[Digital reimplantations and revascularizations. Factors of preservation. 183 fingers]

The causes of vascular failures of a series of 183 injured fingers treated by microsurgery (80 reimplantations, 103 revascularisations) were investigated. This consecutive series was characterised by the fact that the operation was performed even in the presence of classical factors of poor prognosis: patients over the age of 40 years (27%), smoking (51%), crush injury or avulsion (32%), ischaemia time longer than 7 hours (46%). The overall intraoperative and postoperative failure rate was 49% (69% in reimplantations and 31% in revascularisations). Preoperative factors (age, smoking, mechanism, ischaemia time) were not sufficiently important to constitute contraindications to vascular microsurgery. Only storage of the segment in contact with iced water made failure almost certain. Suture of 2 arteries and one or several veins (in the absence of a skin bridge) improved the prognosis. The postoperative use of subcutaneous heparin in reimplantations significantly decreased the failure rate from 77% to 55%. Postoperative surveillance is essential to rapidly detect the arterial or venous mechanism responsible for vascular disorders and to decide appropriate emergency treatment. Arterial ischaemia warrants revision of the sutures with a success rate of about one in two. Disturbances of the venous drainage should initially be treated medically (2/3 of preservation after drainage by leeches), but, when this is not effective, surgical revision salvages one third of failures. Emergency microsurgery units must therefore have access to a specialised postoperative surveillance unit.