key words Replantation, digit, amputation, ischemia, survival rate.

S
From the *Reconstructive Surgery Unit, Clínica Cavadas; and †Private Practice at Hospital INCE THE FIRST REPORTED SURGICAL reattachment
IMED Valencia, Valencia, Spain. of an amputated thumb in 1967,1 replantation
Received for publication March 23, 2017; accepted in revised form February 25, 2018. has become routine in many centers around
No benefits in any form have been received or will be received related directly or the world. Survival rates in digital replantation
indirectly to the subject of this article. range between 53% and 96% according to a recent
Corresponding author: Alessandro Thione, MD, PhD, Clinica Cavadas. Paseo Facultades meta-analysis.2 Although other factors play a role,
1, bajo 8, 46021 Valencia, Spain; e-mail: althione@gmail.com. it is accepted that proper surgical technique is
0363-5023/18/---0001$36.00/0 a critical factor for a successful digital replantation.3
https://doi.org/10.1016/j.jhsa.2018.03.047
Consistently high success rates in digital

Ó 2018 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 DELAYED DIGITAL REPLANTATION
replantation can be achieved only in high-volume
microsurgery centers.
Ischemia time has been traditionally considered a
critical factor in the survival rate but 2 recent meta-
analyses found ischemia time does not have a sig-
nificant influence on the survival of digits replanted
after amputation.2,4 Another recent study found that
only warm ischemia time less than 6 hours and 30
minutes and replantations done during daylight
hours influenced digit survival.5 That study sug-
gested that replantations done in daylight hours,
when feasible, with rested personnel and a fully
staffed operating room, were more likely to be
successful, although the overall success rate of the
series was only 70%. Based on this same observa-
tion, the senior author (P.C.C.) has been using an
overnight-delayed approach for digital replantation
for the last 11 years. This approach consists of
delaying the replantation of amputated fingers in
patients admitted to the hospital after 6 PM, provided
the previous cold ischemia time is less than 12 hours
(6 hours if warm), until the next morning at 8 AM.
We hypothesized that the survival rate is not affected
by the extra time of cold ischemia incurred. The
objective of this study was to compare the survival
rate between immediate digital replantation and
delayed digital replantation.
METHODS
A retrospective analysis of institutional medical re-
cords was undertaken to identify all digital re-
plantations performed at the unit between January
2005 and December 2016. The inclusion criterion
was a complete amputation of 1 or more digits distal
to the palmar-digital crease. All amputated fingers
whose replantation was delayed overnight were kept
in the refrigerator at 4
C to 6
C.
A post hoc power calculation was done to deter-
mine if the sample assembled was sufficiently large to
address the research question. Rate of survival in the
2 groups was considered the primary outcome vari-
able used to establish the power. The number of
predictor variables was determined by the number of
occurrences of interest, replant failures, which was a
total of 48. According to this, up to 6 predictor var-
iables could be modeled. According to the sample
size calculation, the minimum sample size to achieve
a minimally acceptable level of statistical power was
400.6
For each finger, the following variables were
identified: zone of amputation, the age of the patient,
and single- or multiple-digital amputation, which
was considered a surrogate for injury severity.
J Hand Surg Am.
Typically, more severe injuries might be associated
with a greater number of digits amputated. At least 1
arterial and 1 venous anastomosis were done in each
digit. All these variables were considered indepen-
dent. The dependent variable was survival (failure or
success).
Statistical methods
A multivariable analysis was performed using logistic
regression comparing the survival rate between the
immediate digital replantation group and the
overnight-delayed replantation group. A forced entry
method was used with a judicious choosing of the
variables based on a thorough review of the literature.
The survival rates were adjusted by 3 independent
variables and these were presented as odds ratios with
95% confidence intervals. Only 3 independent vari-
ables were included in the model to avoid overfitting.
A P value less than .05 was considered statistically
significant.
The overnight-delay replantation protocol
Patients with amputated digits admitted to the hos-
pital later than 6 PM are replanted the following
morning at 8 AM. In general, only ischemia-sensitive
replants are performed immediately if admitted at
night. These include transmetacarpal or more prox-
imal upper limb amputations, lower limbs, digits
with extended previous ischemia times (> 6 hours
warm or 12 hours cold ischemia), digital amputa-
tions associated with more proximal crushing and
heavily contaminated injuries, or farm-related digital
amputations. The amputated digits are kept at 4
C to
6
C in a refrigerator. The goal is to not exceed 24
hours of total cold ischemia before restoration of
arterial circulation, assuming about 2 hours of
operative time per digit, which is the standard time
for our team. In cases of in-continuity zone I am-
putations connected only by the flexor digitorum
profundus tendon or a stretched and damaged digital
nerve (traction injuries), the amputation was
completed at the bedside (with local anesthesia
instillation if necessary) and the part kept refriger-
ated overnight. Given the minimal active distal
interphalangeal joint flexion and extension after
replantation in zone I, the morbidity added by this
maneuver was considered to be negligible. In zone II
amputations with flexor tendon in continuity, the
replant was performed immediately because there is
no practical way of cooling the digit without
sectioning the flexor tendon.
In order to keep the operative times low (w 2
hours per digit), an artery-last sequence of repairs is
r Vol. -, - 2018
 DELAYED DIGITAL REPLANTATION 3

TABLE 1. The Mean (SD) and the Median (First, Third Quartiles) Were Calculated for Quantitative Variables;
Absolute and Relative Frequencies Were Calculated for Categorical Variables
One-Night Delayed Approach Immediate Approach Total (n ¼ 597)
(n ¼ 185) (31%) (n ¼ 412) (69%) Mean (SD)
Mean (SD) Mean (SD) Median (First,
Variable Median (First Third Quartiles) Median (First, Third Quartiles) Third Quartiles)

Age (y) 38.72 (15.6) 42.78 (13.79) 41.52 (14.47)

39 (29, 50.5) 45 (32, 54) 41.5 (31, 53)
Survival
No (failure) 12 (6.6%) 36 (8.8%) 48 (8.1%)
Yes (success) 174 (93.4%) 375 (91.2%) 549 (91.9%)
Zone
I (60.8%) (68.8%) 396 (66.3%)
II (39.2%) (31.2%) 201 (33.7%)
Finger
1 (32.8%) (19.1%) (23.4%)
2 (19.7%) (28.7%) (25.9%)
3 (23%) (19.9%) (20.8%)
4 (18%) (24.3%) (22.3%)
5 (6.6%) (8.1%) (7.6%)
Unidigital/multidigital
Multidigital (24.6%) (40.8%) 213 (35.8%)
Unidigital (75.4%) (59.2%) 383 (64.2%)
Artery
1 (82%) (89.7%) 521 (87.3%)
2 (18%) (10.3%) 76 (12.7%)
Vein
1 (39.3%) (47.1%) 267 (44.7%)
2 (55.7%) (47.8%) 300 (50.3%)
3 (4.9%) (5.1%) 30 (5.1%)
Vein graft
No (88.5%) (74.3%) 470 (78.7%)
Yes (11.5%) (25.7%) 127 (21.3%)
Gender
Male (83.6%) (82.4%) 494 (82.7%)
Female (16.4%) (17.6%) 103 (17.3%)

followed, sequentially repairing the structures in the
following order under tourniquet control: bone (K-
wires), extensor tendon, dorsal veins, dorsal skin,
artery, nerves, and volar skin. This sequence of re-
pairs allows working in a bloodless field and, in the
senior authors (P.C.C.) experience, is safe and faster
than the more classic sequence of repairing the artery
first. Replantation of 1 digit is a relatively rapid and
straightforward procedure that does not interfere
much with the normal surgical schedule of the day. If
a 2- or more-digit replantation is to be delayed
overnight, the surgery is started at 7 AM to minimize
the impact on the surgical schedule. Four- or more-
digit replants usually require the cancellation
of some scheduled cases or require immediate
overnight replantation, depending on the previous
ischemia time.
RESULTS
Five hundred ninety-seven digital replantations in
456 patients were analyzed. The majority (93%) of
the cases were operated on by the senior author
(P.C.C.). Descriptive statistic values are presented in
Table 1. The mean age was 42 years. There were 494

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4 DELAYED DIGITAL REPLANTATION

DISCUSSION
TABLE 2. Logistic Regression Was Performed to
Test the Effect of Many Variables on Probability of Digital replantation is a sophisticated surgical
Failure procedure that involves judgment and refined skills.
In order to maintain consistently high success rates,
Variable OR 95% CI P Value
the teams need continuous high-volume exposure,
Immediate vs 1.170 0.499e2.980 .73 with 24/7 availability. The logistic burden it adds
delayed approach to an already busy microsurgical practice is sig-
Unidigital/ 0.465 0.203e1.044 .06 nificant, with patients frequently arriving at the
multidigital (Uni) hospital at late hours. The overnight availability of
Vein graft (yes) 1.957 0.759e4.837 .15 the most experienced senior surgeons may be
Zone II 1.133 0.494e2.662 .77 problematic. In small teams, like the authors’, this
Age (y) 0.985 0.957e1.012 .26 is an extra burden for surgeons who already have a
Gender female 0.903 0.306e2.306 .84 busy surgical schedule. The fact that the most
Finger 2 0.873 0.269e2.927 .82 experienced senior surgeons are not usually
Finger 3 0.781 0.222e2.736 .69 involved in finger replantations may, at least in
Finger 4 1.124 0.345e3.832 .85 part, explain the low success rates reported in some
Finger 5 1.645 0.370e6.650 .49 series.
The classic teaching, that longer ischemia times
95% CI, 95% confidence interval; OR, odds ratio. are detrimental to the success of digital replantation,
is not supported by recent literature, which shows
no difference in survival rates below or above 12 h
men (82.7%) and 103 women (17.3%). The level of of ischemia.2,4,7e9 The experience of the senior
amputation was zone I in 396 digits (66.3%) and zone author (P.C.C.) had been the same, and the policy of
II in 201 digits (33.7%). Two hundred thirteen digits overnight-delayed replantation was adopted in 2003.
(35.8%) were replanted in the context of multiple Only 1 recent study including 291 digital replants
digit replantation and 383 digits (64.2%) were shows that ischemia time over 12 hours is a risk
replanted as single digit. Vein grafts were used in 127 factor for replant failure.10 Nonetheless, the main
digits (21.3%). Two arterial anastomoses were done point of the present paper is not to demonstrate that
in 76 digits (12.7%). In 300 digits (50.3%), 2 vein extended ischemia is well tolerated in finger
anastomoses were performed. The digit most replantation (which has already been demonstrated
commonly replanted was the index finger (25.9%), in the literature), but to suggest that delaying the
followed by the thumb (23.4%), the ring (22.3%), the replantation overnight can be a safe and efficient
middle (20.8%), and the little finger (7.6%). maneuver to handle these cases. The findings of the
One hundred eighty-five (31%) digital re- present study are in keeping with the study reported
plantations were performed the morning after by Woo et al11 including 28 digits and 4 hands.
admission (overnight-delayed replantation group) and They reported similar survival rates in delayed
412 (69%) digital replantations were performed the finger replantations compared with immediate
same day of admission (immediate replantation replantation cases and discouraged delayed replan-
group). The survival rate of digital replantation in the tation only in cases of multiple-digit and hand
overnight-delayed replantation group was 93.4% amputations.
(114 of 122) and in the immediate replantation group In our study, there were no statistically significant
was 91.2% (222 of 248). This difference was not differences between the immediate replantation group
statistically significant (odds ratio, 1.15; 95% confi- and the overnight-delayed replantation group, inde-
dence interval, 0.50e2.99; P ¼ .73). pendent of the, age, zone of amputation, use of vein
Neither the age, level of amputation, nor multiple- grafts, or single or multiple amputation. In the
digit amputation negatively affected the survival rate multiple-digit amputation group, the risk for failure
between the 2 groups (Table 2). There were no sta- was higher than in the single-digit replantation group,
tistically significant differences (P > .05) for any of but the difference did not reach statistical significance
these variables comparing the 2 groups. Figure 1 (P ¼ .07).
shows the probability of survival for the different The interference of emergency cases with sched-
categories of every independent variable analyzed in uled surgeries in small teams is also an issue. The
the study. overnight-delayed replantation protocol may

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 DELAYED DIGITAL REPLANTATION 5

SURVIVAL RATE NONSURVIVAL RATE SURVIVAL RATE NONSURVIVAL RATE

100 100

75 75

50 50

25 25

0
0
A DELAYED APPROACH IMMEDIATE APPROACH
B MULTIDIGITAL UNIDIGITAL

SURVIVAL RATE NONSURVIVAL RATE SURVIVAL RATE NONSURVIVAL RATE

100 100

75 75

50 50

25 25

0 0
4 20 40 60 80
ZONE I ZONE II
Age.
C D
FIGURE 1: Probability of survival and 95% confidence intervals are represented for the different categories of all the independent
variables included in the study.

contribute to minimizing this interference, provided
enough experience allows rapid replantation tech-
nique. The present study was performed in a busy
microsurgical, private practice team, with highly
committed members, extensive experience in
replantation surgery, and a very low threshold for
replantation of amputation injuries. These results
should probably not be extrapolated to teams working
in different conditions.
The overnight-delayed replantation approach of-
fers several advantages. It relieves the working
pressure of overnight surgeries on the members of the
team and reduces the overall cost per case. It allows
the surgeries to be performed under optimal condi-
tions, with a rested surgical team and a fully staffed
operating room. This may, in part, explain the good
results obtained in the delayed replantation group, in
keeping with others reporting better survival of re-
plants performed during daylight time.5
The present study has limitations. It is a retro-
spective study, and the data on ischemia time may
not have been accurate. The large size of the
sample and the fact that the vast majority of the
surgeries were performed by a single surgeon are
advantages.
In conclusion, the present study suggests that, in
selected cases, the results of delaying replantation of
digits overnight gives results comparable with those
of immediate replantation. This approach should
be considered only in highly committed and experi-
enced microsurgical teams working in optimal
environments.
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