- Email: [email protected]
Functional Outcomes of Replantation Following Radiocarpal Amputation
SCIENTIFIC ARTICLE
Functional Outcomes of Replantation Following Radiocarpal Amputation Amar Arun Patel, MD, Andrew L. Blount, MD, Patrick W. Owens, MD, Morad Askari, MD
Purpose To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. Methods We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Results Six patients met the inclusion criteria. The mean age was 36 years (range, 26e50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0e6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8e12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45e82), Mayo Wrist Score (23; range, 5e50), Patient-Rated Wrist Evaluation (86; range, 56e98), and Michigan Hand Questionnaire (27; range, 15e55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. Conclusions Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. (J Hand Surg Am. 2015;40(2):266e270. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Replant, radiocarpal, amputation, wrist, outcomes.
From the Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, and Jackson Memorial Hospital, University of Miami, Miami, FL. Received for publication July 17, 2014; accepted in revised form October 8, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Morad Askari, MD, Department of Orthopaedics, Hand and Microvascular Surgery, Miller School of Medicine, University of Miami, 900 NW 17th Street, Miami, FL 33136; e-mail: [email protected]. 0363-5023/15/4002-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.10.017
266
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
M
AJOR UPPER EXTREMITY amputations are uncommon but devastating. Recent data are lacking specifically for the United States, but the prevalence of major upper extremity amputation is estimated to be 11.6 per 100,000 adults in Norway.1 Opinions regarding indications for replantation have been extensively reported, as have the factors associated with successful replants.1e3 Complications, revision rates, and hospital costs are higher in this population relative to those receiving revision amputation.2,4
RADIOCARPAL REPLANTATION OUTCOMES
Aside from the obvious immediate functional and psychosocial difficulties, long-term rehabilitative challenges are immense after major upper extremity replantation. Often, outcomes are not reported or are described in a manner that makes comparison difficult.5 The goal of this study was to present our case series of radiocarpal-level replants and assess their long-term results. Specifically, we describe the clinical course of our patients and describe their improvement through validated functional outcomes measures. MATERIALS AND METHODS After approval by our institutional review board, we conducted a retrospective review on all patients presenting to an urban level 1 trauma center from January 2001 to January 2014. Patients with traumatic amputation at or close to the radiocarpal joint were considered for inclusion. Those with injuries distal to the carpals or proximal to the distal radius and ulna were excluded. Patients were excluded if they had a revision amputation at the index procedure, multilevel injuries, injuries to the contralateral extremity, or a mangled amputated hand that precluded replantation. We queried medical records for demographic information (age, sex, race, occupation, comorbidities, and social history) and injury characteristics (revised trauma score, Glasgow coma score, mechanism of injury, amputation level, ischemia time, contamination, and associated injuries). Perioperative complications, wound complications, and need for further surgeries were noted from progress notes. Follow-up assessment Patients who met inclusion criteria were contacted for long-term follow-up via telephone and evaluated in our clinic by a single examiner. We took radiographs of the wrist and hand to assess for fracture union. During these encounters, we assessed functional results by the following criteria: 1. We evaluated flexor and extensor recovery of all fingers with composite total active motion (TAM) of each digit (TAM ¼ active flexion [metacarpophalangeal (MCP) þ proximal interphalangeal (PIP) þ distal interphalangeal (DIP)] e active extension deficit [MCP þ PIP þ DIP]). Total active motion of each digit and the hand was expressed as a percentage compared with the uninjured, contralateral hand. 2. We assessed grip strength using a calibrated dynamometer (Jamar Hydraulic Hand Dynamometer, Patterson Medical, Warrenville, IL) with J Hand Surg Am.
r
267
the forearm in neutral rotation and the wrist in neutral flexion-extension. The dynamometer was calibrated to position 2, which has been validated as the optimal position for testing.6 Key pinch and tip pinch were assessed with a calibrated pinch gauge (B&L Engineering Pinch Gauge, Patterson Medical). The average of 3 iterations was recorded. These values were compared with the contralateral hand and reported as a percentage. 3. Neurologic recovery of sensitivity was assessed using static 2-point discrimination (2PD) on the ulnar and radial aspect of each digit. These values were averaged for all digits. 4. To standardize outcomes, 4 validated questionnaires were completed at the visits: the Michigan Hand Outcomes Questionnaire (MHQ), Mayo Wrist Score (MWS), Patient-Rated Wrist Evaluation (PRWE), and Disability of the Arm, Shoulder, and Hand (DASH). Lower scores on MWS and MHQ and higher scores on PRWE and DASH indicate higher disability. A patient satisfaction score for overall function was also determined from the MHQ question set (graded as “very satisfied,” “somewhat satisfied,” “neither satisfied nor dissatisfied,” “somewhat dissatisfied,” or “very dissatisfied”).7 Questionnaires could not be completed regarding pre-injury because data were collected retrospectively for part of this study. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Given the small cohort, advanced statistical analysis could not be conducted. RESULTS During the 13-year study, 6 patients met inclusion criteria and the average follow-up was 3.9 years (range, 1.0e6.9 y). Mean age at injury was 36 years (range, 26e50 y). Four patients were men. Occupations of each were electrician, mechanic, other manual labor, office administrator, unemployed, and unknown. Comorbidities included hypertension (n ¼ 1), previous myocardial infarction (n ¼ 1), psychiatric disorder (n ¼ 1), smoker (n ¼ 2), alcohol use (n ¼ 1), and recreational drug use (n ¼ 2). Table 1 lists injury characteristics. Patients were evaluated in the operating room a mean of 6.4 hours after injury. This average delay included one patient who was transferred from a Caribbean island and had an ischemia time of 18 hours owing to complicated transport. Three patients required compartment release of the hand (2 for ischemia time more than 6 h and 1 for Vol. 40, February 2015
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RADIOCARPAL REPLANTATION OUTCOMES
TABLE 1.
TABLE 2.
Injury Characteristics
Mean ischemic time
6 h 24 min (range, 2e18 h)*
Follow-Up Functional Outcomes
Grip strength, kg
3.2/9 (0e9)
Tip pinch, kg
0/0
1
Key pinch, kg
0/0
Glass
1
TAM wrist (degrees)
13/9 (0e36)
Heavy machinery
1
TAM thumb (degrees)
61/47 (23e81)
Machete
2
TAM index (degrees)
105/39 (26e46)
Blade (self-inflicted)
1
TAM middle (degrees)
100/37 (24e70)
Work-related
3
TAM ring (degrees)
106/39 (19e63)
Contamination
3
TAM little (degrees)
88/32 (11e63)
Dominant extremity involvement
5
TAM total hand (degrees)
460/38 (27e59)
2-point discrimination, mm
10.6 (8e12)
Glasgow coma score
13 (range, 11e15)
Revised trauma score
10 (range, 9e11)
Mechanism Electrical wire
Data are average raw value/percentage of contralateral extremity (percent range) unless otherwise indicated.
Associated injuries Neck trauma (sharp)
1
Bilateral eye trauma (sharp)
1
*One patient was transferred from outside the country with 18 hours ischemic time.
staged tendon reconstruction). Proximal row carpectomy was performed in patients with extensive carpal damage (n ¼ 3) and radioscapholunate arthrodesis was performed in one patient in whom bony injury was less extensive. Bone shortening was not performed other than for proximal row carpectomies. Either a wrist fusion plate (n ¼ 5) or dorsal bridge plate (n ¼ 1) was used to attain bony fixation of the amputated hand. After reperfusion, the median and ulnar nerves were primarily repaired in all cases and the radial sensory nerve was located and repaired in only one; no nerve allografts or autografts were used. Neither the dorsal sensory branch of the ulnar nerve nor the palmar cutaneous branch of the median nerve was repaired. In 3 cases, all flexor and extensor tendons were repaired. In others, only extensor carpi ulnaris and flexor carpi radialis (n ¼ 1) or flexor carpi radialis and flexor carpi ulnaris (n ¼ 1) were not repaired owing to the extent of injury. In one case, the extensor digiti quinti was transferred to extensor digitorum communis of the little finger end-to-side. Hospital course and rehabilitation We noted no acute compromise of the replanted hand in the immediate postoperative period for all patients. The average length of stay was 9.5 days (range, 1e17 d). One patient died on the first postoperative day. This patient dismembered the replanted limb during a psychotic episode, hemorrhaged, and subsequently went into cardiopulmonary arrest. J Hand Surg Am.
r
A mean of 2.8 surgeries (range, 2e4 surgeries) were performed spanning from debridement and wound coverage to late tendon reconstruction. Three patients required a split-thickness skin graft, 1 required bone grafting, and 1 had a deep infection requiring debridement and intravenous antibiotics. One patient had staged repair of the flexor and extensor tendons 1 week after the initial replantation. Eight weeks after the index procedure, the patient underwent removal of the fusion plate and tenolysis of the flexor and extensor tendons. Non-viability of multiple tendon repairs was found and she received transfer of the extensor indicis proprius to the extensor pollicis longus, transfer of the extensor carpi ulnaris to the extensor carpi radialis brevis, and primary repair of the flexor digitorum profundus of the ring finger and the flexor pollicis longus. After extensive volar and dorsal tenolysis at follow-up surgery, the hand became ischemic and required reconstruction of arterial in-flow with a saphenous vein graft. Normal circulation was restored to the hand with no further complication. A supervised therapy protocol was initiated during the hospitalization. A therapist worked on passive motion at the shoulder, elbow, and digits within the confines of the postoperative orthosis. At 2 weeks, the orthosis was removed and passive and active range of motion initiated with skilled therapy in the outpatient setting. In addition to motion exercises, our protocol also emphasized early desensitization techniques (with a variety of textures and vibration). Special activities to assist with activities of daily living were performed, including reaching and grasping coordination with cone stacking, grip strength and forearm strengthening with wrist rollers, Vol. 40, February 2015
269
RADIOCARPAL REPLANTATION OUTCOMES
TABLE 3.
Functional Outcome Questionnaire Results Patient 1
2
3
4
5
Average
Real Disabilities of the Arm, Shoulder, and Hand score*
78
68
45
75
82
76
Patient-Rated Wrist Evaluation*
85
75
56
98
85
86
34
36
55
15
24
27
35
35
50
5
15
23
Michigan Hand Questionnaire
†
Mayo Wrist Score† *Higher score signifies greater disability. †Lower score signifies greater disability.
and fine motor/handeeye coordination with pegboard exercises. Place-and-hold exercises and manual resistive strengthening exercises were performed for intrinsic and extrinsic muscles. Follow-up Consultation was completed at an average follow-up of 3.9 years (range, 1.0e6.9 y) (Table 2). The average TAM of the entire hand was 38% of the contralateral side. The patient treated with a radioscapholunate arthrodesis had TAM of the wrist that was 36% of the contralateral extremity. All patients treated with wrist arthrodesis achieved fusion at follow-up and had no wrist motion. Patients recovered on average 10.6 mm (range, 8e12 mm) of 2 PD and all patients noted cold intolerance. No digit necrosis, painful scar, or neuroma was noted in any patient. Functional outcomes were recorded for all patients at follow-up (Table 3). One patient returned to her normal job as an administrative assistant 3 months after injury. Another patient could not continue work as an electrician but worked as a supervisor beginning 7 months after injury. The other 3 patients were unable to return to work and gained total disability benefits (2 owing to pain and function and 1 owing to function). All patients were very satisfied (n ¼ 2) or somewhat satisfied (n ¼ 3) with the results. DISCUSSION Major upper extremity amputations, although uncommon, are functionally and psychosocially devastating.8e10 Long-term rehabilitative challenges are multiple and highly dependent on the type and level of injury. Among amputations proximal to the hand, those at the radiocarpal level allow more options for function owing to intact shoulder, elbow, and distal radioulnar joints.9,10 Considering the entire upper extremity, the most distal replants are associated with the best TAM, grip strength, sensory recovery, and intrinsic recovery.11,12 Amputations portend a more J Hand Surg Am.
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complicated postoperative course compared with less extreme injuries; 80% of replantations require a secondary procedure with an average of 2.6 procedures in total.13 In our series, all replanted hands survived although one patient died from extenuating postoperative circumstances. Despite survival of 100% of digits in the surviving patients, results of the outcomes assessments demonstrated considerable disability in our patient series. Although our patient cohort did not yield the power to perform statistical analysis, outcomes in our population did not reflect ischemia time, contamination level, number of surgeries, or complications. For instance, the patient with the most favorable functional scores also had the longest ischemic time, length of stay, blood loss, and number of surgeries. The 2 patients with the least disability had the most education past high school and were the ones who returned to work. The worst result was the patient who was both unemployed and the oldest of the cohort. Similar results were reported previously. Hoang14 examined a cohort of 5 young men who underwent replantation for radiocarpal-level amputations. At a follow-up between 26 and 46 months, satisfaction was high despite total TAM of 75% to 85% of the contralateral side, static 2PD diminished to 8 to 12 mm, and loss of intrinsic muscle function. Mahajan and Mittal15 reported the results of 17 patients (aged 2e55 y) with radiocarpal replantation. Most patients had a total TAM between 50% and 70% of the contralateral side, diminished intrinsic function, and static 2PD over 10 mm. Of 14 patients with followup, 10 reported fair satisfaction despite these outcomes. Neither of these studies used patient outcomes questionnaires. The TAM values reported in these studies were superior to our results because most of our subjects were treated with wrist arthrodesis using a plate in almost all cases, leading to decreased wrist and digit motion. Similar to our study, patients Vol. 40, February 2015
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RADIOCARPAL REPLANTATION OUTCOMES
regained some active finger motion, many patients were able to return to work, and satisfaction was high; however, intrinsic function was poor (as indicated by loss of grip and pinch strength) and static 2PD was not fully preserved. The results from our outcome scores indicated that patient disability was more evident from subjective questionnaires and not readily apparent from objective measures alone. Limitations of our study are its retrospective nature, multiple surgical teams, the small number of patients with variable extent of injury, and the lack of interval outcomes measures. Follow-up for some patients was short (less than 3 y) and outcomes may be more favorable at more advanced follow-up and after secondary operations. Cost analysis would be valuable to understand the financial impact of replantation. Future multicenter studies may yield valuable information on similar patients by providing a larger cohort. REFERENCES 1. Ostlie K, Skjeldal OH, Garfelt B, Magnus P. Adult acquired major upper limb amputation in Norway: prevalence, demographic features and amputation specific features. A population-based survey. Disabil Rehabil. 2011;33(17e18):1636e1649. 2. Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am. 2011;36(11):1835e1840. 3. Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014;133(2):333e342.
J Hand Surg Am.
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4. Larson JV, Kung TA, Cederna PS, Sears ED, Urbanchek MG, Langhals NB. Clinical factors associated with replantation after traumatic major upper extremity amputation. Plast Reconstr Surg. 2013;132(4):911e919. 5. Bindra RR, Dias JJ, Heras-Palau C, Amadio PC, Chung KC, Burke FD. Assessing outcome after hand surgery: the current state. J Hand Surg Br. 2003;28(4):289e294. 6. Trampisch US, Franke J, Jedamzik N, Hinrichs T, Platen P. Optimal Jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies. J Hand Surg Am. 2012;37(11):2368e2373. 7. Waljee JF, Kim HM, Burns PB, Chung KC. Development of a brief, 12-item version of the Michigan Hand Questionnaire. Plast Reconstr Surg. 2011;128(1):208e220. 8. Atroshi I, Rosberg HE. Epidemiology of amputations and severe injuries of the hand. Hand Clin. 2001;17(3):343e350. vii. 9. Tintle SM, Baechler MF, Nanos GP III, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: part II: upper extremity and future directions. J Bone Joint Surg Am. 2010;92(18):2934e2945. 10. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. Reoperations following combat-related upper-extremity amputations. J Bone Joint Surg Am. 2012;94(16):e1191ee1196. 11. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5): 390e398. 12. Tamai S. Twenty years’ experience of limb replantation—review of 293 upper extremity replants. J Hand Surg Am. 1982;7(6):549e556. 13. Scott FA, Howar JW, Boswick JA Jr. Recovery of function following replantation and revascularization of amputated hand parts. J Trauma. 1981;21(3):204e214. 14. Hoang NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br. 2006;31(1):9e17. 15. Mahajan RK, Mittal S. Functional outcome of patients undergoing replantation of hand at wrist level—7 year experience. Indian J Plast Surg. 2013;46(3):555e560.
Vol. 40, February 2015
Functional Outcomes of Replantation Following Radiocarpal Amputation Amar Arun Patel, MD, Andrew L. Blount, MD, Patrick W. Owens, MD, Morad Askari, MD
Purpose To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. Methods We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Results Six patients met the inclusion criteria. The mean age was 36 years (range, 26e50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0e6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8e12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45e82), Mayo Wrist Score (23; range, 5e50), Patient-Rated Wrist Evaluation (86; range, 56e98), and Michigan Hand Questionnaire (27; range, 15e55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. Conclusions Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. (J Hand Surg Am. 2015;40(2):266e270. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Replant, radiocarpal, amputation, wrist, outcomes.
From the Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, and Jackson Memorial Hospital, University of Miami, Miami, FL. Received for publication July 17, 2014; accepted in revised form October 8, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Morad Askari, MD, Department of Orthopaedics, Hand and Microvascular Surgery, Miller School of Medicine, University of Miami, 900 NW 17th Street, Miami, FL 33136; e-mail: [email protected]. 0363-5023/15/4002-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.10.017
266
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
M
AJOR UPPER EXTREMITY amputations are uncommon but devastating. Recent data are lacking specifically for the United States, but the prevalence of major upper extremity amputation is estimated to be 11.6 per 100,000 adults in Norway.1 Opinions regarding indications for replantation have been extensively reported, as have the factors associated with successful replants.1e3 Complications, revision rates, and hospital costs are higher in this population relative to those receiving revision amputation.2,4
RADIOCARPAL REPLANTATION OUTCOMES
Aside from the obvious immediate functional and psychosocial difficulties, long-term rehabilitative challenges are immense after major upper extremity replantation. Often, outcomes are not reported or are described in a manner that makes comparison difficult.5 The goal of this study was to present our case series of radiocarpal-level replants and assess their long-term results. Specifically, we describe the clinical course of our patients and describe their improvement through validated functional outcomes measures. MATERIALS AND METHODS After approval by our institutional review board, we conducted a retrospective review on all patients presenting to an urban level 1 trauma center from January 2001 to January 2014. Patients with traumatic amputation at or close to the radiocarpal joint were considered for inclusion. Those with injuries distal to the carpals or proximal to the distal radius and ulna were excluded. Patients were excluded if they had a revision amputation at the index procedure, multilevel injuries, injuries to the contralateral extremity, or a mangled amputated hand that precluded replantation. We queried medical records for demographic information (age, sex, race, occupation, comorbidities, and social history) and injury characteristics (revised trauma score, Glasgow coma score, mechanism of injury, amputation level, ischemia time, contamination, and associated injuries). Perioperative complications, wound complications, and need for further surgeries were noted from progress notes. Follow-up assessment Patients who met inclusion criteria were contacted for long-term follow-up via telephone and evaluated in our clinic by a single examiner. We took radiographs of the wrist and hand to assess for fracture union. During these encounters, we assessed functional results by the following criteria: 1. We evaluated flexor and extensor recovery of all fingers with composite total active motion (TAM) of each digit (TAM ¼ active flexion [metacarpophalangeal (MCP) þ proximal interphalangeal (PIP) þ distal interphalangeal (DIP)] e active extension deficit [MCP þ PIP þ DIP]). Total active motion of each digit and the hand was expressed as a percentage compared with the uninjured, contralateral hand. 2. We assessed grip strength using a calibrated dynamometer (Jamar Hydraulic Hand Dynamometer, Patterson Medical, Warrenville, IL) with J Hand Surg Am.
r
267
the forearm in neutral rotation and the wrist in neutral flexion-extension. The dynamometer was calibrated to position 2, which has been validated as the optimal position for testing.6 Key pinch and tip pinch were assessed with a calibrated pinch gauge (B&L Engineering Pinch Gauge, Patterson Medical). The average of 3 iterations was recorded. These values were compared with the contralateral hand and reported as a percentage. 3. Neurologic recovery of sensitivity was assessed using static 2-point discrimination (2PD) on the ulnar and radial aspect of each digit. These values were averaged for all digits. 4. To standardize outcomes, 4 validated questionnaires were completed at the visits: the Michigan Hand Outcomes Questionnaire (MHQ), Mayo Wrist Score (MWS), Patient-Rated Wrist Evaluation (PRWE), and Disability of the Arm, Shoulder, and Hand (DASH). Lower scores on MWS and MHQ and higher scores on PRWE and DASH indicate higher disability. A patient satisfaction score for overall function was also determined from the MHQ question set (graded as “very satisfied,” “somewhat satisfied,” “neither satisfied nor dissatisfied,” “somewhat dissatisfied,” or “very dissatisfied”).7 Questionnaires could not be completed regarding pre-injury because data were collected retrospectively for part of this study. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Given the small cohort, advanced statistical analysis could not be conducted. RESULTS During the 13-year study, 6 patients met inclusion criteria and the average follow-up was 3.9 years (range, 1.0e6.9 y). Mean age at injury was 36 years (range, 26e50 y). Four patients were men. Occupations of each were electrician, mechanic, other manual labor, office administrator, unemployed, and unknown. Comorbidities included hypertension (n ¼ 1), previous myocardial infarction (n ¼ 1), psychiatric disorder (n ¼ 1), smoker (n ¼ 2), alcohol use (n ¼ 1), and recreational drug use (n ¼ 2). Table 1 lists injury characteristics. Patients were evaluated in the operating room a mean of 6.4 hours after injury. This average delay included one patient who was transferred from a Caribbean island and had an ischemia time of 18 hours owing to complicated transport. Three patients required compartment release of the hand (2 for ischemia time more than 6 h and 1 for Vol. 40, February 2015
268
RADIOCARPAL REPLANTATION OUTCOMES
TABLE 1.
TABLE 2.
Injury Characteristics
Mean ischemic time
6 h 24 min (range, 2e18 h)*
Follow-Up Functional Outcomes
Grip strength, kg
3.2/9 (0e9)
Tip pinch, kg
0/0
1
Key pinch, kg
0/0
Glass
1
TAM wrist (degrees)
13/9 (0e36)
Heavy machinery
1
TAM thumb (degrees)
61/47 (23e81)
Machete
2
TAM index (degrees)
105/39 (26e46)
Blade (self-inflicted)
1
TAM middle (degrees)
100/37 (24e70)
Work-related
3
TAM ring (degrees)
106/39 (19e63)
Contamination
3
TAM little (degrees)
88/32 (11e63)
Dominant extremity involvement
5
TAM total hand (degrees)
460/38 (27e59)
2-point discrimination, mm
10.6 (8e12)
Glasgow coma score
13 (range, 11e15)
Revised trauma score
10 (range, 9e11)
Mechanism Electrical wire
Data are average raw value/percentage of contralateral extremity (percent range) unless otherwise indicated.
Associated injuries Neck trauma (sharp)
1
Bilateral eye trauma (sharp)
1
*One patient was transferred from outside the country with 18 hours ischemic time.
staged tendon reconstruction). Proximal row carpectomy was performed in patients with extensive carpal damage (n ¼ 3) and radioscapholunate arthrodesis was performed in one patient in whom bony injury was less extensive. Bone shortening was not performed other than for proximal row carpectomies. Either a wrist fusion plate (n ¼ 5) or dorsal bridge plate (n ¼ 1) was used to attain bony fixation of the amputated hand. After reperfusion, the median and ulnar nerves were primarily repaired in all cases and the radial sensory nerve was located and repaired in only one; no nerve allografts or autografts were used. Neither the dorsal sensory branch of the ulnar nerve nor the palmar cutaneous branch of the median nerve was repaired. In 3 cases, all flexor and extensor tendons were repaired. In others, only extensor carpi ulnaris and flexor carpi radialis (n ¼ 1) or flexor carpi radialis and flexor carpi ulnaris (n ¼ 1) were not repaired owing to the extent of injury. In one case, the extensor digiti quinti was transferred to extensor digitorum communis of the little finger end-to-side. Hospital course and rehabilitation We noted no acute compromise of the replanted hand in the immediate postoperative period for all patients. The average length of stay was 9.5 days (range, 1e17 d). One patient died on the first postoperative day. This patient dismembered the replanted limb during a psychotic episode, hemorrhaged, and subsequently went into cardiopulmonary arrest. J Hand Surg Am.
r
A mean of 2.8 surgeries (range, 2e4 surgeries) were performed spanning from debridement and wound coverage to late tendon reconstruction. Three patients required a split-thickness skin graft, 1 required bone grafting, and 1 had a deep infection requiring debridement and intravenous antibiotics. One patient had staged repair of the flexor and extensor tendons 1 week after the initial replantation. Eight weeks after the index procedure, the patient underwent removal of the fusion plate and tenolysis of the flexor and extensor tendons. Non-viability of multiple tendon repairs was found and she received transfer of the extensor indicis proprius to the extensor pollicis longus, transfer of the extensor carpi ulnaris to the extensor carpi radialis brevis, and primary repair of the flexor digitorum profundus of the ring finger and the flexor pollicis longus. After extensive volar and dorsal tenolysis at follow-up surgery, the hand became ischemic and required reconstruction of arterial in-flow with a saphenous vein graft. Normal circulation was restored to the hand with no further complication. A supervised therapy protocol was initiated during the hospitalization. A therapist worked on passive motion at the shoulder, elbow, and digits within the confines of the postoperative orthosis. At 2 weeks, the orthosis was removed and passive and active range of motion initiated with skilled therapy in the outpatient setting. In addition to motion exercises, our protocol also emphasized early desensitization techniques (with a variety of textures and vibration). Special activities to assist with activities of daily living were performed, including reaching and grasping coordination with cone stacking, grip strength and forearm strengthening with wrist rollers, Vol. 40, February 2015
269
RADIOCARPAL REPLANTATION OUTCOMES
TABLE 3.
Functional Outcome Questionnaire Results Patient 1
2
3
4
5
Average
Real Disabilities of the Arm, Shoulder, and Hand score*
78
68
45
75
82
76
Patient-Rated Wrist Evaluation*
85
75
56
98
85
86
34
36
55
15
24
27
35
35
50
5
15
23
Michigan Hand Questionnaire
†
Mayo Wrist Score† *Higher score signifies greater disability. †Lower score signifies greater disability.
and fine motor/handeeye coordination with pegboard exercises. Place-and-hold exercises and manual resistive strengthening exercises were performed for intrinsic and extrinsic muscles. Follow-up Consultation was completed at an average follow-up of 3.9 years (range, 1.0e6.9 y) (Table 2). The average TAM of the entire hand was 38% of the contralateral side. The patient treated with a radioscapholunate arthrodesis had TAM of the wrist that was 36% of the contralateral extremity. All patients treated with wrist arthrodesis achieved fusion at follow-up and had no wrist motion. Patients recovered on average 10.6 mm (range, 8e12 mm) of 2 PD and all patients noted cold intolerance. No digit necrosis, painful scar, or neuroma was noted in any patient. Functional outcomes were recorded for all patients at follow-up (Table 3). One patient returned to her normal job as an administrative assistant 3 months after injury. Another patient could not continue work as an electrician but worked as a supervisor beginning 7 months after injury. The other 3 patients were unable to return to work and gained total disability benefits (2 owing to pain and function and 1 owing to function). All patients were very satisfied (n ¼ 2) or somewhat satisfied (n ¼ 3) with the results. DISCUSSION Major upper extremity amputations, although uncommon, are functionally and psychosocially devastating.8e10 Long-term rehabilitative challenges are multiple and highly dependent on the type and level of injury. Among amputations proximal to the hand, those at the radiocarpal level allow more options for function owing to intact shoulder, elbow, and distal radioulnar joints.9,10 Considering the entire upper extremity, the most distal replants are associated with the best TAM, grip strength, sensory recovery, and intrinsic recovery.11,12 Amputations portend a more J Hand Surg Am.
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complicated postoperative course compared with less extreme injuries; 80% of replantations require a secondary procedure with an average of 2.6 procedures in total.13 In our series, all replanted hands survived although one patient died from extenuating postoperative circumstances. Despite survival of 100% of digits in the surviving patients, results of the outcomes assessments demonstrated considerable disability in our patient series. Although our patient cohort did not yield the power to perform statistical analysis, outcomes in our population did not reflect ischemia time, contamination level, number of surgeries, or complications. For instance, the patient with the most favorable functional scores also had the longest ischemic time, length of stay, blood loss, and number of surgeries. The 2 patients with the least disability had the most education past high school and were the ones who returned to work. The worst result was the patient who was both unemployed and the oldest of the cohort. Similar results were reported previously. Hoang14 examined a cohort of 5 young men who underwent replantation for radiocarpal-level amputations. At a follow-up between 26 and 46 months, satisfaction was high despite total TAM of 75% to 85% of the contralateral side, static 2PD diminished to 8 to 12 mm, and loss of intrinsic muscle function. Mahajan and Mittal15 reported the results of 17 patients (aged 2e55 y) with radiocarpal replantation. Most patients had a total TAM between 50% and 70% of the contralateral side, diminished intrinsic function, and static 2PD over 10 mm. Of 14 patients with followup, 10 reported fair satisfaction despite these outcomes. Neither of these studies used patient outcomes questionnaires. The TAM values reported in these studies were superior to our results because most of our subjects were treated with wrist arthrodesis using a plate in almost all cases, leading to decreased wrist and digit motion. Similar to our study, patients Vol. 40, February 2015
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regained some active finger motion, many patients were able to return to work, and satisfaction was high; however, intrinsic function was poor (as indicated by loss of grip and pinch strength) and static 2PD was not fully preserved. The results from our outcome scores indicated that patient disability was more evident from subjective questionnaires and not readily apparent from objective measures alone. Limitations of our study are its retrospective nature, multiple surgical teams, the small number of patients with variable extent of injury, and the lack of interval outcomes measures. Follow-up for some patients was short (less than 3 y) and outcomes may be more favorable at more advanced follow-up and after secondary operations. Cost analysis would be valuable to understand the financial impact of replantation. Future multicenter studies may yield valuable information on similar patients by providing a larger cohort. REFERENCES 1. Ostlie K, Skjeldal OH, Garfelt B, Magnus P. Adult acquired major upper limb amputation in Norway: prevalence, demographic features and amputation specific features. A population-based survey. Disabil Rehabil. 2011;33(17e18):1636e1649. 2. Friedrich JB, Poppler LH, Mack CD, Rivara FP, Levin LS, Klein MB. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am. 2011;36(11):1835e1840. 3. Prucz RB, Friedrich JB. Upper extremity replantation: current concepts. Plast Reconstr Surg. 2014;133(2):333e342.
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4. Larson JV, Kung TA, Cederna PS, Sears ED, Urbanchek MG, Langhals NB. Clinical factors associated with replantation after traumatic major upper extremity amputation. Plast Reconstr Surg. 2013;132(4):911e919. 5. Bindra RR, Dias JJ, Heras-Palau C, Amadio PC, Chung KC, Burke FD. Assessing outcome after hand surgery: the current state. J Hand Surg Br. 2003;28(4):289e294. 6. Trampisch US, Franke J, Jedamzik N, Hinrichs T, Platen P. Optimal Jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies. J Hand Surg Am. 2012;37(11):2368e2373. 7. Waljee JF, Kim HM, Burns PB, Chung KC. Development of a brief, 12-item version of the Michigan Hand Questionnaire. Plast Reconstr Surg. 2011;128(1):208e220. 8. Atroshi I, Rosberg HE. Epidemiology of amputations and severe injuries of the hand. Hand Clin. 2001;17(3):343e350. vii. 9. Tintle SM, Baechler MF, Nanos GP III, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: part II: upper extremity and future directions. J Bone Joint Surg Am. 2010;92(18):2934e2945. 10. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. Reoperations following combat-related upper-extremity amputations. J Bone Joint Surg Am. 2012;94(16):e1191ee1196. 11. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5): 390e398. 12. Tamai S. Twenty years’ experience of limb replantation—review of 293 upper extremity replants. J Hand Surg Am. 1982;7(6):549e556. 13. Scott FA, Howar JW, Boswick JA Jr. Recovery of function following replantation and revascularization of amputated hand parts. J Trauma. 1981;21(3):204e214. 14. Hoang NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br. 2006;31(1):9e17. 15. Mahajan RK, Mittal S. Functional outcome of patients undergoing replantation of hand at wrist level—7 year experience. Indian J Plast Surg. 2013;46(3):555e560.
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