The Learning Curve in Digital Replant Surgery: 46 Prospectively Collected Cases From a Single Surgeon Over a 10-Year Period

PURPOSE:  Digital replantation is a technically difficult microsurgery requiring significant surgical skill. The aim of this study was to investigate postoperative outcomes associated with the surgical learning curve for microvascular digital replantation. METHODS:  A prospectively maintained surgical database of consecutive patients who underwent digital replantation from 2002 to 2012 was reviewed. All cases were performed by a single surgeon and began immediately after the surgeon's fellowship. A total of 46 patients were identified. Outcomes of digital replantation were tested for association with time since fellowship, total microvascular operative experience, and location and type of injury. RESULTS:  Overall, 38/46 (82.6%) of patients underwent a successful digital replantation. There was a significant difference between survival percentages over the years (p=0.04), with improvement seen over time. Total microvascular experience was significantly associated with successful outcomes (p<0.001). After 100 hours of microvascular experience, there was a significant increase in the survival odds ratio (OR 8.5, 95% CI 1.5-47.9). Crush and thumb injuries were more likely to have detrimental outcomes. CONCLUSIONS:  There was marked improvement in replant survival over time, with a significant increase in odds of survival after 100 hours of microvascular experience. One hundred operating hours under the microscope occurred around 2 years in practice for this high-volume surgeon. There is strong evidence that a steep learning curve occurs in microvascular digit replantation surgery.

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Across 46 prospectively collected digital replantations by one surgeon, 82.6% survived overall, with outcomes improving over time; beyond 100 hours of microvascular experience survival odds rose markedly (OR 8.5), while crush and thumb injuries fared worse.

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