Bioceramics, because of its excellent biocompatible and mechanical properties, has always been considered as the most promising materials for hard tissue repair. It is well know that an appropriate cellular response to bioceramics surfaces is essential for tissue regeneration and integration. As the in vivo implants, the implanted bioceramics are immediately coated with proteins from blood and body fluids, and it is through this coated layer that cells sense and respond to foreign implants. Hence, the adsorption of proteins is critical within the sequence of biological activities. However, the biological mechanisms of the interactions of bioceramics and proteins are still not well understood. In this review, we will recapitulate the recent studies on the bioceramic–protein interactions.

A review of protein adsorption on bioceramics

The replantation of a single digit amputated proximal to the insertion of the flexor digitorum superficialis (FDS) is contra-indicated in adults because this replanted digit usually leads to a stiff proximal interphalangeal joint (PIPJ) that interferes with overall hand function.1–4 Replantation of distal amputations is analogous to the commonly performed distal interphalangeal joint (DIPJ) fusion that still maintains PIPJ motion. However, distal replantation is not commonly performed because it is a technically challenging operation and the loss of function due to a missing fingertip is perceived to be negligible. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes has not been performed. A randomized controlled trial is not possible because it would be unethical and unfeasible to randomize patients to replantation, revision amputation, or some form of reconstruction. A systematic review is the only possible research method to use best available evidence from the literature to determine the outcomes of digital replantation.

The specific aim of this study is to apply strict inclusion criteria to select publications with sufficient details in the data presentation in order to provide comparable data to assess outcomes of distal finger replantation. We hypothesize that replantation of distal digital amputations will have good outcomes.

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A systematic review of the outcomes of replantation of distal digital amputation.

The decision to replant a severed part is based on the numerous factors that influence survival of the part and the functional and aesthetic benefits gained from replanting. Not all amputees will benefit from or are candidates for replantation. The decision to proceed is therefore made by the surgeon who must consider the mechanism and extent of injury, the age of the patient, the presence of other medical or surgical conditions, the likely functional outcomes, and the patient's motivation to undergo a difficult procedure, which is followed by a lengthy recovery. This is a meta-analysis of the available studies that tracks the outcomes, based on 9 criteria, after the amputation of a total of 1803 digits in 1299 patients. By combining the data from numerous sources, a statistically significant picture emerges which may be used to educate patients and help guide the surgeon in the decision to replant.

A meta-analysis of success rates for digit replantation.

Purpose Replantation remains an important technique in the management of hand trauma. Given the resources necessary for a successful replantation program, regionalization of replantation care may ultimately be required. The purposes of this study were to analyze the geographic distribution of upper extremity replant procedures, analyze factors of patients undergoing replantation, and characterize the facilities performing these procedures. Methods We performed a cohort study using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2001, 2004, and 2007. Patients with an upper extremity amputation were defined, and a subgroup of patients undergoing replantation was delineated. We analyzed patient demographics and injury characteristics and characteristics of treating facilities. Results A total of 9,407 patients were treated for upper extremity amputation, 1,361 of whom underwent replantation. Mean age of patients undergoing replantation was 36 years (range, 0–86 y), compared with 44 years (range, 0–104 y) in patients not undergoing replantation. Hospital charges ( P P Conclusions Patients who undergo replantation are younger, incur higher hospital charges, and have longer hospital stays compared with patients who do not undergo replantation. Treatment at large, urban, and teaching facilities is associated with higher replantation rates. Payer status appears to have some bearing on replantation rates. Further studies are needed to better elucidate the relationship between patient and injury characteristics, treatment location, and outcomes, to adequately distribute the finite resources for replantation. Type of study/level of evidence Economic and Decision Analysis IV.

Epidemiology of upper extremity replantation surgery in the United States.

Purpose Recent studies presenting functional outcomes after replantation of finger avulsion injuries have challenged the historical practice of performing revision amputation for all complete finger avulsion injuries. The aim of this study is to conduct a systematic review of the English literature of replantation of finger avulsion injuries to provide best evidence of survival rates and functional outcomes. Methods A Medline literature search yielded 1,398 studies, using key words “traumatic amputation” or “replantation”, with limitation to humans and finger injuries. Inclusion criteria required that studies meet the following requirements: (1) primary data are presented; (2) the study includes at least 5 cases with either complete or incomplete finger avulsion injuries at or distal to the metacarpophalangeal joint; (3) the study presents survival rates, total active arc of motion (TAM), or static 2-point discrimination (2PD) data; (4) data for incomplete and complete avulsions are reported separately; (5) patients are treated with microvascular revascularization or replantation. Survival rates, TAM, and 2PD data were recorded and a weighted mean of each was calculated. Results Thirty-two studies met the inclusion criteria. Of these 32 studies, all reported survival outcomes, 13 studies reported TAM (metacarpophalangeal, proximal interphalangeal, and distal interphalangeal), and 9 studies reported sensibility. The mean survival rate for complete finger and thumb avulsions having replantation was 66% (n = 442). The mean TAM of complete finger avulsions after successful replantation was 174° (n = 75), with a large number of patients in the included studies having arthrodesis of the distal interphalangeal joint. The mean 2PD in patients after replantation was 10 mm (n = 32). Conclusions We found that functional outcomes of sensibility and range of motion after replantation of finger avulsion injuries are better than what is historically cited in the literature. The results of this systematic review challenge the practice of performing routine revision amputation of all complete finger avulsion injuries. Type of study/level of evidence Prognostic III.

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Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes.

To find out the influencing factors of the immediate and late outcome of replantation and revascularization of the digits the study was carried out as a prospective survey research during 1983 to 1995 with at least 2 year follow up. Traumatic total or subtotal amputation with inadequate circulation of the digits distal to the metacarpal head were included in the study. There were 552 patients with 366 males (675 digits) and 186 females (343 digits). Successful operation was found in 508 patients (92%) with 946 digits (92.9%). Type of injury was the most important factor influencing immediate and late outcome. Regular cigarette smoking resulted in poor immediate survival rate. Prolonged ischaemia had a significant influence in final functional outcome. Using composite skin and subcutaneous vein graft gave good survival rate. Injury at the no man's land area resulted in poor range of movement of the digit. Connecting the profundus tendon stump of the proximal part to the superficialis tendon of the amputated part gave a better result than 2 tendon repair and repairing only the profundus tendon. Replantation should be carried out even if only one digit is involved. At the 2 year follow up 195 patients (38%) were classified in grade I of Chen et al., functional outcome, while 153 (31%) were in grade II, 124 (24%) were in grade III and 36 (7%) were in grade IV.

Results of 1018 digital replantations in 552 patients.

Fracture of the neck of the femoral component after total hip arthroplasty is an infrequent complication. We present a report of 2 cases of trunnion fractures of fully porous-coated femoral stems (AML A Plus, DePuy International, Leeds, England), which had been implanted for 6 and 7 years after the index procedures. In both cases, failure emanated from a region where the trunnion had been intentionally grooved; and in both cases, the diameter of the trunnion was small, and evidence of corrosion contributing to the initiation of the failure was noted. Although this is the first report of trunnion fractures in this particular implant design, a close monitoring of prostheses with this specific trunnion should be considered. In addition, further analysis of clinical results and complications with this implant is warranted.

Trunnion fracture of the anatomic medullary locking a plus femoral component.

The result after anterior decompression and fusion for cervical spondylotic myelopathy
was retrospectively studied in 49 patients. There were 33 men and 16 women, their ages ranged
from 27 to 82 years (average 53.7 years). The most common level of involvement was C5-6â€¢
followed by C3-4Â· Walking difficulty of various degrees in combination of numbness and
weakness of upper limbs were the most common presenting symptoms. The duration of preoperative
symptoms ranged from 1 month to 10 years (average 6 months). The functional results
at final follow-up were evaluated using the author's grading criterias. Mean follow-up time was
5.3 years (range 1-10 years). Forty-six patients were neurologically improved at various
degrees, three cases were unchanged, none had neurological deterioration. There was no time
limit of neural recovery as to the duration of disease prior to surgery. The potential cord
recovery might be partly affected by age, duration of the symptoms, and pre-operative functional
grade.

Anterior decompression and fusion for cervical spondylotic myelopathy.

To find out the effect of sharp dissection compared to electrocautery for soft tissue release and balancing in total knee replacement on proprioceptive sense, the study was carried out as a parellel double blind trial with 2 year follow-up. There were 52 patients in the sharp dissection group and 42 patients in the electrocautery group. Position sense of the operated knees was evaluated by the ability to reproduce the same angles as the non operative knees which acted as reference knees. The absolute different angles were used to evaluate the position sense. Before the operation, the patients in both groups had similar biographic data, pathology, and absolute different angles of knee positioning. After the operation, both groups had improvement in knee position sense; however, the sharp dissection group had more rapid improvement in the 1st post operative year. There was no significant difference at the 2 year follow-up.

Amnuay Unnanuntana

Papers

Results of 1018 digital replantations in 552 patients.

Trunnion fracture of the anatomic medullary locking a plus femoral component.

Anterior decompression and fusion for cervical spondylotic myelopathy.

Recovery of joint position sense after total knee replacement: the effects of soft tissue dissection.