Hand replantation after 54 hours of cold ischemia: A case report A number of case reports and series have reported successful replantation after prolonged periods of ischemia.
However, the acceptable range of normothermic
remains controversial.
and hypothermic
ischemic storage
There is little question that the tolerance of composite tissue for ischemia
is dependent on the quantity of contained skeletal muscle. We report a successful hand replantation after 54 hours of cold ischemia. period yet reported for successful
We believe that this case documents
hand replantation.
results obtained confirm the value of hand replantation interval. (J HAND SURG 1992;17A:217-20.)
Russell
S. VanderWilde,
and Su Zeng-gui,
MD,
B. Wood, MD, Rochester, People’s Republic of China
I
schemia time is one of the important factors influencing the success of limb replantation. Proper tissue handling, including appropriate cooling, has been shown to prolong tissue survival in both experimental and clinical studies. Recent reports have shown that digits may be successfully replanted after prolonged periods of cold ischemia. However, replantation at more proximal levels involves the additional problems of myonecrosis with potential for infection and renal toxicity due to myoglobin products. We have recently cared for a patient who underwent successful replantation of a complete wrist disarticulation after 54 hours of cold ischemia. CASE REPORT The patient, a 15year-old girl, sustained a sharp blade injury to the wrist. The hand was totally severed except for a thin remnant of the intercarpal ligament (Fig. 1). Initial treatment involved completion of the wrist disarticulation and closure of the amputation stump at an outside hospital after
From the Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn.. the Department of Orthopedics, Lanzhou Army General Hospital. Lanzhou. People’s Republic of China. Received for publication April 15, 1991.
Jan.
17. 1991: accepted
in revised form
No benetits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Michael B. Wood, MD, Department of Orthopedic Surgery. Mayo Clinic/Mayo Foundation. Rochester, MN 55905. 311130633
even after such a prolonged
Michael
MD, Lanzhou,
the longest anoxic
We further believe that the functional ischemic
Minn.,
a delay of several hours because of the self-inflicted nature of the injury. The warm ischemia time was estimated to be 3 hours. After completion of the amputation, the hand was placed into a refrigeration unit for future anatomic dissection. The temperature of this refrigeration unit was estimated at 2” to 5” C. The patient’s father, who was a visiting scientist outside the country, received word of the injury after a 36hour delay. He voiced concerns about possible hand replantation. After discussion with both the patient and other family members. a strong desire for reattachment resulted in the decision to transfer the patient to the Lanzhou General Army Hospital in Lanzhou, People’s Republic of China. At the time of transfer the amputated part was found on a windowsill, but the period of time it was out of the refrigerator was not known. The ambient temperature during this period was estimated to range from 3” to 9”. At the time of replantation the carpal bones were excised because of extensive soft tissue trauma. A revascularization procedure was carried out. First the radial artery was anastomosed with Nakiyama ring couplers. The ulnar artery was then grafted with a 6 cm length of saphenous vein. After observation of good flow, four venous anastomoses were carried out, also with the use of Nakiyama devices. Prophylactic fasciotomies were performed because of the intense swelling noted after restoration of the vascular supply. Obviously necrotic tissue from the thenar. hypothenar, and intrinsic compartments was debrided. No muscle biopsy specimens were taken. The incisions were closed over drains. The decision to delay tendon and nerve repair was based on the belief that this could be performed later if the hand replantation proved viable. The total delay from injury to restoration of arterial flow was estimated at 54 hours. Twenty-three days later a direct ulnar neurorrhaphy was performed. as well as an ipsilateral sural nerve grafting of a
THE
JOURNAL
OF HAND
SI!RGERY
217
218
The Journal of HAND SURGERY
VanderWilde et al.
Fig. 2. Radiographic appearance wrist and first metacarpal.
Fig. 1. Photograph of amputated hand at transcarpal after completion of wrist disarticulation.
level
4 cm median nerve defect and a 5 cm radial nerve defect. Delayed primary repair of the deep tendons was also carried out. Because of a tendon deficit, a common proximal flexor tendon was used for both the third and fourth digits. Very little intrinsic muscle tissue remained. No intrinsic muscle biopsy was performed.
after bony stabilization
of
The patient was first seen at the Mayo Clinic 6 months after replantation. At that time she had well-healed surgical and traumatic incisions with shortening of the wrist. Her wrist and thumb were unstable. She demonstrated a palpable ulnar pulse and a Doppler audible radial pulse. There was physiologic capillary refill in all five digits. Neurologically, she perceived deep pressure sensation in the median, ulnar, and radial nerve distributions. She was not able to discriminate between sharp and dull, and she had no two-point sensibility. The wrist was positioned in palmar flexion and ulnar deviation, and the first metacarpal was adducted to the plane of the palm. Passive digital motion was nearly full in all digits. Limited active extrinsic thumb and finger flexion and exten-
Vol. l7A, No. 2 March 1992
Fig. 3. A and B, Photographs plantation
Hand replantation after 54 hours of cold ischemia
demonstrating
sion were present. No flexor digitorum supetlicialis or intrinsic motor function was detectable. The third and fourth digits moved synchronously and could not be actively ranged independently. An electromyogram showed a complete median neuropathy with early evidence of abductor digiti minimi reinnervation. The initial reconstructive procedure was performed 7 months after replantation and consisted of a radius-to-first, second, and third metacarpal arthrodesis with iliac crest graft and Kirschner wire fixation. Wrist fixation was supplemented with tension band wiring (Fig. 2). The first metacarpal was positioned in midopposition to the plane of the palm. The radius-to-metacarpal fusions healed uneventfully. After this the patient was placed in a supervised mobilization program for the fingers. This program included the use of ultrasound, gentle prolonged passive stretching, and resistance. Her psychiatric status remained stable.
219
active finger range of motion 30 months after re-
At follow-up 30 months after replantation, the patient demonstrated a complete range of passive finger motion. Active finger extension to the metacarpal plane was present, and active finger flexion to the midpalmar line was present for the index and long fingers. The patient lacked complete flexion to the midpalmar line by 1.5 and 2 cm for the ring and small fingers, respectively (Fig. 3). She demonstrated very weak activity of the first dorsal interosseous muscle but otherwise had no intrinsic motor function. The presence of protective sensibility, with the ability to discriminate sharp from dull and heat from cold, and the presence of sudomotor activity were confirmed. She reported that she used the hand for grasp and assisted functions in most activities of daily living. Her major complaints were of her inability to flex her long and ring fingers independently and of impaired active flexion of the small finger, both of which made keyboard activities difficult. At that time she was advised to undergo
The Journal VanderWilde et al.
HAND
flexor tenolysis with reconstruction of the independent flexor tendon to the ring finger. She is currently pursuing a higher education and is enrolled as a full-time university student.
DISCUSSION This report of a successful wrist replantation after a 54-hour period of cold ischemia illustrates a number of interesting challenges in both the initial and late phases of treatment. Early problems include the prolonged ischemia time and soft tissue defects. Late problems include wrist instability, thumb stance, combined low nerve lesions, and the loss of intrinsic muscle tissue. A number of case reports and series have reported successful replantation after prolonged periods of ischemia. The value of immediate and appropriate tissue cooling in prolonged tissue survival is well established. However, the acceptable range of normothermic and hypothermic ischemic storage remains controversial. There is little question that the tolerance of composite tissue for ischemia is dependent on the quantity of contained skeletal muscle.’ Digit replantation has been reported after a hypothermic ischemic interval as long as
Hand replantation amputation: N. John Yousif,
Hani S. Matloub,
MD, Vincent Muoneke, MD, James R. Sanger, MD, and MD, Milwaukee, @‘is.
From the Department of Plastic and Reconstructive Received
for publication
Surgery, Medical
Wis.
Jan. 23, 1991; accepted
in revised form
April 30, 1991. No benefits in any form have been received or will be received from a commercial this article.
party related directly or indirectly
to the subject of
Reprint requests: N. John Yousif, MD, Department of Plastic Surgery, Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226. 3/l/31163
220
REFERENCES Reid DAC, McGrouther DA, eds. Surgery of the thumb. New York: Butterworths, 1986:65. Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plastic Reconstr Surg 1988;82:346-50. Wood MB. Cooney WP. Above elbow iimb replantation: functional results. J HAND SURG 1986;l lA:682-7. Naraynsingh V, Moze R. Successful replantation of severed limbs. West Indian Med J 1987;36:45-7.
A case report
survival of parts after upper extremity replantation surgery reflects nearly three decades of advances in microsurgical technique and proper patient selection. We know, however, that survival of the replanted part is not the equivalent of success; return of function is the ultimate purpose of replantation.
Milwaukee,
94 hours.’ Experimentally, successful revascularization has been carried out with anoxic periods exceeding 100 hours. We are aware of successful replantation of major human limbs with ischemic times of up to 13% hours3 and of successful human hand replantation after anoxic intervals of 7 hours4 and 36 hours.” We believe this case documents the longest anoxic period yet reported for successful hand replantation. We further believe that the functional result attained confirms the value of hand replantation even after such a prolonged ischemic interval.
following three-level
Improved
College of Wisconsin,
of
SURGERY
THE JOURNALOF HANDSURGERY
Multiple-level amputation has been cited as a contraindication for replantation surgery. ’ We believe the paucity of reported cases of multiple-level replantations in the English-language literatureze4 is indicative of the hesitancy to undertake such a procedure. We report our experience with a three-level amputation, in which the hand was replanted, and discuss the surgical techniques and functional results.
Case report A 25year-old right-handed factory worker sustained a three-level amputation when his right hand was caught in a vacuum mold machine (Figs. 1 and 2). Proximally, the amputation occurred across the bases of the metacarpals and obliquely across the thenar eminence, leaving the wrist flexors and extensors intact. The second level of the injury passed obliquely from the base of the proximal phalanx of the small finger across to the proximal shaft of the proximal phalanx of the index finger. The third level involved only the three ulnar digits, passing just distal
However, the acceptable range of normothermic
remains controversial.
and hypothermic
ischemic storage
There is little question that the tolerance of composite tissue for ischemia
is dependent on the quantity of contained skeletal muscle. We report a successful hand replantation after 54 hours of cold ischemia. period yet reported for successful
We believe that this case documents
hand replantation.
results obtained confirm the value of hand replantation interval. (J HAND SURG 1992;17A:217-20.)
Russell
S. VanderWilde,
and Su Zeng-gui,
MD,
B. Wood, MD, Rochester, People’s Republic of China
I
schemia time is one of the important factors influencing the success of limb replantation. Proper tissue handling, including appropriate cooling, has been shown to prolong tissue survival in both experimental and clinical studies. Recent reports have shown that digits may be successfully replanted after prolonged periods of cold ischemia. However, replantation at more proximal levels involves the additional problems of myonecrosis with potential for infection and renal toxicity due to myoglobin products. We have recently cared for a patient who underwent successful replantation of a complete wrist disarticulation after 54 hours of cold ischemia. CASE REPORT The patient, a 15year-old girl, sustained a sharp blade injury to the wrist. The hand was totally severed except for a thin remnant of the intercarpal ligament (Fig. 1). Initial treatment involved completion of the wrist disarticulation and closure of the amputation stump at an outside hospital after
From the Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn.. the Department of Orthopedics, Lanzhou Army General Hospital. Lanzhou. People’s Republic of China. Received for publication April 15, 1991.
Jan.
17. 1991: accepted
in revised form
No benetits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Michael B. Wood, MD, Department of Orthopedic Surgery. Mayo Clinic/Mayo Foundation. Rochester, MN 55905. 311130633
even after such a prolonged
Michael
MD, Lanzhou,
the longest anoxic
We further believe that the functional ischemic
Minn.,
a delay of several hours because of the self-inflicted nature of the injury. The warm ischemia time was estimated to be 3 hours. After completion of the amputation, the hand was placed into a refrigeration unit for future anatomic dissection. The temperature of this refrigeration unit was estimated at 2” to 5” C. The patient’s father, who was a visiting scientist outside the country, received word of the injury after a 36hour delay. He voiced concerns about possible hand replantation. After discussion with both the patient and other family members. a strong desire for reattachment resulted in the decision to transfer the patient to the Lanzhou General Army Hospital in Lanzhou, People’s Republic of China. At the time of transfer the amputated part was found on a windowsill, but the period of time it was out of the refrigerator was not known. The ambient temperature during this period was estimated to range from 3” to 9”. At the time of replantation the carpal bones were excised because of extensive soft tissue trauma. A revascularization procedure was carried out. First the radial artery was anastomosed with Nakiyama ring couplers. The ulnar artery was then grafted with a 6 cm length of saphenous vein. After observation of good flow, four venous anastomoses were carried out, also with the use of Nakiyama devices. Prophylactic fasciotomies were performed because of the intense swelling noted after restoration of the vascular supply. Obviously necrotic tissue from the thenar. hypothenar, and intrinsic compartments was debrided. No muscle biopsy specimens were taken. The incisions were closed over drains. The decision to delay tendon and nerve repair was based on the belief that this could be performed later if the hand replantation proved viable. The total delay from injury to restoration of arterial flow was estimated at 54 hours. Twenty-three days later a direct ulnar neurorrhaphy was performed. as well as an ipsilateral sural nerve grafting of a
THE
JOURNAL
OF HAND
SI!RGERY
217
218
The Journal of HAND SURGERY
VanderWilde et al.
Fig. 2. Radiographic appearance wrist and first metacarpal.
Fig. 1. Photograph of amputated hand at transcarpal after completion of wrist disarticulation.
level
4 cm median nerve defect and a 5 cm radial nerve defect. Delayed primary repair of the deep tendons was also carried out. Because of a tendon deficit, a common proximal flexor tendon was used for both the third and fourth digits. Very little intrinsic muscle tissue remained. No intrinsic muscle biopsy was performed.
after bony stabilization
of
The patient was first seen at the Mayo Clinic 6 months after replantation. At that time she had well-healed surgical and traumatic incisions with shortening of the wrist. Her wrist and thumb were unstable. She demonstrated a palpable ulnar pulse and a Doppler audible radial pulse. There was physiologic capillary refill in all five digits. Neurologically, she perceived deep pressure sensation in the median, ulnar, and radial nerve distributions. She was not able to discriminate between sharp and dull, and she had no two-point sensibility. The wrist was positioned in palmar flexion and ulnar deviation, and the first metacarpal was adducted to the plane of the palm. Passive digital motion was nearly full in all digits. Limited active extrinsic thumb and finger flexion and exten-
Vol. l7A, No. 2 March 1992
Fig. 3. A and B, Photographs plantation
Hand replantation after 54 hours of cold ischemia
demonstrating
sion were present. No flexor digitorum supetlicialis or intrinsic motor function was detectable. The third and fourth digits moved synchronously and could not be actively ranged independently. An electromyogram showed a complete median neuropathy with early evidence of abductor digiti minimi reinnervation. The initial reconstructive procedure was performed 7 months after replantation and consisted of a radius-to-first, second, and third metacarpal arthrodesis with iliac crest graft and Kirschner wire fixation. Wrist fixation was supplemented with tension band wiring (Fig. 2). The first metacarpal was positioned in midopposition to the plane of the palm. The radius-to-metacarpal fusions healed uneventfully. After this the patient was placed in a supervised mobilization program for the fingers. This program included the use of ultrasound, gentle prolonged passive stretching, and resistance. Her psychiatric status remained stable.
219
active finger range of motion 30 months after re-
At follow-up 30 months after replantation, the patient demonstrated a complete range of passive finger motion. Active finger extension to the metacarpal plane was present, and active finger flexion to the midpalmar line was present for the index and long fingers. The patient lacked complete flexion to the midpalmar line by 1.5 and 2 cm for the ring and small fingers, respectively (Fig. 3). She demonstrated very weak activity of the first dorsal interosseous muscle but otherwise had no intrinsic motor function. The presence of protective sensibility, with the ability to discriminate sharp from dull and heat from cold, and the presence of sudomotor activity were confirmed. She reported that she used the hand for grasp and assisted functions in most activities of daily living. Her major complaints were of her inability to flex her long and ring fingers independently and of impaired active flexion of the small finger, both of which made keyboard activities difficult. At that time she was advised to undergo
The Journal VanderWilde et al.
HAND
flexor tenolysis with reconstruction of the independent flexor tendon to the ring finger. She is currently pursuing a higher education and is enrolled as a full-time university student.
DISCUSSION This report of a successful wrist replantation after a 54-hour period of cold ischemia illustrates a number of interesting challenges in both the initial and late phases of treatment. Early problems include the prolonged ischemia time and soft tissue defects. Late problems include wrist instability, thumb stance, combined low nerve lesions, and the loss of intrinsic muscle tissue. A number of case reports and series have reported successful replantation after prolonged periods of ischemia. The value of immediate and appropriate tissue cooling in prolonged tissue survival is well established. However, the acceptable range of normothermic and hypothermic ischemic storage remains controversial. There is little question that the tolerance of composite tissue for ischemia is dependent on the quantity of contained skeletal muscle.’ Digit replantation has been reported after a hypothermic ischemic interval as long as
Hand replantation amputation: N. John Yousif,
Hani S. Matloub,
MD, Vincent Muoneke, MD, James R. Sanger, MD, and MD, Milwaukee, @‘is.
From the Department of Plastic and Reconstructive Received
for publication
Surgery, Medical
Wis.
Jan. 23, 1991; accepted
in revised form
April 30, 1991. No benefits in any form have been received or will be received from a commercial this article.
party related directly or indirectly
to the subject of
Reprint requests: N. John Yousif, MD, Department of Plastic Surgery, Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226. 3/l/31163
220
REFERENCES Reid DAC, McGrouther DA, eds. Surgery of the thumb. New York: Butterworths, 1986:65. Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plastic Reconstr Surg 1988;82:346-50. Wood MB. Cooney WP. Above elbow iimb replantation: functional results. J HAND SURG 1986;l lA:682-7. Naraynsingh V, Moze R. Successful replantation of severed limbs. West Indian Med J 1987;36:45-7.
A case report
survival of parts after upper extremity replantation surgery reflects nearly three decades of advances in microsurgical technique and proper patient selection. We know, however, that survival of the replanted part is not the equivalent of success; return of function is the ultimate purpose of replantation.
Milwaukee,
94 hours.’ Experimentally, successful revascularization has been carried out with anoxic periods exceeding 100 hours. We are aware of successful replantation of major human limbs with ischemic times of up to 13% hours3 and of successful human hand replantation after anoxic intervals of 7 hours4 and 36 hours.” We believe this case documents the longest anoxic period yet reported for successful hand replantation. We further believe that the functional result attained confirms the value of hand replantation even after such a prolonged ischemic interval.
following three-level
Improved
College of Wisconsin,
of
SURGERY
THE JOURNALOF HANDSURGERY
Multiple-level amputation has been cited as a contraindication for replantation surgery. ’ We believe the paucity of reported cases of multiple-level replantations in the English-language literatureze4 is indicative of the hesitancy to undertake such a procedure. We report our experience with a three-level amputation, in which the hand was replanted, and discuss the surgical techniques and functional results.
Case report A 25year-old right-handed factory worker sustained a three-level amputation when his right hand was caught in a vacuum mold machine (Figs. 1 and 2). Proximally, the amputation occurred across the bases of the metacarpals and obliquely across the thenar eminence, leaving the wrist flexors and extensors intact. The second level of the injury passed obliquely from the base of the proximal phalanx of the small finger across to the proximal shaft of the proximal phalanx of the index finger. The third level involved only the three ulnar digits, passing just distal
