Digital Nerve Injury: Assessment and Treatment.

Undertreated digital nerve injuries may result in sensory deficits and pain. Early recognition and treatment will optimize outcomes, and providers should maintain a high index of suspicion when assessing patients with open wounds. Acute, sharp lacerations may be amenable to direct repair while avulsion injuries or delayed repairs require adequate resection and bridging with nerve autograft, processed nerve allograft, or conduits. Conduits are most appropriate for gaps less than 15 mm, and processed nerve allografts have demonstrated reliable outcomes across longer gaps.

Patient outcomes and costs after isolated flexor tendon repairs of the hand.

BACKGROUND: Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries. PURPOSE: We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care. STUDY DESIGN: A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued. METHODS: A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs. RESULTS: The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation. CONCLUSION: Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair.

STUDY DESIGN: Interpretive description study. PURPOSE: In management of patients with flexion tendon injuries, passive, control active and active motion protocols were proposed after repair to minimize tendon adhesion. The purpose of this study was to compare the excursion distance and the tension of Flexor Digitorum Profundus (FDP) during simulated active and passive motion using ultrasonography techniques using normal subjects. METHODS: Ultrasonographic assessment of FDP tendon of the middle finger was performed at the wrist level on 20 healthy college students using 3 types of treatment protocols: modified Kleinert protocol, modified Duran protocol, and active finger flexion protocol. The excursion distance was measured following the musculotendinous junction of FDP using the B mode ultrasound system. The elasticity of FDP tendon was measured using the shear wave elastography technique. The excursion distance and the elasticity value were compared among 3 protocols using one-way ANOVA analysis. RESULTS: Twelve male and 8 female students with mean age of 22.6 ± 1.8 years were invited to join the study. The excursion distance of FDP was 21.82 ± 3.77 mm using the active finger flexion protocol, 8.59 ± 2.59 mm using the modified Duran protocol, and 12.26 ± 2.71 mm using the modified Kleinert protocol. The elasticity was significantly higher in extension position when compared to passive flexion positions, but found lower than active flexion position. DISCUSSION: The active finger protocol was found to require strongest tension of the tendon and with longest excursion. There was similar tension generated using both passive motion protocols. The modified Duran protocol appeared to create less excursion upon movements than the modified Kleinert approach using the objective ultrasonic evaluation. It is suggested that if the surgical repair was strong and without any complications, the active flexion protocol might work best to regain tension excursion. However, if there are complex problems involved, then the Kleinert approach or Duran approach would be chosen.

Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation.

PURPOSE: Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation. METHODS: Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted. RESULTS: Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission. CONCLUSIONS: In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Clinical Applications of Meshed Multilayered Anatomical Models by Low-Cost Three-Dimensional Printer.

SUMMARY: In recent years, even low-cost fused deposition modeling-type three-dimensional printers can be used to create a three-dimensional model with few errors. The authors devised a method to create a three-dimensional multilayered anatomical model at a lower cost and more easily than with established methods, by using a meshlike structure as the surface layer. Fused deposition modeling-type three-dimensional printers were used, with opaque polylactide filament for material. Using the three-dimensional data-editing software Blender (Blender Foundation, www.blender.org) and Instant Meshes (Jakob et al., https://igl.ethz.ch/projects/instant-meshes/) together, the body surface data were converted into a meshlike structure while retaining its overall shape. The meshed data were printed together with other data (nonmeshed) or printed separately. In each case, the multilayer model in which the layer of the body surface was meshed could be output without any trouble. It was possible to grasp the positional relationship between the body surface and the deep target, and it was clinically useful. The total work time for preparation and processing of three-dimensional data ranged from 1 hour to several hours, depending on the case, but the work time required for converting into a meshlike shape was about 10 minutes in all cases. The filament cost was $2 to $8. In conclusion, the authors devised a method to create a three-dimensional multilayered anatomical model to easily visualize positional relationships within the structure by converting the surface layer into a meshlike structure. This method is easy to adopt, regardless of the available facilities and economic environment, and has broad applications.

A cadaveric assessment of percutaneous trigger finger release with 15° stab knife: its effectiveness and complications.

Percutaneous release of the A1 pulley has been introduced as a therapeutic approach for trigger fingers and is suggested as an effective and safe alternative, where conservative treatments fail. The aim of the current study was to determine if percutaneous release with a 15° stab knife can effectively result in acceptable efficacy and lower complication rate. METHODS: In the present study, the percutaneous release of the A1 pulley was evaluated by percutaneous release using a 15° stab knife in 20 fresh-frozen cadaver hands (10 cadavers). One hundred fingers were finally included in the present study. The success rate of A1 pulley release as well as the complications of this method including digital vascular injury, A2 pulley injury, and superficial flexor tendon injury was evaluated, and finally, the data were analyzed by the SPSS software. RESULTS: The results showed a success rate of 75% for A1 pulley release in four fingers, followed by eleven fingers (90%) and eighty-five fingers (100%). Therefore, the A1 pulley was found to be completely released in eighty-five fingers (100%). Overall, the mean of A1 pulley release for these fingers was determined as 97.9%, indicating that percutaneous trigger finger release can be an effective technique using a 15° stab knife. Furthermore, our findings revealed no significant difference in the amount of A1 pulley release in each of the fingers in the right and left hands. Additionally, 17 fingers developed superficial scrape in flexor tendons, while 83 fingers showed no flexor tendons injuries and no other injuries (i.e., vascular, digital nerve, and A2 pulley injuries). CONCLUSIONS: Percutaneous release of the A1 pulley using a 15° stab knife was contributed to acceptable efficacy and a relatively good safety in the cadaveric model.

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution.

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6 months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes-Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3 months) as compared with adult patients (4.1 months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable.Level of evidence: IV.

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation.

Importance: Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation. Objective: To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success. Design, Setting, and Participants: This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020. Exposures: Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation. Main Outcomes and Measures: Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes. Results: Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level. Conclusions and Relevance: In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.

Assessment of sensory outcomes after successful fingertip replantation with or without nerve repair according to amputation level.

BACKGROUND: Good sensory outcome in fingertip replantation is a major part of the success of reconstruction and using the finger. Although some sensorial outcomes have been reported in various series in the literature, there is no controlled study, which demonstrates the anatomical levels where nerve repair should or should not be performed. We aimed to assess sensorial outcomes of fingertip amputations with or without nerve coaptation according to amputation level. METHODS: Between January 2013 and July 2018, patients with Tamai Zone 1 and Zone 2 amputations underwent replantation. The patients were divided two main groups. Patients underwent nerve coaptation were grouped as Group 1, and those coaptation not performed as Group 2. In addition, subgroups were designed according to level of the amputation. Tamai zone 1 amputations were grouped as groups 1a and 2a. Tamai zone 2 amputations were grouped as groups 1b and 2b. The mean age was 30.8 ± 30.8 years in Group 1a, 33.2 ± 12.6 years in Group 1b, 34.1 ± 13.6 years in Group 2a, 34.3 ± 11.1 years in Group 2b. Type of injury were evaluated as clean cut (with knife, saw etc.), moderately crushed, and severely crushed and/or avulsion. In Group 1a, one prominent branch of the nerve was repaired, and in Group 1b, the nerve in both side was repaired. The mean duration of replantation in Group 1a was 1 h and 40 min (1 h and 15 min-2 h), whereas this time was 1 h and 15 min (1 h - 1 h and 35 min) in Group 2a. Then, 2 h 15 min (1 h and 55 min-2 h and 50 min) in Group 1b, and 2 h (1 h and 45-2 h 25 min) in Group 2b. Mean age, type of injury and length of follow-up were statistically compared. Sensorial outcome was evaluated by 2-point discrimination test and the Semmes-Weinstein test. RESULTS: According to the Semmes-Weinstein test, 33% of the fingers tested were normal, 58% had diminished light touch, 8% had diminished protective sensation, and 0% had loss of protective sensation in Group 1a; In Group 1b, these values were 35% (7/20), 55% (11/20), 10% (2/20), 0%; in Group 2a, 38% (6/16), 56% (9/16), 6% (1/16), 0%; in Group 2b, 25% (4/16), 44% (7/16), %25 (4/16), 6% (1/16), respectively Mean static two-point discriminations in Groups 1a, 1b, 2a, and 2b were 4.17 ± 0.58, 4.55 ± 0.69, 4.25 ± 0.68, and 5.9 ± 1.26 mm, respectively. The mean follow-up duration was 24 months in Group 1a, 24 months in Group 1b, 26 months in Group 2a, 21 months in Group 2b. Then, 17 (3 in Group 1a, 6 in Group 1b, 4 in Group 2a, 4 in Group 2b) of the 64 fingers were clean cut amputation, 45 (9 in Group 1a, 14 in Group 1b, 11 in Group 2a, 11 in Group 2b) were moderately crushed amputation, and 2 (1 in Group 2a, 1 in Group 2b) were severely crushed and/or avulsion injury. There was no statistically significant difference between groups 1a and 2a (p = .71). On the other hand, there was a statistically significant increase in sensory outcomes of patients in Group 1b compared to Group 2b (p = .009). There was no statistically significant between the groups in terms of mean age, type of injury and length of follow-up. CONCLUSION: We think that nerve repair does not have a positive effect on sensorial recovery in Tamai Zone 1 amputations, but nerve coaptation should be performed in Tamai Zone 2 replantations if possible for better sensorial result.

Functional and Disability Assessment Among Hispanics With Zone 2 Flexor Tendon Injuries: Comparative Study Between Flexor Digitorum Superficialis Repair and Flexor Digitorum Superficialis Excision.

INTRODUCTION: Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients. METHODS: Total active motion, original Strickland criteria, and the disability of arm shoulder and hand questionnaire were provided postoperatively at 3 and 6 months to all consecutive Hispanic patients who underwent zone II flexor tendon repair. The cohort was divided into two groups, those who underwent FDS repair and those underwent FDS excision. RESULTS: Functional and disability outcome analysis showed a notable improvement with FDS repair using total active motion, Strickland criteria, and disability of arm shoulder and hand score at the 3 months postoperative interval. No statistical differences were identified regarding functional and disability outcomes at the 6-month evaluation between both groups. CONCLUSIONS: Among Hispanics, the FDS-repaired group had similar functional and disability outcomes at their 6 months postoperative evaluation compared with the FDS-excised group. Increased awareness for tendon rerupture during the initial 3 months of index surgery is recommended for FDS-excised patients.

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations.

Importance: Optimal treatment for traumatic finger amputation is unknown to date. Objective: To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint. Design, Setting, and Participants: This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis. Exposures: Treatment with revision amputation or replantation. Main Outcomes and Measures: Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation. Results: Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries. Conclusions and Relevance: The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.

Cost-Effectiveness of Initial Revision Digit Amputation Performed in the Emergency Department Versus the Operating Room.

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR (P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

Cost-effectiveness of Finger Replantation Compared With Revision Amputation.

Importance: Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown. Objective: To assess the cost-effectiveness of finger replantation compared with revision amputation. Design, Setting, and Participants: This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis. Exposures: Revision amputation or replantation of traumatic finger amputations. Main Outcomes and Measures: Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness. Results: Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns. Conclusions and Relevance: With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.

An In-Depth Review of Physician Reimbursement for Digit and Thumb Replantation.

PURPOSE: To examine physician and hospital reimbursement for digit and thumb replantation compared with revision amputation. METHODS: Using the 2009-2016 Truven Health MarketScan Research Databases, we identified patients with a digit or thumb amputation. Following application of our inclusion and exclusion criteria, we divided patients into replantation and revision amputation groups. We extracted the mean physician and hospital reimbursement associated with each patient encounter. For comparison, we examined the work Relative Value Unit (wRVU) and Medicare Physician Fee Schedule (MPFS) for the respective procedures in addition to several common hand surgery procedures. RESULTS: We identified 51,716 patients. Following application of our inclusion and exclusion criteria, 219 replantation and 6,209 revision amputation patients were included in our analysis. For replantation, the mean physician and hospital reimbursements ranged from $3,938 to $7,753 and $30,683 to $56,256, respectively. For revision amputation, the mean physician and hospital reimbursements ranged from $1,030 to $1,206 and $2,877 to $4,188, respectively. On multivariable analysis, hospitals performing replantation earned $37,788 more per case compared with revision amputation. Using the wRVU and MPFS data, we determined that replantation reimburses at $78/wRVU compared with higher earnings for revision amputation ($108), carpal tunnel release ($101), cubital tunnel release ($97), trigger finger release ($116), open reduction and internal fixation (ORIF) distal radius fracture ($87), flexor tendon repair ($98), extensor tendon repair ($122), repair of digital nerve ($89), and ORIF articular fracture ($82), respectively. CONCLUSIONS: Low physician reimbursement for replantation compared with less complex hand procedures makes it difficult to recruit and retain hand surgeons for this purpose. By understanding the wRVU and MPFS system, hand surgeons and professional societies can explore ways to promote change in the way replantation is valued by the Centers for Medicare and Medicaid Services (CMS) as well as by hospital administrators. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

[Finger amputation following a minor injury: insurance aspects in Germany and practical approaches]. / Fingeramputation nach Bagatellverletzung ­ versicherungsrechtliche Aspekte in Deutschland und praktische Herangehensweise.

Expert medical assessments are an integral part of a physician's sphere of activity today. Since subspecialisation is constantly advancing, there is often a limited pool of medical experts available for specific assessment matters. Medical experts have to assess the full proof of facts and the probability of correlations. As regards assessments issued to the statutory accident insurance, the issue of possible pre-existing conditions/damage plays an important role in the discussion surrounding the grounds for liability. Occasional causes or minor injuries are relevant for insurance claims and must be recognised.An insured person with an acral, non-arteriosclerotic circulatory disorder (thrombangiitis obliterans) was involved in an accident at work that resulted in a soft tissue skin defect and the need to amputate the finger. A vascular medical examination found that there was no occasional cause. A hand surgery expert proposed a 25 percent reduction in earning capacity. The accident insurance company followed the decision of the medical experts.

Experience of nail bed injuries at a tertiary hand trauma unit: a 12-month review and cost analysis.

The aim of this study was to analyse the management of nail bed injuries from a clinical and economic perspective. We carried out a retrospective analysis of nail bed injuries treated operatively at a tertiary Plastic Surgery Hand Trauma Unit during 2016. The National Schedule of Reference Costs (2015-2016) was used to estimate the costs of treating 630 patients. The most common mechanism was a crush injury in a door (33%). Fifty-five per cent of patients had an associated tuft fracture. The minimum cost per annum for patients treated for nail bed injuries in our unit was calculated to be £511,560 (€573,362; US$666,664). Many nail bed injuries are preventable and because they present a very high financial burden on the National Health Service, targeted prevention strategies should be considered. Level of evidence: IV.

[The revenue from finger replantation and revision amputation: Is it cost-covering?] / Fingeramputationen und -replantationen bei unterschiedlichen Kostenträgern: Ist die Vergütung kostendeckend?

BACKGROUND: Finger amputation injuries are frequently treated conditions in occupational accident hospitals. They are either treated by replantation or revision amputation. The costs of these two treatment options differ significantly. This study aims to determine if the revenue generated from the treatment of finger amputation injuries in the German DRG system is cost-covering and if there are differences depending on the type of health insurance. METHODS: Based on our hospital's cost data from the years 2014 and 2015, we performed an analysis of the revenue generated from finger replantation and finger revision amputation and compared it with the cost data of the nationwide calculation hospitals in Germany. In addition, we compared the revenue generated from patients with statutory health insurance with the revenue from patients with workers' compensation insurance. RESULTS: During the study period, a total of 90 patients were treated for finger amputation. For primary finger revision amputation, the actual costs were lower compared to the cost data of the nationwide calculation hospitals (€ 3551 vs. € 3809, p = 0.442). After deduction of all costs, the revenue was 1,008 Euros for patients with statutory health insurance and 688 Euros for patients with workers' compensation insurance (p = 0.578). In contrast, the costs of complex finger reconstruction procedures were considerably underestimated. In cases of primary finger replantation or secondary finger revision amputation, losses of 260 Euros were recorded for patients with statutory health insurance. In patients with workers' compensation insurance, the revenue of complex finger reconstruction procedures after deduction of all costs was cost-covering (€ 900, p = 0.403). CONCLUSIONS: In the German DRG system, the reimbursement for the treatment of finger amputation depends on the type of health insurance. In patients with workers' compensation insurance, cost-covering revenue is generated from both finger revision amputation and finger replantation, whereas in patients with statutory health insurance, only the revenue of primary finger revision amputation appears to be cost-covering. Hence for finger amputation injuries with subsequent complex reconstruction procedures, a revision of the cost calculation is required to avoid inappropriate incentives in patient care.

Finger Replantation Optimization Study (FRONT): Update on National Trends.

PURPOSE: Traumatic digit amputations have an adverse impact on patients' daily living. Despite experts advocating for digit replantation, studies have shown a continued decrease in rate of replantation. We performed a national-level investigation to examine the recent trend of practice for digital replantation. METHODS: We used the National Inpatient Sample database under the Healthcare Cost and Utilization Project to select adult patients with traumatic digit amputation from 2001 to 2014. We calculated the rate of attempted and rate of successful digit replantation per year, subcategorizing for digit type (thumb or finger) and for hospital type (rural, urban nonteaching, or urban teaching). We also analyzed the pattern of distribution of case volume to each hospital type per year. We used 2 multivariable logistic regression models to investigate patient demographic and hospital characteristics associated with the odds of replantation attempt and success. RESULTS: Among the 14,872 adult patients with a single digit amputation from 2001 to 2014, only 1,670 (11.2%) underwent replantation. The rate of replantation attempt trended down over the years for both thumb and finger injuries at all hospital types, despite increasing proportions of cases being sent to urban teaching hospitals where they were more than twice as likely to undergo replantation. The rate of successful replantation stayed stable for the thumb at 82.9% and increased for fingers from 76.1% to 82.4% over the years. Patients were more likely to undergo replantation if they had private insurance or a higher level of income. Neither hospital case volume nor hospital type was predictive of successful replantation. CONCLUSIONS: Although more single-digit amputations were treated by urban teaching hospitals with higher likelihood to replant, the downward trend in rate of attempt regardless of hospital type demonstrates that concentration of case volume is not the solution to reverse the declining trend. CLINICAL RELEVANCE: Financial aspects of digit replantation need to be considered from both the patients' and the surgeons' perspectives to improve delivery of care for digit replantation.