Sunday, October 10, 2004

Review of re-plantation of amputations of the wrist and distal forearm: A 12 year experience

Nicholas Bastidas, BA, Sheil Sharma, MD, and David W. Friedman, MD.

Introduction: Advances in microsurgery have made not only the revascularization of partially severed limbs possible, but re-attachment of entirely amputated limbs are now considered routine, offering the possibility of limb salvage to patients that have suffered traumatic hand injuries. Bellevue Hospital, being one of the leading trauma centers in the United States, and a regional microsurgery and replantation center, has, over the years, cared for a large number of these patients.

Methods: We have conducted a retrospective chart review on all patients who underwent hand replantation at Bellevue Hospital since 1990 and are now reporting long-term results and success rates following re-plantation surgery for 25 patients. Specifically, we have organized the information regarding surgical techniques performed, reconstruction of hand anatomy, duration of surgery, re-operations or failures, and length of hospitalization. We have also reported the context in which the injury occurred involving the mechanism and anatomical level of injury, as well as the demographics of each patient. All patients documented had a minimum of one year of follow up to assess functionality of the replanted limb. Successful outcome was considered an improvement in the patientís lifestyle, including performance of daily tasks, return to employment and satisfaction of the patient.

Results: Of the 25 patients requiring hand replant/revascularization over the last 12 yrs, 24 were men with an average age of 38.5 years. 10 injuries involved a crush/avulsion mechanism with an average operating time of 8hrs and length of hospitalization of 14.67 days. 8 Injuries involved a saw mechanism, op time of 12 hrs and LOH of 13.67 days. 7 Injuries involved sharp lacerations, op time of 9.5hrs and LOH of 11 days. There were 22 successful re-plantations (88%), the three failures (12%) involved crush/avulsion injuries and were related to acute arterial thrombosis. 13 people received a heparin bolus intra-operatively (including 1 failure replant). Following replantation, 3/7 of the lacerating amputees reported increased function, and 2/7 were able to return to work. 4/8 of the circular saw amputees reported increased function, however no one returned to work. 2/10 crush/avulsion amputee reported increased function, 2/10 developed severe contractures requiring re-operation, and no one returned to work.

Conclusion: Hand replantation not only offers the patient an aesthetically pleasing alternative to amputation, but also allows for the restoration of limited functionality of the replanted limb, such as the ability to grasp objects. Greatest success is achieved in patients suffering lacerating or saw injuries, likely due to less damage of surrounding tissues. The advantage of this study over those previously described includes the positive contribution of technological advances over the last 20 years, the elaboration of fine details regarding the effect of the injury as well as surgical outcome and follow-up, and the availability of access to detailed medical records from Bellevue hospital.