Perioperative Thromboprophylaxis in Digital Replantation: A Systematic Review

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Background: There is no international consensus on the use of perioperative thromboprophylaxis in digital replantation. Suboptimal perioperative management may lead to replant failure, which compromises extremity function, worsens psychosocial outcomes for patients, and incurs significant cost. This systematic review evaluates and compares the efficacy and safety of perioperative antithrombotic protocols used in digital replantation. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)--compliant prospectively registered (PROSPERO, CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE, and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by 2 independent reviewers. All comparative studies that examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion. Results: Collectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% men, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%), with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications among patients treated with systemic heparin. Conclusions: The clinical efficacy and safety of perioperative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available.