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Hand amputations proximal but close to the wrist joint: Prime candidates for reattachment (long-term functional results)
Hand amputations proximal but close to the wrist joint: Prime candidates for reattachment (long-term functional results) Viktor E. Meyer, M.D., P.D.
Although not a life-threatening event, the loss of a whole hand is extremely tragic. When the famous German expres sionist Ernst Ludwig Kirchner was called for military service during World War I, he expressed his fears and anxiety in a self-portrait in which he is portrayed as a soldier who had suffered an amputation of his right hand. Obviously, it was more the possible loss of a hand, the most important extension of human intellect, rather than death that frightened him the most. Fortunately, this horrifying injury is a relatively rare incident. A retrospective analysis of patients who had replantation after they sustained complete severance at various levels of the hand and upper limb was gathered from the replantation centers of Shanghai (No. 6 People's Hospital), Louisville, and Zurich and was published in 1981. 1 This series included 129 cases of replantation proximal to the carpometacarpal joint: 100 cases from the No. 6 People's Hospital in Shanghai, 16 from the Louisville replantation center, and 13 from Zurich (Table 1). All three centers used the same system for evaluation of the functional results as proposed by Chen et al. 1 This system recognizes four grades of functional recovery on the basis of the following four parameters: Grade I (Excellent) A. Ability to resume original work with a critical contri bution from the reattached parts B. Collective range of joint motion exceeds 60% of nor mal, including the joint immediately proximal to the reattached part C. Recovery of sensibility to a high grade without exces sive intolerance of cold D . Muscular power of 4 to 5 on a scale of 1 to 5 Grade II (Good) A. Ability to resume some gainful work but not original employment B . Range of joint motion exceeds 40% of normal C. Recovery of near normal sensibility in the median and ulnar nerve distributions without severe intolerance of cold D. Muscular power of grade 3 to 4
From the Division for Surgery of the Hand and Peripheral Nerves, Surgical Clinic B, University of Zurich, Medical School. Reprint requests: Viktor E. Meyer, M.D., P.D., Abteilung fiir Hand chirurgie Universitiitsspital, CH-8091 Zurich, Switzerland.
Table I. Results of upper limb replantations (minimum of 2 years' follow-up) from Shanghai, Louisville, and Zurich Level of amputation
No. of cases
Shoulder Arm Proximal forearm Distal forearm Wrist (carpus) Total
3 26 20 49 31 129
Grades I and II
Grade Ill
Grade IV
(%)
(%)
(%)
0 35 40 80 81 63
33.3 65 35 20 19 32
66.6 0 25 0 0 5
Grade III (Fair) A. Independence in activities of daily living B . Range of motion of joints exceeds 30% of normal C . Poor but useful recovery of sensibility (e.g. , only me dian or ulnar recovery is good or quality is only pro tective in both median and ulnar areas) D. Muscular power of grade 3 Grade IV (Poor) A. Tissue survival with no recovery of useful function Despite the obvious and important variations in these stud ies, it became evident that the independent experience of replantation centers in three different continents is remarkably similar. 1 The results are summarized in Table I. Amputations proximal but close to the wrist
In the reported series, there were 49 cases of amputations proximal to the wrist but close to the joint (distal forearm), including 40 cases from Shanghai, four from Louisville, and five from Zurich. One patient in our series of five cases has been added after the 1981 publication. 1 Replantation for amputations through the carpus showed results similar to those with distal forearm amputations. The latter amputation level is emphasized because in cases of amputation through the wrist joint, special problems of skel etal management are introduced; these include primary ar throdesis of the wrist, eventual proximal row carpectomy, or some type of primary arthroplasty. A minimum follow-up of 2 years is too short to assess the final result of transcarpal replantations. Therefore, patients with amputations proximal but close to the wrist joint are considered to be the most favorable candidates for replantation at this time. As shown in Table I, 80% of these patients achieved a grade I or II
THE JOURNAL OF HAND SURGERY
989
990
The Journal of HAND SURGERY
Meyer
Fig. 2. Guillotine-type amputation in a 21-year-old manual worker; results 42 months after surgery. Notice excellent intrinsic muscle recovery. (Reprinted with permission from Meyer VE: Upper ex tremity replantation: basic principles, surgical technique, and strat egy. New York, 1985, Churchill Livingstone Inc.)
Fig. 1. Distal forearm amputation in a 3 \/z-year-old girl and clinical results 8'12 years later. (Reprinted with permission from Meyer VE: Upper extremity replantation: basic principles, surgical technique, and strategy. New York, 1985, Churchill Livingstone Inc.)
functional result, and 20% had a grade Ill; there were no grade IV results. Why is the level proximal but close to the wrist joint so favorable for reattachment? The following 11 reasons may account for these rewarding results: (1) Innervation of the forearm muscles remains intact. (2) The distance for nerve regeneration is relatively short. (3) Only two major nerves (median and ulnar) mandatorily need repair. (4) The median and ulnar nerves are severed at a level in which assessment of their motor and sensory components is possible, and therefore the chance for good recovery of sensibility and intrinsic muscle function is high. (5) The cal iber and number of blood vessels to be repaired are such that restoration of good circulation is generally easy and safe. (6) Because there usually is no joint damage, skeletal manage ment is relatively easy; and in almost all cases sufficient bone
shortening, mainly at the proximal stump, is possible for optimal soft tissue repair. Even radical bone shortening alone does not necessarily introduce major functional impairments. Therefore, less favorable types of injuries (e.g., compression amputation) may be transformed into a guillotine-type am putation. (7) Repair of motor units involves tendons rather than muscles and is in an anatomically and biologically fa vorable area. (8) Skeletal severance is at a level with usually rapid bone healing. (9) The operating time needed is relatively short; the entire procedure can be done by the same surgeon. (1 0) Because no major muscle mass is involved in the am putated part, the risk of metabolic disturbances and/or infec tion is relatively small. (II) The only muscle with a consis tently poor prognosis is the pronator quadratus; however, its function is well compensated by the pronator teres.
Clinical cases Our personal series of proximal but close to the wrist joint amputation includes five cases of complete severance with no (not even "minor") tissue bridges. The longest follow-up is 8 Vz years and the shortest is 3 Vz years. The patients' ages ranged from 3Vz to 62 years. A total primary repair had been performed in all patients. Additional secondary surgery, other than removal of hardware, was required in one patient who sustained an avulsion amputation and in whom poor pri mary skeletal management had led to formation of a pseud arthrosis.
Vol. lOA, No. 6, Part 2 November 1985
A grade I or II functional recovery was achieved in four patients. The patient who had secondary surgery had a grade III result. The long-term functional results will be illustrated for three patients of different age groups and a similarly favorable type of amputation injury (Figs. I to 3). Case 1 (Fig. 1). This 3Vz-year-old girl sustained an am putation of her left hand in a lawn mower accident. Replan tation was performed with total primary repair. The functional results are illustrated at 8Vz years' follow-up. Growth of the reattached hand was normal. The initial forearm was short ened 4 em, but it did not level out completely; there is still a difference of 18 mm in the length of both forearms. The two-point discrimination is 6 mm in the median and 8 mm in the ulnar nerve distribution. There is no cold intolerance. No secondary surgery has been performed except for the removal of the metal plates. The girl successfully started to play the piano 6 years after the accident. Case 2 (Fig. 2). This 21-year-old laborer sustained a guil lotine-type amputation by a plastic-cutting machine. Intraos seous wiring at the radius was used to preserve the wrist joint. The ulna was fixed with a one-third tubular plate. The func tional result 42 months after reattachment with total primary repair is illustrated. No secondary surgery was performed except for removal of the plate at the ulna. Mainly because of the remarkable reinnervation of the intrinsic muscles, he has the best result of all our cases of proximal but close to wrist amputation. The initial skeletal shortening, in this case of a clean-cut amputation, was 2.5 em. The patient has no pain in the reattached hand and only very moderate cold intolerance. The two-point discrimination in the median nerve is 6 mm and 8 mm in the ulnar nerve distribution. The patient returned to his original job as a manual worker. His work men's compensation is only 10% of his salary before injury. Case 3 (Fig. 3). This clean-cut amputation occurred in a 62-year-old joiner (welder). The functional result is illustrated 6 years after replantation with total primary repair. Because the patient refused removal of the metal plates used for rigid skeletal fixation, no secondary surgery was performed. The patient recovered without any problems from the long general anesthesia, and healing was uncomplicated. He has only pro tective sensibility in both the median and ulnar nerve distri bution. He has no two-point discrimination. There is no pain except for pronounced cold intolerance in the reattached hand. This patient did not return to his job as a welder, but re tired 2 years earlier than he would have without the ac cident.
Hand amputations
991
Fig. 3. Proximal but close to the wrist joint amputation in a 62-year old joiner. Clinical results 6 years after replantation. (Reprinted with permission from Meyer VE: Upper extremity replantation: basic prin ciples, surgical technique, and strategy. New York, 1985, Churchill Livingstone Inc.)
REFERENCE I. Chen ZW, Meyer VE, Kleinert HE, Beasley RW: Present indi cations and contraindications for replantation as reflected by long term functional results. Orthop Clin North Am 12:849-70, 1981
Although not a life-threatening event, the loss of a whole hand is extremely tragic. When the famous German expres sionist Ernst Ludwig Kirchner was called for military service during World War I, he expressed his fears and anxiety in a self-portrait in which he is portrayed as a soldier who had suffered an amputation of his right hand. Obviously, it was more the possible loss of a hand, the most important extension of human intellect, rather than death that frightened him the most. Fortunately, this horrifying injury is a relatively rare incident. A retrospective analysis of patients who had replantation after they sustained complete severance at various levels of the hand and upper limb was gathered from the replantation centers of Shanghai (No. 6 People's Hospital), Louisville, and Zurich and was published in 1981. 1 This series included 129 cases of replantation proximal to the carpometacarpal joint: 100 cases from the No. 6 People's Hospital in Shanghai, 16 from the Louisville replantation center, and 13 from Zurich (Table 1). All three centers used the same system for evaluation of the functional results as proposed by Chen et al. 1 This system recognizes four grades of functional recovery on the basis of the following four parameters: Grade I (Excellent) A. Ability to resume original work with a critical contri bution from the reattached parts B. Collective range of joint motion exceeds 60% of nor mal, including the joint immediately proximal to the reattached part C. Recovery of sensibility to a high grade without exces sive intolerance of cold D . Muscular power of 4 to 5 on a scale of 1 to 5 Grade II (Good) A. Ability to resume some gainful work but not original employment B . Range of joint motion exceeds 40% of normal C. Recovery of near normal sensibility in the median and ulnar nerve distributions without severe intolerance of cold D. Muscular power of grade 3 to 4
From the Division for Surgery of the Hand and Peripheral Nerves, Surgical Clinic B, University of Zurich, Medical School. Reprint requests: Viktor E. Meyer, M.D., P.D., Abteilung fiir Hand chirurgie Universitiitsspital, CH-8091 Zurich, Switzerland.
Table I. Results of upper limb replantations (minimum of 2 years' follow-up) from Shanghai, Louisville, and Zurich Level of amputation
No. of cases
Shoulder Arm Proximal forearm Distal forearm Wrist (carpus) Total
3 26 20 49 31 129
Grades I and II
Grade Ill
Grade IV
(%)
(%)
(%)
0 35 40 80 81 63
33.3 65 35 20 19 32
66.6 0 25 0 0 5
Grade III (Fair) A. Independence in activities of daily living B . Range of motion of joints exceeds 30% of normal C . Poor but useful recovery of sensibility (e.g. , only me dian or ulnar recovery is good or quality is only pro tective in both median and ulnar areas) D. Muscular power of grade 3 Grade IV (Poor) A. Tissue survival with no recovery of useful function Despite the obvious and important variations in these stud ies, it became evident that the independent experience of replantation centers in three different continents is remarkably similar. 1 The results are summarized in Table I. Amputations proximal but close to the wrist
In the reported series, there were 49 cases of amputations proximal to the wrist but close to the joint (distal forearm), including 40 cases from Shanghai, four from Louisville, and five from Zurich. One patient in our series of five cases has been added after the 1981 publication. 1 Replantation for amputations through the carpus showed results similar to those with distal forearm amputations. The latter amputation level is emphasized because in cases of amputation through the wrist joint, special problems of skel etal management are introduced; these include primary ar throdesis of the wrist, eventual proximal row carpectomy, or some type of primary arthroplasty. A minimum follow-up of 2 years is too short to assess the final result of transcarpal replantations. Therefore, patients with amputations proximal but close to the wrist joint are considered to be the most favorable candidates for replantation at this time. As shown in Table I, 80% of these patients achieved a grade I or II
THE JOURNAL OF HAND SURGERY
989
990
The Journal of HAND SURGERY
Meyer
Fig. 2. Guillotine-type amputation in a 21-year-old manual worker; results 42 months after surgery. Notice excellent intrinsic muscle recovery. (Reprinted with permission from Meyer VE: Upper ex tremity replantation: basic principles, surgical technique, and strat egy. New York, 1985, Churchill Livingstone Inc.)
Fig. 1. Distal forearm amputation in a 3 \/z-year-old girl and clinical results 8'12 years later. (Reprinted with permission from Meyer VE: Upper extremity replantation: basic principles, surgical technique, and strategy. New York, 1985, Churchill Livingstone Inc.)
functional result, and 20% had a grade Ill; there were no grade IV results. Why is the level proximal but close to the wrist joint so favorable for reattachment? The following 11 reasons may account for these rewarding results: (1) Innervation of the forearm muscles remains intact. (2) The distance for nerve regeneration is relatively short. (3) Only two major nerves (median and ulnar) mandatorily need repair. (4) The median and ulnar nerves are severed at a level in which assessment of their motor and sensory components is possible, and therefore the chance for good recovery of sensibility and intrinsic muscle function is high. (5) The cal iber and number of blood vessels to be repaired are such that restoration of good circulation is generally easy and safe. (6) Because there usually is no joint damage, skeletal manage ment is relatively easy; and in almost all cases sufficient bone
shortening, mainly at the proximal stump, is possible for optimal soft tissue repair. Even radical bone shortening alone does not necessarily introduce major functional impairments. Therefore, less favorable types of injuries (e.g., compression amputation) may be transformed into a guillotine-type am putation. (7) Repair of motor units involves tendons rather than muscles and is in an anatomically and biologically fa vorable area. (8) Skeletal severance is at a level with usually rapid bone healing. (9) The operating time needed is relatively short; the entire procedure can be done by the same surgeon. (1 0) Because no major muscle mass is involved in the am putated part, the risk of metabolic disturbances and/or infec tion is relatively small. (II) The only muscle with a consis tently poor prognosis is the pronator quadratus; however, its function is well compensated by the pronator teres.
Clinical cases Our personal series of proximal but close to the wrist joint amputation includes five cases of complete severance with no (not even "minor") tissue bridges. The longest follow-up is 8 Vz years and the shortest is 3 Vz years. The patients' ages ranged from 3Vz to 62 years. A total primary repair had been performed in all patients. Additional secondary surgery, other than removal of hardware, was required in one patient who sustained an avulsion amputation and in whom poor pri mary skeletal management had led to formation of a pseud arthrosis.
Vol. lOA, No. 6, Part 2 November 1985
A grade I or II functional recovery was achieved in four patients. The patient who had secondary surgery had a grade III result. The long-term functional results will be illustrated for three patients of different age groups and a similarly favorable type of amputation injury (Figs. I to 3). Case 1 (Fig. 1). This 3Vz-year-old girl sustained an am putation of her left hand in a lawn mower accident. Replan tation was performed with total primary repair. The functional results are illustrated at 8Vz years' follow-up. Growth of the reattached hand was normal. The initial forearm was short ened 4 em, but it did not level out completely; there is still a difference of 18 mm in the length of both forearms. The two-point discrimination is 6 mm in the median and 8 mm in the ulnar nerve distribution. There is no cold intolerance. No secondary surgery has been performed except for the removal of the metal plates. The girl successfully started to play the piano 6 years after the accident. Case 2 (Fig. 2). This 21-year-old laborer sustained a guil lotine-type amputation by a plastic-cutting machine. Intraos seous wiring at the radius was used to preserve the wrist joint. The ulna was fixed with a one-third tubular plate. The func tional result 42 months after reattachment with total primary repair is illustrated. No secondary surgery was performed except for removal of the plate at the ulna. Mainly because of the remarkable reinnervation of the intrinsic muscles, he has the best result of all our cases of proximal but close to wrist amputation. The initial skeletal shortening, in this case of a clean-cut amputation, was 2.5 em. The patient has no pain in the reattached hand and only very moderate cold intolerance. The two-point discrimination in the median nerve is 6 mm and 8 mm in the ulnar nerve distribution. The patient returned to his original job as a manual worker. His work men's compensation is only 10% of his salary before injury. Case 3 (Fig. 3). This clean-cut amputation occurred in a 62-year-old joiner (welder). The functional result is illustrated 6 years after replantation with total primary repair. Because the patient refused removal of the metal plates used for rigid skeletal fixation, no secondary surgery was performed. The patient recovered without any problems from the long general anesthesia, and healing was uncomplicated. He has only pro tective sensibility in both the median and ulnar nerve distri bution. He has no two-point discrimination. There is no pain except for pronounced cold intolerance in the reattached hand. This patient did not return to his job as a welder, but re tired 2 years earlier than he would have without the ac cident.
Hand amputations
991
Fig. 3. Proximal but close to the wrist joint amputation in a 62-year old joiner. Clinical results 6 years after replantation. (Reprinted with permission from Meyer VE: Upper extremity replantation: basic prin ciples, surgical technique, and strategy. New York, 1985, Churchill Livingstone Inc.)
REFERENCE I. Chen ZW, Meyer VE, Kleinert HE, Beasley RW: Present indi cations and contraindications for replantation as reflected by long term functional results. Orthop Clin North Am 12:849-70, 1981