MICROSURGERY

Thirty-Year Follow-up of Total Hand Replantation A Case Report Samuel O. Poore, MD, PhD, Jacqueline S. Israel, MD, and Venkat K. Rao, MD, MBA

Abstract: The loss of a limb is a devastating yet relatively common injury with a vast panoply of effects. Beyond the obvious potential for the loss of livelihood are profound social, psychological, and aesthetic consequences. Thus, despite significant improvements in functional prostheses and rehabilitation for traumatic hand amputations, the option for replantation should always be carefully considered. We present a case of a total hand replantation at the level of the wrist performed 30 years ago, which to our knowledge exceeds the longest reported follow-up by 11 years. The excellent outcome observed in this patient demonstrates the importance of presurgical planning and analysis of the amputated segment, the utility of therapy, and the durable functionality of extremity replantation over an extended period. Key Words: hand, replantation, amputation, long-term follow-up (Ann Plast Surg 2016;76: 521Y523)

‘‘Where the spirit does not work with the hand, there is no art.’’ VLeonardo da Vinci

W

ork-related hand amputations are typically not life-threatening, but they undoubtedly negatively impact one’s quality of life. In addition to the obvious functional sequelae of upper extremity amputation, serious disfigurements frequently imply profound psychological and social debilitations. Thus, adequate management of traumatic hand injuries, particularly the ability to perform replantation if necessary, is an essential skill for the hand surgeon. The indications for replantation, which include the potential for long-term function and mechanism of injury, remain similar to those several years ago. The purpose of this report is to present a case of a total hand replantation performed 30 years ago, argue the benefits of replantation in the carefully selected patient, and review the significance of long-term follow-up in an era of transformation and growth in the field of microsurgery.

CASE The patient was a 21-year-old man who presented to the senior author (V.K.R.) in 1984 after a work-related circular saw amputation of the left, nondominant hand (Fig. 1). The amputation occurred through the carpal bones and a clean-cut mechanism was noted. The risks, benefits, and alternatives to replantation were discussed with

Received February 5, 2014, accepted for publication, after revision, June 4, 2014. From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. Conflicts of interest sources of funding: none declared. Reprints: Samuel O. Poore, MD, PhD, Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, CSC G5/361, Madison, WI 53792. Email: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7605-0521 DOI: 10.1097/SAP.0000000000000299

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the patient who elected to proceed and expressed understanding of the need for aggressive postoperative rehabilitation. The patient was taken emergently to the operating room, and the amputated hand was irrigated, debrided, and carefully examined to determine if replantation was possible. It was determined that the amputated segment was clean with viable structures available for anastomoses, and would thus have a high probability of success. A proximal row carpectomy was performed, as well as osteosynthesis using Kirschner wires. The f lexor and extensor tendons were repaired in sequence with 4-0 Tycron sutures. The radial and ulnar arteries were then repaired using interposition vein grafting from the right greater saphenous vein, followed by repair of the nerves and veins. The abductor pollicis longus (APL) and extensor pollicis longus (EPL) tendons were left unrepaired due to observed compression of the radial artery. Skin closure was achieved with primary closure and a skin graft to the volar wrist. Operative time was 11 hours, and total cold ischemia time was less than 24 hours. The time to first postoperative active range of motion (aROM) hand therapy was 25 days. At 6 months follow-up, the patient returned to the operating room a second time for left thumb extensor lag, given that the EPL and APL could not be repaired initially. A 12-cm graft from the right foot second toe extensor digitorum tendon was harvested for repair of the EPL and APL. At 12 months after the initial operation, the patient was attending hand therapy 2 to 3 times per week. He subjectively denied pain at rest and with activity. The patient’s wrist aROM was 60/20 degrees f lexion/extension (expected 75/75), and small finger flexion was limited due to adhesions of the flexor digitorum superficialis (tip-to-midpalm 4.5 cm). Grip was 22 psi in the affected hand, compared to 113 psi on the right (19% L vs R). Lateral key pinch was 3 psi on the left, compared to 21.5 psi on the nonaffected hand (14%). The patient returned to our clinic 30 years after his initial operation. He was subjectively evaluated using the Michigan Hand Outcomes Questionnaire.1 Range of motion (ROM) was assessed using a goniometer. Grip strength and lateral key pinch were measured by hand dynamometer and pinch meter in both the affected and contralateral hands, and strength was measured in pounds per square inch. Two-point sensation was tested using a Dellon-McKinnon Disk-Criminator (US Neurologicals LLC, Poulsbo, Wash). Subjectively, the patient expressed satisfaction with his left, affected hand, with no reported impairments in activities of daily living (ADLs). He works at a desk job in an office and is an avid golfer (Video 1, Supplemental Digital Content 1, http://links.lww.com/SAP/A117). His Michigan Hand Outcomes Questionnaire scores were high in the affected compared to unaffected hand: total score of the injured hand was 85/100, compared to 99 in the unaffected limb; the scored components included overall function (65 in affected hand), ability to perform ADLs (90), ability to work (100), pain (95), aesthetics (88), and satisfaction (75).1 Examination of the replanted hand revealed a well-healed scar on the volar wrist, and slight asymmetry (L compared to R) when the patient was asked to make a fist (Fig. 2). Total aROM of the L wrist was approximately 65% of R wrist. Small finger tip-to-mid-palm was 3 cm, compared to 4.5 cm at 1 year. Two-point sensation of each fingertip on the affected hand was an average of 10 mm, compared www.annalsplasticsurgery.com

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FIGURE 1. Complete amputation of the left hand via a circular saw before (A) and after (B) replantation.

to 5 mm on the opposite hand. Grip strength in the affected hand was 55 psi, compared to 95 psi in the unaffected hand (58% L vs R). Lateral key pinch was also 58% in the affected hand (14 vs 24 psi).

DISCUSSION This case represents what is to our knowledge the longest described follow-up after hand replantation, and serves as an example of significant improvement in results at 30 years post-surgery compared to results at 1 year. Our review of the literature reveals that there are relatively few reports that focus primarily on amputation at or proximal to the wrist, and even fewer with follow-up beyond 12 months.2Y8 In a study of 261 replantations performed on patients with upper extremity injuries, 4 were complete amputations near the level of the wrist, and the mean follow-up for all patients was 9 months.2 In one of the largest reviews of major limb replantation (n = 24), Russell et al3 report that 11 of 24 replantations had greater than 50% total aROM, 19/24 protective sensation, and 22/24 overall satisfaction with outcomes. Two

recent studies each presented 5 patients who underwent replantation at or near the level of the wrist, with mean follow-up of 27 and 33 months, respectively.5,6 The patients discussed in these articles were evaluated using different grading scales, although both criteria evaluated subjective and objective elements of hand form and function after replantation.5,6 Woo et al5 found that all 5 patients had ‘‘good’’ (grade 2) outcomes: the patients were able to resume work, ROM was greater than 40%, and strength was diminished although not debilitating. Results were similar in the second series, with a 100% rate of ability to perform ADLs despite some objective deficits.6 Although reporting of outcomes is not standardized, and much of the literature is somewhat dated, many centers have demonstrated lasting functional results after hand replantation.2,3,5,8 Tark and colleagues2 emphasize the importance not only of survival of the replanted segment, but also on functional superiority compared to a revision amputation. In addition, progressive improvement in sensation is ideal. In their comparison of patients undergoing either replantation or revision amputation with subsequent prosthesis after

FIGURE 2. A to C, Clinical results 30 years after replantation. 522

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major upper extremity limb trauma, Graham et al7 observed superior functional outcomes years after injury (average, 7.3 years) in patients who underwent replantation. Further, outcomes were even better in the replanted group when intrinsic function was recoverable. Regarding success and durability of replantation, Tintle et al9 claim, ‘‘a ‘bad hand’ may be more functional than a ‘good amputation’ in the upper extremity.’’ Extremity replantation after traumatic injury is not always indicated, and outcomes are best when multiple factors are considered. In our experience, the indications for replantation and the general principles of repair remain similar compared to 30 years ago. Replantation would likely be attempted in this patient today, given his age at the time of injury, guillotine-type injury, and time of presentation after injury. The factors related to good outcomes after replantation include the potential for long-term function, the patient’s overall clinical status (including psychosocial wellbeing), the mechanism of injury, and the location of injury.6,10 Specifically, better outcomes at 1 to 2 years have been observed in patients experiencing guillotine-type injuries near the level of the carpus.4Y6 Similar long-term results were observed by Sugun et al,8 where avulsion or crush amputations near the elbow, as opposed to the wrist, were associated with a worse prognosis. The aforementioned case series (n = 26) reports an average follow-up length of 11.3 years (range, 5Y19 years), and includes patients who underwent replantation between the level of the metacarpals and upper arm.8 The favorable, durable long-term outcomes observed in patients like ours support replantation in the carefully selected patient. In the patient described previously, there were notable differences between results after 1 year compared to those at year 30: subjective sensation, small finger ROM, and grip and pinch strength improved considerably. In addition, the patient likely adapted significantly over time, and his self-perceived function both at work and with hobbies improved. On the basis of examination findings of improved pinch strength, minimal atrophy, and lack of claw deformity, intrinsic muscle function seems to have recovered to some degree. Improvement in key pinch likely ref lects recovery of muscles in both the median and ulnar nerve distributions, particularly f lexor pollicis longus and abductor pollicis brevis.11 Our review of this case facilitated a review of differences in perioperative management at our institution now compared to 30 years prior. A notable change relates to postoperative ROM; while the time to first aROM in our patient was greater than 3 weeks,

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Hand Replantation

patients who have undergone replantation in the recent past typically begin early finger mobilization as early as 5 days postoperatively (eg, Duran Protocol) to minimize tendon adherence and to maximize finger motion.

CONCLUSIONS We have presented a case of replantation at the wrist with 30-year follow-up and positive long-term results. The outcomes observed in this patient support the use of replantation when deemed clinically appropriate, and remind us of the utility of long-term follow-up in all postoperative patients, including those undergoing major extremity replantation both now and in the future. REFERENCES 1. Chung KC, Hamill JB, Walters MR, et al. The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to clinical change. Ann Plast Surg. 1999;42:619Y622. 2. Tark KC, Kim YW, Lee YH, et al. Replantation and revascularization of hands: clinical analysis and functional results of 261 cases. J Hand Surg Am. 1989; 14:17Y27. 3. Russell RC, Obrien B, Morrison WA. The late functional results of upper limb revascularization and replantation. J Hand Surg Am. 1984;9:623Y633. 4. Meyer VE. Hand amputations proximal but close to the wrist joint: prime candidates for reattachment (long-term functional results). J Hand Surg Am. 1985;10:989Y991. 5. Woo SH, Lee YK, Lee HH, et al. Hand replantation with proximal row carpectomy. Hand (N Y). 2009;4:55Y61. 6. Hoang NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br. 2006;31:9Y17. 7. Graham B, Adkins P, Tsai TM, et al. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am. 1998;23:783Y791. 8. Sugun TS, Ozaksar K, Ada S, et al. Long-term results of major upper extremity replantations. Acta Orthop Traumatol Turc. 2009;43:206Y213. 9. Tintle SM, Baechler MF, Nanos GP3rd, et al. Traumatic and trauma-related amputations: Part II: Upper extremity and future directions. J Bone Joint Surg Am. 2010;92:2934Y2945. 10. El-Sherbiny KM, Aboulwafa AM, Nasser S, et al. Hand replantation following complete amputations: a study of both form and functional outcome. J Plast Reconstr Surg. 2009;33:291Y296. 11. Goetz TJ, Costa JA, Slobogean G, et al. Contribution of flexor pollicis longus to pinch strength: an in vivo study. J Hand Surg Am. 2012;37:2304Y2309.

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Thirty-Year Follow-up of Total Hand Replantation: A Case Report.

The loss of a limb is a devastating yet relatively common injury with a vast panoply of effects. Beyond the obvious potential for the loss of liveliho...
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