Cases of Interest 67
Successful Replantation of 2 Fingers in an 82-year-old Patient: A Case Report
Authors
Z. Szlosser, I. Walaszek, A. Zyluk
Affiliation
Department of General and Hand Surgery, Pomeranian Medical University, Szczecin, Poland
Key words ▶ replantation ● ▶ osteosynthesis ● ▶ finger ● ▶ upper limb ●
Abstract
Zusammenfassung
We present the case of an 82-year-old patient who had successfully replanted 2 of his 4 amputated fingers in the left, non-dominant hand. Amputation was caused by a circular saw and the patient was delivered to the hospital 3 h after injury with amputated part of the hand appropriately stored. The patient’s general health status was good, with no serious systemic diseases. He also did not smoke. Post-operative course was uneventful for the replanted fingers, but after his return home the patient developed left-sided pneumonia, treated successfully with i.v. antibio tics. 8 months after replantation the patient presented with slight movement in the replanted fingers (AROM 45 °), a total grip strength 8 Kg and the qDASH score 24; however, he could firmly grasp objects due to having an intact, well-functioning thumb.
Wir berichten über einen 82-jährigen Patienten mit erfolgreicher Replantation von 2 seiner 4 amputierten Finger der linken, nicht dominanten Hand durch eine Kreissägenverletzung. Der Patient wurde 3 Stunden nach dem Unfall eingeliefert samt korrekt gelagerter Amputate. Der Patient erfreute sich guter Gesundheit und rauchte nicht. Der postoperative Verlauf war im Hinblick auf die replantierten Finger komplikationslos, allerdings entwickelte der Patient nach seiner Entlassung eine linksseitige Pneumonie, die mittels iv-Antibiose erfolgreich behandelt wurde. 8 Monate nach der Replantation fand sich lediglich eine geringe Beweglichkeit der replantierten Finger von 45 °, die Grobkraft betrug 8 kg und der qDASH lag bei 24 Punkten. Ungeachtet dessen konnte der Patient aufgrund seines gut funktionie renden Daumens Gegenstände greifen mit den beiden replantierten Fingern als Gegenlager.
Schlüsselwörter ▶ Replantation ● ▶ Osteosynthese ● ▶ Finger ● ▶ Obere Extremität ●
received 18.4.2014 accepted 20.10.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1395546 Published online: December 22, 2014 Handchir Mikrochir Plast Chir 2015; 47: 67–69 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Andrzej Zyluk Department of General and Hand Surgery Pomeranian Medical University ul. Unii Lubelskiej 1 Szczecin Poland 71-252 [email protected]
▼
Introduction
▼
Finger or hand replantation in elderly patients (over 70 years) may be challenging. One may expect technical problems during the operation, post-operative complications and a poorer final result, due to the patient’s reduced capacity to follow the rehabilitation regime. Nevertheless, the literature shows some satisfactory results for replantation in this age group [1]. We present the case of an 82-year-old patient who had 2 of his 4 amputated fingers successfully replanted.
Case Report
▼
The patient sustained distal transmetacarpal amputation of his 4 fingers in the left (non-domi▶ Fig. 1a, b) and nant) hand by a circular saw ( ●
▼
was delivered to our institution 3 h after injury with the amputated part the hand appropriately stored (cooled). Amputation level was distal to the superficial palmar arch, which made replantation “en-block” impossible. The MP joints were also involved. The patient’s general health status was good, with no serious diseases except mild coronary disease and hypertension. He did not smoke. We decided to replant 2 of the 4 amputated fingers: the index and the middle finger ▶ Fig. 2a). ( ● The operation was done under brachial plexus anesthesia with the use of a tourniquet. After shortening of the skeleton, K-wire bone fixation ▶ Fig. 2b), followed by repairs of was performed ( ● the extensor and flexor tendons in both fingers. Next, the veins (2 in the index and 1 in the middle finger) and 1 digital artery in each finger were anastomosed. We noted greater technical prob-
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
Erfolgreiche Replantation von 2 Fingern bei einem 82-jährigen Patienten: ein Fallbericht
68 Cases of Interest
b
b
a
a
Fig. 1 a 4-finger, en-block amputation. b The stump of the metacarpus.
Fig. 2 a Appearence of the hand immediately after 2 fingers replantation. b Bone fixation in the presented case.
b
lems with arterial anastomosis than for the veins: the veins were wide and easy to suture, in contrast to the narrow digital arteries. The digital nerves were also sutured, one in each finger: the radial digital nerve in the index and the ulnar in the middle finger. After release of the tourniquet the replanted fingers showed good vascularization. The total time of the operation was 4 h, including 40 min preparation of the amputation part, 150 min tourniquet time (bone fixation, tendons suturing, vessels anastomosing) and 50 min of nerve repair, hemostasis and skin closure, without tourniquet. Post-op protocol included heparin i. v. infusion for 7 days, followed by fractioned heparin for the next 2 weeks. Blood replacement was needed during and after the operation, 4 units in total. The post-operative course was uneventful for the replanted fingers, but after having returned home at 2 weeks, the patient developed left-sided pneumonia, treated successfully with i. v. antibiotics in the local hospital. Partial necrosis of the skin around the wound was observed, which eventually healed at 4 weeks. The K-wires were removed 2 months after replantation and at that time the patient presented only slight movements of the replanted fingers. He was
Fig. 3 a, b Appearence of the hand and range of motion of the fingers at 6 months.
referred to rehabilitation and at the 8 months follow-up examination, an active range of motion of replanted fingers was 45 ° (mostly in the MP joints – ● ▶ Fig. 3a, b), a total grip strength of the hand 8 kg (32 % of the other side) and the qDASH score 24. He could firmly grasp objects due to having an intact, well-functioning thumb. He also regained a protective sensation in his replanted fingers. In the Burton scale of assessment of the results, the patient achieved a score of 41 (range 0 – the poorest to 100 – perfect). It included 10 points in socioeconomic subscale, 10 points in objective measurements and 21 points in subjective assessment [2].
Discussion
▼
There is little information in the literature on finger or hand replantation in the elderly. Liverneaux reported hand replantation performed in an 88-year-old man who was active and in good general condition. No post-operative complications were noted and the functional result at 2 years was satisfactory, because the
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
a
Cases of Interest 69
Zbigniew Szlosser Age 32 years. Born in 1982 in Szczecin, Poland. Graduated in 2007 in Pomeranian Medical University in Szczecin, Poland. MD thesis in 2011 in Pomeranian Medical University. Assistant in the Department of General and Hand Surgery in Szczecin since 2008. Member of Polish Society for Surgery of the Hand since 2009. Trained microsurgical skills in Ganga Microsurgery Training Institute, Coimbatore, India in 2009. Main topic of interest: hand trauma, microsurgery, hand reconstruction.
Conflict of interest: None. References
1 Meyer VE. Upper extremity replantation – a review. Eur Surg 2003; 35: 167–173 2 Burton RI. Problems in the evaluation of results from replantation surgery. Orth Clin North Am 1981; 12: 909–912 3 Liverneaux P. Hand replantation in an 88-year-old man: replanted senior? Chir Main 2002; 21: 355–358 4 Leung PC. Hand replantation in an 83-year-old woman – the oldest replantation? Plast Reconstr Surg 1979; 64: 416–418 5 Okada T, Ishikura N, Tsukada S. Digital replantation in the aged patient. J Reconstr Microsurg 1988; 4: 351–357 6 Barzin A, Hernandez-Boussard T, Lee GK et al. Adverse events following digital replantation in the elderly. J Hand Surg Am 2011; 36: 870–874
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
patient could write, dig his garden and drive a car [3]. Leung reported successful hand replantation in an 83-year-old woman and satisfactory early functional return [4]. Okada et al. (1988) presented results of digital replantation in 8 elderly (65–74 years) patients. 5 of the 9 fingers were successfully replanted. Although restored function in the replanted fingers was poor, all the patients were satisfied with the results [5]. Barzin et al. (2011) reported on complications in 616 elderly (65–75 years) patients receiving finger and thumb replantation over a 10-year period (1998–2007) in the United States. They found no higher in-hospital mortality and serious complication rate in this group when compared to the younger population. Survival rate and functional results were not addressed. Age alone should not be an absolute contraindication to finger replantation. The type of injury and the patient's, general state of health should guide the decision about replantation [1, 6]. In the presented case, the desistance from the replantation would probably have resulted in poorer functional outcome, as a grasp of the thumb against the metacarpal stump, although possible, would be weaker and less dexterous. The patient was very satisfied with the final outcome of the operation. He would opt for the same procedure if the amputation occurs again. Therefore, we believe that, in spite of non-perfect functional outcome, the decision to replant 2 of the 4 amputated fingers in this 82-year-old patient brought him real benefit.
Successful Replantation of 2 Fingers in an 82-year-old Patient: A Case Report
Authors
Z. Szlosser, I. Walaszek, A. Zyluk
Affiliation
Department of General and Hand Surgery, Pomeranian Medical University, Szczecin, Poland
Key words ▶ replantation ● ▶ osteosynthesis ● ▶ finger ● ▶ upper limb ●
Abstract
Zusammenfassung
We present the case of an 82-year-old patient who had successfully replanted 2 of his 4 amputated fingers in the left, non-dominant hand. Amputation was caused by a circular saw and the patient was delivered to the hospital 3 h after injury with amputated part of the hand appropriately stored. The patient’s general health status was good, with no serious systemic diseases. He also did not smoke. Post-operative course was uneventful for the replanted fingers, but after his return home the patient developed left-sided pneumonia, treated successfully with i.v. antibio tics. 8 months after replantation the patient presented with slight movement in the replanted fingers (AROM 45 °), a total grip strength 8 Kg and the qDASH score 24; however, he could firmly grasp objects due to having an intact, well-functioning thumb.
Wir berichten über einen 82-jährigen Patienten mit erfolgreicher Replantation von 2 seiner 4 amputierten Finger der linken, nicht dominanten Hand durch eine Kreissägenverletzung. Der Patient wurde 3 Stunden nach dem Unfall eingeliefert samt korrekt gelagerter Amputate. Der Patient erfreute sich guter Gesundheit und rauchte nicht. Der postoperative Verlauf war im Hinblick auf die replantierten Finger komplikationslos, allerdings entwickelte der Patient nach seiner Entlassung eine linksseitige Pneumonie, die mittels iv-Antibiose erfolgreich behandelt wurde. 8 Monate nach der Replantation fand sich lediglich eine geringe Beweglichkeit der replantierten Finger von 45 °, die Grobkraft betrug 8 kg und der qDASH lag bei 24 Punkten. Ungeachtet dessen konnte der Patient aufgrund seines gut funktionie renden Daumens Gegenstände greifen mit den beiden replantierten Fingern als Gegenlager.
Schlüsselwörter ▶ Replantation ● ▶ Osteosynthese ● ▶ Finger ● ▶ Obere Extremität ●
received 18.4.2014 accepted 20.10.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1395546 Published online: December 22, 2014 Handchir Mikrochir Plast Chir 2015; 47: 67–69 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0722-1819 Correspondence Andrzej Zyluk Department of General and Hand Surgery Pomeranian Medical University ul. Unii Lubelskiej 1 Szczecin Poland 71-252 [email protected]
▼
Introduction
▼
Finger or hand replantation in elderly patients (over 70 years) may be challenging. One may expect technical problems during the operation, post-operative complications and a poorer final result, due to the patient’s reduced capacity to follow the rehabilitation regime. Nevertheless, the literature shows some satisfactory results for replantation in this age group [1]. We present the case of an 82-year-old patient who had 2 of his 4 amputated fingers successfully replanted.
Case Report
▼
The patient sustained distal transmetacarpal amputation of his 4 fingers in the left (non-domi▶ Fig. 1a, b) and nant) hand by a circular saw ( ●
▼
was delivered to our institution 3 h after injury with the amputated part the hand appropriately stored (cooled). Amputation level was distal to the superficial palmar arch, which made replantation “en-block” impossible. The MP joints were also involved. The patient’s general health status was good, with no serious diseases except mild coronary disease and hypertension. He did not smoke. We decided to replant 2 of the 4 amputated fingers: the index and the middle finger ▶ Fig. 2a). ( ● The operation was done under brachial plexus anesthesia with the use of a tourniquet. After shortening of the skeleton, K-wire bone fixation ▶ Fig. 2b), followed by repairs of was performed ( ● the extensor and flexor tendons in both fingers. Next, the veins (2 in the index and 1 in the middle finger) and 1 digital artery in each finger were anastomosed. We noted greater technical prob-
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
Erfolgreiche Replantation von 2 Fingern bei einem 82-jährigen Patienten: ein Fallbericht
68 Cases of Interest
b
b
a
a
Fig. 1 a 4-finger, en-block amputation. b The stump of the metacarpus.
Fig. 2 a Appearence of the hand immediately after 2 fingers replantation. b Bone fixation in the presented case.
b
lems with arterial anastomosis than for the veins: the veins were wide and easy to suture, in contrast to the narrow digital arteries. The digital nerves were also sutured, one in each finger: the radial digital nerve in the index and the ulnar in the middle finger. After release of the tourniquet the replanted fingers showed good vascularization. The total time of the operation was 4 h, including 40 min preparation of the amputation part, 150 min tourniquet time (bone fixation, tendons suturing, vessels anastomosing) and 50 min of nerve repair, hemostasis and skin closure, without tourniquet. Post-op protocol included heparin i. v. infusion for 7 days, followed by fractioned heparin for the next 2 weeks. Blood replacement was needed during and after the operation, 4 units in total. The post-operative course was uneventful for the replanted fingers, but after having returned home at 2 weeks, the patient developed left-sided pneumonia, treated successfully with i. v. antibiotics in the local hospital. Partial necrosis of the skin around the wound was observed, which eventually healed at 4 weeks. The K-wires were removed 2 months after replantation and at that time the patient presented only slight movements of the replanted fingers. He was
Fig. 3 a, b Appearence of the hand and range of motion of the fingers at 6 months.
referred to rehabilitation and at the 8 months follow-up examination, an active range of motion of replanted fingers was 45 ° (mostly in the MP joints – ● ▶ Fig. 3a, b), a total grip strength of the hand 8 kg (32 % of the other side) and the qDASH score 24. He could firmly grasp objects due to having an intact, well-functioning thumb. He also regained a protective sensation in his replanted fingers. In the Burton scale of assessment of the results, the patient achieved a score of 41 (range 0 – the poorest to 100 – perfect). It included 10 points in socioeconomic subscale, 10 points in objective measurements and 21 points in subjective assessment [2].
Discussion
▼
There is little information in the literature on finger or hand replantation in the elderly. Liverneaux reported hand replantation performed in an 88-year-old man who was active and in good general condition. No post-operative complications were noted and the functional result at 2 years was satisfactory, because the
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
a
Cases of Interest 69
Zbigniew Szlosser Age 32 years. Born in 1982 in Szczecin, Poland. Graduated in 2007 in Pomeranian Medical University in Szczecin, Poland. MD thesis in 2011 in Pomeranian Medical University. Assistant in the Department of General and Hand Surgery in Szczecin since 2008. Member of Polish Society for Surgery of the Hand since 2009. Trained microsurgical skills in Ganga Microsurgery Training Institute, Coimbatore, India in 2009. Main topic of interest: hand trauma, microsurgery, hand reconstruction.
Conflict of interest: None. References
1 Meyer VE. Upper extremity replantation – a review. Eur Surg 2003; 35: 167–173 2 Burton RI. Problems in the evaluation of results from replantation surgery. Orth Clin North Am 1981; 12: 909–912 3 Liverneaux P. Hand replantation in an 88-year-old man: replanted senior? Chir Main 2002; 21: 355–358 4 Leung PC. Hand replantation in an 83-year-old woman – the oldest replantation? Plast Reconstr Surg 1979; 64: 416–418 5 Okada T, Ishikura N, Tsukada S. Digital replantation in the aged patient. J Reconstr Microsurg 1988; 4: 351–357 6 Barzin A, Hernandez-Boussard T, Lee GK et al. Adverse events following digital replantation in the elderly. J Hand Surg Am 2011; 36: 870–874
Szlosser Z et al. Successful Replantation of 2 … Handchir Mikrochir Plast Chir 2015; 47: 67–69
Downloaded by: The University of Hong Kong. Copyrighted material.
patient could write, dig his garden and drive a car [3]. Leung reported successful hand replantation in an 83-year-old woman and satisfactory early functional return [4]. Okada et al. (1988) presented results of digital replantation in 8 elderly (65–74 years) patients. 5 of the 9 fingers were successfully replanted. Although restored function in the replanted fingers was poor, all the patients were satisfied with the results [5]. Barzin et al. (2011) reported on complications in 616 elderly (65–75 years) patients receiving finger and thumb replantation over a 10-year period (1998–2007) in the United States. They found no higher in-hospital mortality and serious complication rate in this group when compared to the younger population. Survival rate and functional results were not addressed. Age alone should not be an absolute contraindication to finger replantation. The type of injury and the patient's, general state of health should guide the decision about replantation [1, 6]. In the presented case, the desistance from the replantation would probably have resulted in poorer functional outcome, as a grasp of the thumb against the metacarpal stump, although possible, would be weaker and less dexterous. The patient was very satisfied with the final outcome of the operation. He would opt for the same procedure if the amputation occurs again. Therefore, we believe that, in spite of non-perfect functional outcome, the decision to replant 2 of the 4 amputated fingers in this 82-year-old patient brought him real benefit.
