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Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion
SCIENTIFIC ARTICLE
Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion Pedro C. Cavadas, MD, PhD,* Alessandro Thione, MD, PhD,* Carlos Rubí, MD*
Purpose To report a series of 6 radiocarpal avulsion amputations in 5 patients. Method We replanted 6 radiocarpal amputations in 5 patients with proximal musculotendinous and nerve avulsion between 2005 and 2013 and reviewed them retrospectively. All 5 patients were men, age range from 21 to 32 years. Functional results were evaluated through total active motion (TAM) of the fingers, 2-point discrimination, monofilament test, grip strength, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Follow-up was 4 to 10 years. Results All replanted parts survived without systemic complications. No infections or major wound complications occurred despite the preservation of presumably avascular tendons. The functional results of the right side in patient 1 who suffered bilateral amputations, were very modest, with only 360 of TAM (about 30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This was the only hand in which the tendons were not reinserted primarily. The other hands achieved TAM between 590 and 820 , which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and mean of 10-kg grip force. Conclusions Radiocarpal amputation with proximal musculotendinous avulsion is an infrequent pattern of injury in which replantation with tendon reinsertion can yield functional results comparable with those reported for sharp wrist-level amputations. (J Hand Surg Am. 2016;41(1):70e75. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Hand, amputation, tendon, avulsion, microsurgery.
W
generally considered to be a good indication for replantation with the functional result depending mainly on the mechanism of amputation.1 Radiocarpal amputation associated with forearm musculotendinous rupture and nerve avulsion is an infrequent pattern of injury that results from a violent pull at the wrist.2 The tendons are stripped from the muscle bellies, and the RIST-LEVEL AMPUTATIONS ARE
From the *Reconstructive Surgery Unit, Clinica Cavadas, Hospital de Manises, Valencia, Spain. Received for publication June 25, 2015; accepted in revised form October 21, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Alessandro Thione, MD, PhD, Clinica Cavadas, Paseo Facultades 1, Bajo 8, 46021 Valencia, Spain; e-mail: [email protected]. 0363-5023/16/4101-0011$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.10.023
70
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Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
major nerves are avulsed in the proximal forearm (Figs. 1, 2). The usual treatment is either a revision amputation or a replantation with extensive musculotendinous debridement and limited distal repair.3 Because the muscle bellies remaining in the forearm stump are neither devascularized nor denervated, there exists the possibility of reinserting the avulsed tendons into them to achieve digital flexion and extension. We report a series of 6 radiocarpal avulsion amputations in 5 patients. In 1 hand (the first in our series), radical tendinous debridement and hand revascularization was performed; in the other 5 hands, primary musculotendinous repair was done. PATIENTS AND METHODS Six radiocarpal amputations with proximal musculotendinous and nerve avulsion were replanted in
CARPAL HAND AMPUTATIONS
71
FIGURE 2: Case 3. The stump with associated forearm diaphyseal fractures. The muscle bellies are vascularized and innervated.
the resultant nerve and muscular defects. The left hand of this patient and all the other amputated hands were replanted with primary tendinous reinsertion. Functional results were evaluated through total active motion (TAM) of the fingers (and thumb when applicable). The TAM of the wrist was not applicable because all patients underwent wrist arthrodesis. Twopoint discrimination (2PD) and Semmes-Weinstein monofilament testing were performed to assess sensory recovery in the thumb (when applicable), index, and middle fingers, and the results were averaged. Grip strength was measured with a Jamar dynamometer (Jamar Hydraulic Hand Dynamometer; Patterson Medical, Warrenville, IL) averaging 3 consecutive measurements. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was administered for patients’ self-evaluation.
FIGURE 1: Case 3. Left hand avulsion with proximal forearm musculotendinous avulsion and proximal avulsion of the median and ulnar nerves.
5 patients between 2005 and 2013. Follow-up ranged from 4 to 10 years. This study was approved by the institutional review board of our hospital, and informed consent was obtained from each patient. All 5 patients were men, with ages between 21 and 32 years. One patient had bilateral amputations (case 1). The right hand was involved in 4 cases and the left in 2. All accidents were industry-related (entrapment of the wrist and hand in conveyor belts, power torques, gear assemblies or cogs, with violent traction). Primary ischemia time (mainly cold) was 3 to 5 hours. The skeletal injury was a radiocarpal disarticulation with varying degrees of carpal bone and or distal radius injury. All tendons at the wrist were proximally avulsed. Ulnar and median nerves were avulsed distal to the elbow in all cases. The radial and ulnar vascular bundles were ruptured usually more distally. One case had diaphyseal radius and ulna fractures (case 3), and 1 case did not include replantation of the the thumb (case 4, with a severe, in-continuity devascularizing injury of the thumb). The first patient had bilateral amputations. The avulsed tendons and nerves were debrided on the right side. Secondary surgeries were performed to reconstruct J Hand Surg Am.
Surgical technique Hand replantation followed an artery-last sequence of repairs, using temporary catheter arterial perfusion if the ischemia time upon admittance was more than 4 hours. The tourniquet was elevated after the temporary reperfusion, reducing blood loss and allowing a bloodless field for bone, tendon, and nerve repairs. The total ischemia time was thus split into 2 shorter, less harmful, periods.4 The proximal stump usually needed minimal debridement. The avulsed tendons in the distal part were identified, and all remnants of muscle in them were thoroughly removed and trimmed to 6 to 8 cm. Bone shortening was liberal and included carpal resection and/or distal radius shortening. Bone fixation was initially performed with K-wires for expediency. Management of the distal radioulnar joint depended on its integrity. Formal wrist plate arthodesis was performed at a later stage after wound healing (4 cases). The tendons were reinserted into the substance of the remaining muscle r
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bellies in the forearm through dorsal and volar incisions. Wrist flexors and extensors were not repaired. The flexor pollicis longus and flexor digitorum profundus tendons were reinserted into the volar flexor mass. The digital extensor tendons were repaired to the extensor mass. The extensor pollicis longus was reinserted into the muscle mass of the abductor pollicis longus and the long and short thumb extensors proximally. If the proximal ulnar nerve could be transferred to the distal median nerve without tension (because of reciprocal proximal-distal avulsion), this transfer was performed primarily (case 1 left side, and case 3). Otherwise, delayed nerve grafting was performed. The dorsal veins were repaired and the dorsal skin closed. The radial and ulnar arteries were both repaired, along with venae comitantes. A tourniquet was used throughout the procedure to reduce intraoperative blood loss. Fasciotomies of the hand were not performed. Delayed nerve repair was performed about 2 months postinjury (case 1 right side, and cases 2, 4, and 5).The proximal ulnar nerve in the forearm was transferred to the distal median nerve with cable nerve grafts (superficial peroneal nerve grafts, supplemented with sural grafts if needed). The decision to use the proximal median or ulnar nerve to graft to the distal median depended on the location of the Tinel sign. If the median neuroma was in the proximal third of the forearm, the ulnar nerve was used to avoid further denervation of the digital flexors. The median nerve was grafted in 1 case with its neuroma at the midforearm level, distal to the main motor branches to the flexor digitorum superficialis. The ulnar and radial nerves were not reconstructed. Postoperative passive mobilization of the digits was started at 5 days and gradually increased. Active movement was initiated at 3 weeks. The metacarpophalangeal (MCP) joints were splinted with a 45 extension block orthosis for 4 weeks and then gradually allowed full extension.
TABLE 1.
Case
Number of Secondary Procedures
1 right
5
Specific Procedures Plate wrist arthrodesis Nerve grafts proximal ulnar to distal median (2 cables 9 cm, SPN) Thumb CMC arthrodesis FFMT for flexors FFMT for extensors
1 left
2
2
2
Thumb CMC arthrodesis Volar MCP capsulodesis Volar MCP capsulodesis Nerve grafts proximal ulnar to distal median (3 cables 10 cm, SPN and SN)
3
2
Thumb CMC arthrodesis Plate wrist arthrodesis
4
3
Plate wrist arthrodesis Volar MCP capsulodesis Nerve grafts proximal ulnar to distal median (3 cables 11 cm, SPN and SN)
5
4
Plate wrist arthrodesis Thumb CMC arthrodesis Volar MCP capsulodesis Nerve grafts median nerve (3 cables x 8 cm, SPN and SN)
CMC, carpometacarpal; FFMT, free functional muscle transfer; MCP, metacarpophalangeal; SPN, superficial peroneal nerve; SN, sural nerve.
proximal ulnar and distal median nerves (3 hands), median nerve grafts (1 case), volar MCP capsulodesis for intrinsic minus (4 hands), free functioning muscle transfers (2 flaps in 1 case), and trapeziometacarpal arthrodesis of the thumb in 4 hands (Table 1). Cold intolerance was reported by the patients only when questioned about it. None of the patients returned to their previous employment. One patient resumed an active manual working activity, whereas the others remained out of work. The TAM of the patients is shown in Table 2. The mean TAM of the fingers in the hands treated with tendon reinsertion was 640 excluding the thumb and 673 including the thumb (Fig. 3). The TAM of the single hand in which the tendons were not acutely reinserted was 360 . The small number of cases precludes statistical analysis. The TAM of the thumb was
RESULTS All replanted parts survived without systemic complications. No infections or major wound complications occurred, despite the preservation of the avascular tendons. Primary bone union with K-wire fixation occurred in 2 hands, and elective plate arthrodesis was performed in 4 hands after 2 to 3 months. All wrist arthrodeses eventually healed. The average number of secondary surgical procedures, excluding minor wound debridement and skin grafting, was 3 (range, 2e5) including plate arthrodesis of the wrist (4 hands), grafts between J Hand Surg Am.
Secondary Surgical Procedures
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TABLE 2.
Case
TAM of the Digits of the Replanted Hands
Side
FU (y)
TAM Thumb ( )
TAM Index ( )
TAM Middle ( )
TAM Ring ( )
TAM Little ( )
TAM Total ( )
TAM Total Without Thumb ( )
1
R (d)
10
10
90
80
110
70
360
350
1
L (nd)
10
30
160
160
160
120
630
600
2
R (d)
9
20
220
230
190
160
820
800
3
L (nd)
7
20
160
150
160
100
590
570
4
R (d)
6
NA
160
150
140
150
N/A
600
5
R (d)
4
Mean
20
170
150
170
140
630
600
23
174
168
164
134
673
640
FU, follow-up; R (d), right side, dominant hand; L (nd): left side, nondominant hand.
FIGURE 3: Case 3. A, B Functional result at 5 years after 2 secondary surgeries. The TAM was 570 ; 2PD was 10 mm; and SemmesWeinstein test was 0.2 g in the lateral digits. Grip strength was 12 kg. The DASH score was 15 points.
23 (20 e30 ). None of the hands recovered ulnar intrinsic function (the distal ulnar nerve was not repaired) or thenar muscles. Volar MCP joint capsulodesis was necessary in 4 cases (Table 3). Mean static 2PD was 12 mm (range, 10e15 mm) on the lateral 3 digits. Semmes-Weinstein monofilament test in these digits was 0.2 g in 1 patient (nearnormal superficial sensation), 2.0 g in 2 patients (diminished superficial sensation), 4.0 g in 2 hands (protective sensation), and 200 g in 1 case (diminished J Hand Surg Am.
protective sensation). Grip strength was 10 kg on average (range, 1e14 kg). The DASH score was 49 in the bilateral case, and 15 to 26 (mean, 20) in the unilateral cases (Table 3). The case with the best sensation corresponded to 1 of the hands with primary ulnar to median nerve transfer (case 3), although the small number of cases precluded statistical analysis. The right hand of the patient with bilateral amputations had the weakest grip and lowest TAM. Both free functional muscle transfers were functional (1 for r
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TABLE 3.
Functional Results
Case
Nerve Repair
Grip Strength (kg)
2PD (mm)
S-W Monofilament (g)
DASH
1 right
Grafts UM
1
12
2.0 (pink)
1 left
Direct UM
12
15
200 (orange)
49
2
Grafts UM
10
13
4.0 (red)
18
3
Direct UM
12
10
0.2 (blue)
15
4
Grafts UM
14
12
2.0 (pink)
26
5
Grafts M
11
10
4.0 (red)
20
Direct UM, direct acute transfer of the proximal ulnar to the distal median nerves; Grafts M, secondary nerve grafts to the median nerve; Grafts UM, secondary nerve grafts from the proximal ulnar to the distal median nerves; S-W, Semmes-Weinstein monofilament test (result in grams and color of the filament).
finger flexion coapted to the volar-medial fascicle of the median nerve, and 1 for finger extension coapted to the posterior interosseous nerve).
30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This hand was the only 1 in which the tendons were not reinserted primarily. The contralateral hand was replanted with tendinous reinsertion. The striking difference in function in both hands prompted us to adopt this technique in subsequent cases. The subsequent hands achieved TAM between 590 and 820 , which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and 10 kg of mean grip force. Although not statistically rigorous, these numbers are comparable with those reported in sharp amputations. Sensory nerve recovery was rather modest regarding 2PD and mixed in the Semmes-Weinstein monofilament test, with 5 out of 6 hands achieving protective sensation or better. Because of the nature of the injury, only the lateral digits were targeted, ignoring the medial digits and the radial nerve. Despite this modest sensory recovery and the lack of intrinsic function, DASH scores were low, averaging 20 points. With the previously mentioned caution, these results compare favorably with those of sharp injuries. Secondary surgery is an integral part of the treatment in complex replantations. The number of secondary procedures reported for major replantations is around 3,13 which coincides with our series. Because of the complete lack of intrinsic function, thumb trapeziometacarpal joint arthrodesis and volar MCP joint capsulodesis were frequently performed. Tendon transfers were not performed owing to the lack of uninjured potential motors. Free functional muscle transfers have been recommended for proximal avulsive injuries of the forearm.14 Combining our experience with that previously reported, for wrist-level avulsive amputations, we favor primary tendinous reinsertion over delayed free functional muscle transfer because it yields good functional results.
DISCUSSION Wrist-level amputations are severe injuries. With proper surgical technique and rehabilitation, the functional results of replantation at this level are better than transmetacarpal or more proximal forearm amputations.5e9 The results, nonetheless, depend on the mechanism of injury. Avulsion amputations carry a worse functional prognosis than clean sharp injuries. A radiocarpal amputation with proximal musculotendinous and nerve avulsion is an infrequent pattern of injury whose treatment has not been well defined. Avulsive mechanism is usually considered a strong relative contraindication for replantation. The fact that the muscles remain vascularized and innervated in the forearm may allow function recovery after tendinous reinsertion. Few studies report the functional results of wristlevel replantations. Functional evaluation of the published cases is not homogeneous, and comparison is difficult. Hoang10 reported on 5 sharp wrist amputations. The total TAM of the hand was 75% to 85% of the contralateral hand, with limited intrinsic function and 2PD less than 12 mm. Mahajan and Mittal11 reported on the follow-up of 14 cases with TAM between 50% and 70% of the contralateral side, reduced intrinsic function, and 2PD greater than 10 mm. Patel et al12 reported on the functional result of replantation in 6 clean wrist amputations. The TAM was 25% to 60% of the normal side with diminished intrinsic function and 2PD 8 to 10 mm. The mean DASH score was 76. Reported patient satisfaction was high despite these apparently modest numbers. In none of these 3 series were avulsion injuries included. The functional results of the right side in our first patient were modest, with 360 of total TAM (about J Hand Surg Am.
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The present study has limitations. The pattern of injury described is infrequent, and thus, the number of patients in the series is small and no control group was included. The comparison with reported series of sharp replantations lacks statistical rigor but allows some perspective of the functional results.
6. 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. 7. Tamai S. Twenty years’ experience of limb replantation—review of 293 upper extremity replants. J Hand Surg Am. 1982;7(6):549e556. 8. 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):1191e1196. 9. Scott FA, Howar JW, Boswick JA Jr. Recovery of function following replantation and revascularization of amputated hand parts. J Trauma. 1981;21(3):204e214. 10. Hoang NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br. 2006;31(1):9e17. 11. 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. 12. Patel AA, Blount AL, Owens PW, Askari M. Functional outcomes of replantation following radiocarpal amputation. J Hand Surg Am. 2015;40(2):266e270. 13. Fufa D, Lin CH, Lin YT, Hsu CC, Chuang CC, Lin CH. Secondary reconstructive surgery following major upper extremity replantation. Plast Reconstr Surg. 2014;134(4):713e720. 14. Chuang DC, Lai JB, Cheng SL, Jain V, Lin CH, Chen HC. Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management and strategies for secondary reconstruction. Plast Reconstr Surg. 2001;108(6): 1624e1638.
REFERENCES 1. 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(6 Pt 2):989e991. 2. Sharma S, Lin S, Panozzo A, Tepper R, Friedman D. Thumb replantation: a retrospective review of 103 cases. Ann Plast Surg. 2005;55(4):352e356. 3. Kuri M, Watt A, Buncke GM. Replantation at the level of the radiocarpal joint. In: Salyapongse AN, et al., eds. Extremity Replantation: A Comprehensive Clinical Guide. New York: Springer Scienceþ Business Media; 2015:67e81. 4. Cavadas PC, Landin L, Ibañez J. Temporary catheter perfusion and artery-last sequence of repair in macro-replantations. J Plast Reconstr Aesthet Surg. 2009;62(10):1321e1325. 5. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5): 390e398.
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Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion Pedro C. Cavadas, MD, PhD,* Alessandro Thione, MD, PhD,* Carlos Rubí, MD*
Purpose To report a series of 6 radiocarpal avulsion amputations in 5 patients. Method We replanted 6 radiocarpal amputations in 5 patients with proximal musculotendinous and nerve avulsion between 2005 and 2013 and reviewed them retrospectively. All 5 patients were men, age range from 21 to 32 years. Functional results were evaluated through total active motion (TAM) of the fingers, 2-point discrimination, monofilament test, grip strength, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Follow-up was 4 to 10 years. Results All replanted parts survived without systemic complications. No infections or major wound complications occurred despite the preservation of presumably avascular tendons. The functional results of the right side in patient 1 who suffered bilateral amputations, were very modest, with only 360 of TAM (about 30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This was the only hand in which the tendons were not reinserted primarily. The other hands achieved TAM between 590 and 820 , which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and mean of 10-kg grip force. Conclusions Radiocarpal amputation with proximal musculotendinous avulsion is an infrequent pattern of injury in which replantation with tendon reinsertion can yield functional results comparable with those reported for sharp wrist-level amputations. (J Hand Surg Am. 2016;41(1):70e75. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Hand, amputation, tendon, avulsion, microsurgery.
W
generally considered to be a good indication for replantation with the functional result depending mainly on the mechanism of amputation.1 Radiocarpal amputation associated with forearm musculotendinous rupture and nerve avulsion is an infrequent pattern of injury that results from a violent pull at the wrist.2 The tendons are stripped from the muscle bellies, and the RIST-LEVEL AMPUTATIONS ARE
From the *Reconstructive Surgery Unit, Clinica Cavadas, Hospital de Manises, Valencia, Spain. Received for publication June 25, 2015; accepted in revised form October 21, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Alessandro Thione, MD, PhD, Clinica Cavadas, Paseo Facultades 1, Bajo 8, 46021 Valencia, Spain; e-mail: [email protected]. 0363-5023/16/4101-0011$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.10.023
70
r
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
major nerves are avulsed in the proximal forearm (Figs. 1, 2). The usual treatment is either a revision amputation or a replantation with extensive musculotendinous debridement and limited distal repair.3 Because the muscle bellies remaining in the forearm stump are neither devascularized nor denervated, there exists the possibility of reinserting the avulsed tendons into them to achieve digital flexion and extension. We report a series of 6 radiocarpal avulsion amputations in 5 patients. In 1 hand (the first in our series), radical tendinous debridement and hand revascularization was performed; in the other 5 hands, primary musculotendinous repair was done. PATIENTS AND METHODS Six radiocarpal amputations with proximal musculotendinous and nerve avulsion were replanted in
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FIGURE 2: Case 3. The stump with associated forearm diaphyseal fractures. The muscle bellies are vascularized and innervated.
the resultant nerve and muscular defects. The left hand of this patient and all the other amputated hands were replanted with primary tendinous reinsertion. Functional results were evaluated through total active motion (TAM) of the fingers (and thumb when applicable). The TAM of the wrist was not applicable because all patients underwent wrist arthrodesis. Twopoint discrimination (2PD) and Semmes-Weinstein monofilament testing were performed to assess sensory recovery in the thumb (when applicable), index, and middle fingers, and the results were averaged. Grip strength was measured with a Jamar dynamometer (Jamar Hydraulic Hand Dynamometer; Patterson Medical, Warrenville, IL) averaging 3 consecutive measurements. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was administered for patients’ self-evaluation.
FIGURE 1: Case 3. Left hand avulsion with proximal forearm musculotendinous avulsion and proximal avulsion of the median and ulnar nerves.
5 patients between 2005 and 2013. Follow-up ranged from 4 to 10 years. This study was approved by the institutional review board of our hospital, and informed consent was obtained from each patient. All 5 patients were men, with ages between 21 and 32 years. One patient had bilateral amputations (case 1). The right hand was involved in 4 cases and the left in 2. All accidents were industry-related (entrapment of the wrist and hand in conveyor belts, power torques, gear assemblies or cogs, with violent traction). Primary ischemia time (mainly cold) was 3 to 5 hours. The skeletal injury was a radiocarpal disarticulation with varying degrees of carpal bone and or distal radius injury. All tendons at the wrist were proximally avulsed. Ulnar and median nerves were avulsed distal to the elbow in all cases. The radial and ulnar vascular bundles were ruptured usually more distally. One case had diaphyseal radius and ulna fractures (case 3), and 1 case did not include replantation of the the thumb (case 4, with a severe, in-continuity devascularizing injury of the thumb). The first patient had bilateral amputations. The avulsed tendons and nerves were debrided on the right side. Secondary surgeries were performed to reconstruct J Hand Surg Am.
Surgical technique Hand replantation followed an artery-last sequence of repairs, using temporary catheter arterial perfusion if the ischemia time upon admittance was more than 4 hours. The tourniquet was elevated after the temporary reperfusion, reducing blood loss and allowing a bloodless field for bone, tendon, and nerve repairs. The total ischemia time was thus split into 2 shorter, less harmful, periods.4 The proximal stump usually needed minimal debridement. The avulsed tendons in the distal part were identified, and all remnants of muscle in them were thoroughly removed and trimmed to 6 to 8 cm. Bone shortening was liberal and included carpal resection and/or distal radius shortening. Bone fixation was initially performed with K-wires for expediency. Management of the distal radioulnar joint depended on its integrity. Formal wrist plate arthodesis was performed at a later stage after wound healing (4 cases). The tendons were reinserted into the substance of the remaining muscle r
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bellies in the forearm through dorsal and volar incisions. Wrist flexors and extensors were not repaired. The flexor pollicis longus and flexor digitorum profundus tendons were reinserted into the volar flexor mass. The digital extensor tendons were repaired to the extensor mass. The extensor pollicis longus was reinserted into the muscle mass of the abductor pollicis longus and the long and short thumb extensors proximally. If the proximal ulnar nerve could be transferred to the distal median nerve without tension (because of reciprocal proximal-distal avulsion), this transfer was performed primarily (case 1 left side, and case 3). Otherwise, delayed nerve grafting was performed. The dorsal veins were repaired and the dorsal skin closed. The radial and ulnar arteries were both repaired, along with venae comitantes. A tourniquet was used throughout the procedure to reduce intraoperative blood loss. Fasciotomies of the hand were not performed. Delayed nerve repair was performed about 2 months postinjury (case 1 right side, and cases 2, 4, and 5).The proximal ulnar nerve in the forearm was transferred to the distal median nerve with cable nerve grafts (superficial peroneal nerve grafts, supplemented with sural grafts if needed). The decision to use the proximal median or ulnar nerve to graft to the distal median depended on the location of the Tinel sign. If the median neuroma was in the proximal third of the forearm, the ulnar nerve was used to avoid further denervation of the digital flexors. The median nerve was grafted in 1 case with its neuroma at the midforearm level, distal to the main motor branches to the flexor digitorum superficialis. The ulnar and radial nerves were not reconstructed. Postoperative passive mobilization of the digits was started at 5 days and gradually increased. Active movement was initiated at 3 weeks. The metacarpophalangeal (MCP) joints were splinted with a 45 extension block orthosis for 4 weeks and then gradually allowed full extension.
TABLE 1.
Case
Number of Secondary Procedures
1 right
5
Specific Procedures Plate wrist arthrodesis Nerve grafts proximal ulnar to distal median (2 cables 9 cm, SPN) Thumb CMC arthrodesis FFMT for flexors FFMT for extensors
1 left
2
2
2
Thumb CMC arthrodesis Volar MCP capsulodesis Volar MCP capsulodesis Nerve grafts proximal ulnar to distal median (3 cables 10 cm, SPN and SN)
3
2
Thumb CMC arthrodesis Plate wrist arthrodesis
4
3
Plate wrist arthrodesis Volar MCP capsulodesis Nerve grafts proximal ulnar to distal median (3 cables 11 cm, SPN and SN)
5
4
Plate wrist arthrodesis Thumb CMC arthrodesis Volar MCP capsulodesis Nerve grafts median nerve (3 cables x 8 cm, SPN and SN)
CMC, carpometacarpal; FFMT, free functional muscle transfer; MCP, metacarpophalangeal; SPN, superficial peroneal nerve; SN, sural nerve.
proximal ulnar and distal median nerves (3 hands), median nerve grafts (1 case), volar MCP capsulodesis for intrinsic minus (4 hands), free functioning muscle transfers (2 flaps in 1 case), and trapeziometacarpal arthrodesis of the thumb in 4 hands (Table 1). Cold intolerance was reported by the patients only when questioned about it. None of the patients returned to their previous employment. One patient resumed an active manual working activity, whereas the others remained out of work. The TAM of the patients is shown in Table 2. The mean TAM of the fingers in the hands treated with tendon reinsertion was 640 excluding the thumb and 673 including the thumb (Fig. 3). The TAM of the single hand in which the tendons were not acutely reinserted was 360 . The small number of cases precludes statistical analysis. The TAM of the thumb was
RESULTS All replanted parts survived without systemic complications. No infections or major wound complications occurred, despite the preservation of the avascular tendons. Primary bone union with K-wire fixation occurred in 2 hands, and elective plate arthrodesis was performed in 4 hands after 2 to 3 months. All wrist arthrodeses eventually healed. The average number of secondary surgical procedures, excluding minor wound debridement and skin grafting, was 3 (range, 2e5) including plate arthrodesis of the wrist (4 hands), grafts between J Hand Surg Am.
Secondary Surgical Procedures
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TABLE 2.
Case
TAM of the Digits of the Replanted Hands
Side
FU (y)
TAM Thumb ( )
TAM Index ( )
TAM Middle ( )
TAM Ring ( )
TAM Little ( )
TAM Total ( )
TAM Total Without Thumb ( )
1
R (d)
10
10
90
80
110
70
360
350
1
L (nd)
10
30
160
160
160
120
630
600
2
R (d)
9
20
220
230
190
160
820
800
3
L (nd)
7
20
160
150
160
100
590
570
4
R (d)
6
NA
160
150
140
150
N/A
600
5
R (d)
4
Mean
20
170
150
170
140
630
600
23
174
168
164
134
673
640
FU, follow-up; R (d), right side, dominant hand; L (nd): left side, nondominant hand.
FIGURE 3: Case 3. A, B Functional result at 5 years after 2 secondary surgeries. The TAM was 570 ; 2PD was 10 mm; and SemmesWeinstein test was 0.2 g in the lateral digits. Grip strength was 12 kg. The DASH score was 15 points.
23 (20 e30 ). None of the hands recovered ulnar intrinsic function (the distal ulnar nerve was not repaired) or thenar muscles. Volar MCP joint capsulodesis was necessary in 4 cases (Table 3). Mean static 2PD was 12 mm (range, 10e15 mm) on the lateral 3 digits. Semmes-Weinstein monofilament test in these digits was 0.2 g in 1 patient (nearnormal superficial sensation), 2.0 g in 2 patients (diminished superficial sensation), 4.0 g in 2 hands (protective sensation), and 200 g in 1 case (diminished J Hand Surg Am.
protective sensation). Grip strength was 10 kg on average (range, 1e14 kg). The DASH score was 49 in the bilateral case, and 15 to 26 (mean, 20) in the unilateral cases (Table 3). The case with the best sensation corresponded to 1 of the hands with primary ulnar to median nerve transfer (case 3), although the small number of cases precluded statistical analysis. The right hand of the patient with bilateral amputations had the weakest grip and lowest TAM. Both free functional muscle transfers were functional (1 for r
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CARPAL HAND AMPUTATIONS
TABLE 3.
Functional Results
Case
Nerve Repair
Grip Strength (kg)
2PD (mm)
S-W Monofilament (g)
DASH
1 right
Grafts UM
1
12
2.0 (pink)
1 left
Direct UM
12
15
200 (orange)
49
2
Grafts UM
10
13
4.0 (red)
18
3
Direct UM
12
10
0.2 (blue)
15
4
Grafts UM
14
12
2.0 (pink)
26
5
Grafts M
11
10
4.0 (red)
20
Direct UM, direct acute transfer of the proximal ulnar to the distal median nerves; Grafts M, secondary nerve grafts to the median nerve; Grafts UM, secondary nerve grafts from the proximal ulnar to the distal median nerves; S-W, Semmes-Weinstein monofilament test (result in grams and color of the filament).
finger flexion coapted to the volar-medial fascicle of the median nerve, and 1 for finger extension coapted to the posterior interosseous nerve).
30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This hand was the only 1 in which the tendons were not reinserted primarily. The contralateral hand was replanted with tendinous reinsertion. The striking difference in function in both hands prompted us to adopt this technique in subsequent cases. The subsequent hands achieved TAM between 590 and 820 , which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and 10 kg of mean grip force. Although not statistically rigorous, these numbers are comparable with those reported in sharp amputations. Sensory nerve recovery was rather modest regarding 2PD and mixed in the Semmes-Weinstein monofilament test, with 5 out of 6 hands achieving protective sensation or better. Because of the nature of the injury, only the lateral digits were targeted, ignoring the medial digits and the radial nerve. Despite this modest sensory recovery and the lack of intrinsic function, DASH scores were low, averaging 20 points. With the previously mentioned caution, these results compare favorably with those of sharp injuries. Secondary surgery is an integral part of the treatment in complex replantations. The number of secondary procedures reported for major replantations is around 3,13 which coincides with our series. Because of the complete lack of intrinsic function, thumb trapeziometacarpal joint arthrodesis and volar MCP joint capsulodesis were frequently performed. Tendon transfers were not performed owing to the lack of uninjured potential motors. Free functional muscle transfers have been recommended for proximal avulsive injuries of the forearm.14 Combining our experience with that previously reported, for wrist-level avulsive amputations, we favor primary tendinous reinsertion over delayed free functional muscle transfer because it yields good functional results.
DISCUSSION Wrist-level amputations are severe injuries. With proper surgical technique and rehabilitation, the functional results of replantation at this level are better than transmetacarpal or more proximal forearm amputations.5e9 The results, nonetheless, depend on the mechanism of injury. Avulsion amputations carry a worse functional prognosis than clean sharp injuries. A radiocarpal amputation with proximal musculotendinous and nerve avulsion is an infrequent pattern of injury whose treatment has not been well defined. Avulsive mechanism is usually considered a strong relative contraindication for replantation. The fact that the muscles remain vascularized and innervated in the forearm may allow function recovery after tendinous reinsertion. Few studies report the functional results of wristlevel replantations. Functional evaluation of the published cases is not homogeneous, and comparison is difficult. Hoang10 reported on 5 sharp wrist amputations. The total TAM of the hand was 75% to 85% of the contralateral hand, with limited intrinsic function and 2PD less than 12 mm. Mahajan and Mittal11 reported on the follow-up of 14 cases with TAM between 50% and 70% of the contralateral side, reduced intrinsic function, and 2PD greater than 10 mm. Patel et al12 reported on the functional result of replantation in 6 clean wrist amputations. The TAM was 25% to 60% of the normal side with diminished intrinsic function and 2PD 8 to 10 mm. The mean DASH score was 76. Reported patient satisfaction was high despite these apparently modest numbers. In none of these 3 series were avulsion injuries included. The functional results of the right side in our first patient were modest, with 360 of total TAM (about J Hand Surg Am.
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CARPAL HAND AMPUTATIONS
The present study has limitations. The pattern of injury described is infrequent, and thus, the number of patients in the series is small and no control group was included. The comparison with reported series of sharp replantations lacks statistical rigor but allows some perspective of the functional results.
6. 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. 7. Tamai S. Twenty years’ experience of limb replantation—review of 293 upper extremity replants. J Hand Surg Am. 1982;7(6):549e556. 8. 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):1191e1196. 9. Scott FA, Howar JW, Boswick JA Jr. Recovery of function following replantation and revascularization of amputated hand parts. J Trauma. 1981;21(3):204e214. 10. Hoang NT. Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br. 2006;31(1):9e17. 11. 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. 12. Patel AA, Blount AL, Owens PW, Askari M. Functional outcomes of replantation following radiocarpal amputation. J Hand Surg Am. 2015;40(2):266e270. 13. Fufa D, Lin CH, Lin YT, Hsu CC, Chuang CC, Lin CH. Secondary reconstructive surgery following major upper extremity replantation. Plast Reconstr Surg. 2014;134(4):713e720. 14. Chuang DC, Lai JB, Cheng SL, Jain V, Lin CH, Chen HC. Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management and strategies for secondary reconstruction. Plast Reconstr Surg. 2001;108(6): 1624e1638.
REFERENCES 1. 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(6 Pt 2):989e991. 2. Sharma S, Lin S, Panozzo A, Tepper R, Friedman D. Thumb replantation: a retrospective review of 103 cases. Ann Plast Surg. 2005;55(4):352e356. 3. Kuri M, Watt A, Buncke GM. Replantation at the level of the radiocarpal joint. In: Salyapongse AN, et al., eds. Extremity Replantation: A Comprehensive Clinical Guide. New York: Springer Scienceþ Business Media; 2015:67e81. 4. Cavadas PC, Landin L, Ibañez J. Temporary catheter perfusion and artery-last sequence of repair in macro-replantations. J Plast Reconstr Aesthet Surg. 2009;62(10):1321e1325. 5. Kleinert HE, Jablon M, Tsai TM. An overview of replantation and results of 347 replants in 245 patients. J Trauma. 1980;20(5): 390e398.
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