Some observations on the autografting of digits and upper limb replantation

Some Observations on the Autografting of Digits and Upper Limb Replantation - - J . S. P. Wilson, l. F. McNeill

SOME O B S E R V A T I O N S O N T H E A U T O G R A F T I N G U P P E R LIMB R E P L A N T A T I O N

O F DIGITS A N D

J. S. P. WILSON, London and I. F. McNEILL, Newcastle-upon-Tyne The restoration of the function of the hand in patients who have sustained an accidental amputation of arm, forearm, hand or digits, is a subject of overwhelming interest to hand surgeons. There is no doubt that prosthetic replacement of the amputated parts is unsatisfactory, functionally and cosmetically. A great deal of interest was therefore aroused when Malt (1964) demonstrated that in favourable circumstances, a completely amputated arm could be replaced with satisfactory results. Since then, amputed arms, forearms and hands have been replaced with sufficient frequency, and with such success, that this technique must be considered in the treatment of any accidental amputation, through, or proximal to, the level of the carpus. In more distal amputations through metacarpus or digits, attempts at replacement of the amputated part have been largely unsuccessful. The main problem in these distal amputations has been the difficulty in obtaining a satisfactory repair of the small arteries and veins so that patency endures. The failure of small vessel anastomoses does not however preclude the use of parts of the amputated digits in an attempt to restore function to the hand. In this paper we report three cases in which autografting was used to maintain hand function after accidental amputation at widely different levels. CASE REPORTS Case I

A sixteen year old boy sustained an amputation of his right thumb and thenar eminence while making a firework. The skin and subcutaneous tissue of the amputated part were discarded and the thumb skeleton was buried in a lower

Fig. I (a) Defect on thenar eminence closed by abdominal flap. Vol. 2

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Fig. 1 Case 1 (b) Bony skeleton of thumb in thoracic tube pedicle.

Fig. 1. (c) Tube pedicle and thumb implanted. 146

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Fig. 1 (d) Post operative

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Replantation 1. F. McNeil1

10 years later.

thoracic skin pocket Gillies (1940). The defect on the radial aspect of the hand was repaired by an abdominal pedicle flap (Fig. la). Subsequently the skin pocket was converted into a tube pedicle around the thumb (Fig. lb), and the digit was implanted in the position of function (Fig. lc). The poor terminal blood supply and lack of sensation necessitated the transfer of an island flap from the middle finger to thumb pulp. The result is satisfactory in that the boy uses his thumb and the overall hand function is good (Fig. Id). The interphalangeal joint however has become completely ankylosed (Wilson and Braithwaite 1964). Reasoning that the lack of nerve supply to the joint probably played a part in the ankylosis of the interphalangeal joint, it was resolved at the next opportunity to preserve the digital nerves and carry out primary nerve suture with an immediate replacement of the digit. Case II

A- suitable opportunity arose some four years later-an eighteen year old boy suffered a severe injury to his right hand, amputating all four fingers through the proximal phalanges (Fig. 2a). It was decided to autograft the index finger in order

Fig. 2 Case 2 (a) Amputation Vol. 2

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Some Observations on the Autografting of Digits and Upper Limb Replantation --J. S. P. Wilson, 1. F. McNeill

Fig. 2. (b) Amputated index finger with dissection of the digital nerves.

Fig. 2. (c) Finger replaced with suture of the digital nerves. (d) Skin defects repaired by thoracic tube pedicle and abdominal pedicle flap. to establish a post for a pinch grip. Skin cover over the middle, ring and little finger stumps was achieved by a pediele flap. The skin and nail were dissected off the index finger, preserving all other structures, ,in particular the digital nerves (Fig. 2b). The core of the finger was then implanted into the base of the proximal phalanx and fixation was achieved using a bone peg made from one of the other amputated fingers. The digital nerves were carefully sutu,red (Fig. 2c) and a tube pedicle supplied immediate skin cover (Fig. 2d). 148

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The finger survived although an area of the terminal phalanx had to be removed. Four months later the pedicle skin was thinned, giving an opportunity to explore the site of nerve repair. This revealed a slight thickening at the sutu,re line, the distal digital nerve was not atrophied, and therefore some degree of regeneration was presumed to have taken place. The autografted finger functioned well as an opposition post allowing a pinch grip (Fig. 2e), but once again the proximal interphalangeal joint became ankylosed. The quality of sensory recovery was disappointing, although adequate for protection. Unfortunately, no island flap was available for transfer. The experience gained with these two cases convinced us that this method ottered only limited possibilities for development. A similar conclusion was drawn by Wilflingseder (1967) who, in fifteen years of experience in autografting thumbs, failed to obtain a single primary bony union. A more promising and physiological approach to the problem seemed to be a complete replacement of the part with immediate vascular anastomosis.

Fig. 2. (d) Post operative. Case H I A fourteen year old boy trapped his right arm in a conveyor belt and suffered a disarticulation at the elbow. The forearm remained attached to the arm by stretched and traumatized median and ulnar nerves. All other tissues were divided. Three and a quarter hours later an operation to replace the arm was started. The amputated limb was perfused with heparinised saline to flush thrombi from the vessels. The limb was shortened by excising two inches from the lower end of the humerus. Stability was achieved by fixing the ulna at right angles to the humerus with a Rush pin and a lag screw. Two su~perficial veins in the forearm were first anastomosed to the cephalic and basilic veins. The brachial artery was then trimmed and anastomosed. The radial nerve was irreparably damaged but the other soft tissues were united. The circulation was re-established within five hours of the injury. After the operation moderate, temporary oedema developed, in spite of elevation of the arm. An area of skin behind the elbow required excision and skin grafting. There were no other complications. Vol. 2

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This boy was assessed eighteen months later; the hand had an excellent circulation, and sensation had returned to the finger tips. The main defect in hand function was due to the radial nerve palsy (Fig. 3a). Subsequently tendon transfers were undertaken. The pronator teres was sutured to the extensor carpi radialis longus and brevis, correcting the wrist drop, The flexor carpi radialis was inserted obliquely into the extensor digitorum communis and the palmaris longus sutured to the extensor pollicis longus; thus reanimating the extensors. The boy then had an intensive course of physiotherapy followed by a period at an industrial rehabilitation centre. He obtained employment in light industry.

Fig. 3 Case 3

(a) Replanted arm showing loss of radial nerve function.

Fig. 3 (b) Replanted arm after tendon transplants. 150

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Assessment three years after his injury revealed adequate finger tip sensation, but impairment of two point discrimination. Wrist function had returned (Fig. 3b) and the fingers flexed to within one cm. of the distal palmar crease, although there was some limitation in full extension of the fingers. The boy used his hand naturally and could write with it (Fig. 3d).

Fig. 3 (c) Post operative. T H E PROBLEMS OF A U T O G R A F T I N G

Reimplantation following amputation through or proximal to the carpus has now been carried out with sufficient frequency, experimentally and clinically, to allow the recognition of particular problems associated with this type of surgery. These problems fall into three groups, the Early, the Intermediate and the Late. The early problems arise mainly from the loss of plasma into the replaced part as a result of increased capillary permeability. In experimental animals up to fifty per cent of the plasma volume may be sequestered in the limb within six hours of its replacement. Such a catastrophic depletion of the plasma volume has not been observed in any of the reports on human limb reimplantation. Restoration of the circulation in the tissues of the replaced limb also mobilises into the general circulation an acute load of lactic acid and intracellular cations such as K+ and Mg+ +. The intermediate problems in limb replacement in experimental animals has in the main resulted from infection, although, in human cases, infection has not been such a serious complication. The late problems in limb replacement have been due to a variety of causes but outstanding among these has been failure in satisfactory nerve regeneration. Inadequate reinnervation of the replaced part has emerged as the most serious problem limiting the potential benefits of limb replacement in both experimental and clinical work. Vol. 2

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As neurological recovery of the limb is the keystone of limb replantations, an assessment of the results in animals and man is of considerable interest. A S S E S S M E N T O F R E P L A N T A T I O N OF LIMBS I N D O G S

Lapchinsky (1960) reported excellent function in sixteen replanted limbs that had been followed up for over six years. He found no evidence of trophic ulceration or muscular atrophy. The gastrocnemius had a normal electromyogram 133 days post-operatively and he claimed that histological examination of this muscle showed no abnormality. Reinnervation of the paw developed in six to eight months. These outstanding results have not been repeated by any other investigation. Eiken (1964) carried out a more detailed study of the function of replanted hind limbs in fifteen dogs. He found that all the dogs walked on three limbs for the first month but subsequently used all four legs. The paws were smaller and there was a weakness of the small muscles of the toes. However, the main disability in all cases was a "foot drop" due to a peroneal palsy. This was complicated by some degree of flexion contracture of the knee in six dogs. The return of sensation was difficult to demonstrate but five dogs retracted their paw on pin prick after six months had elapsed. Conduction velocities in the larger fibres of the sciatic nerve improved over the first nine months to over fifty per cent of the normal and histological examination of the nerve distal to the site of anastomosis revealed many normal fibres after one year. Microsurgical nerve suture technique seemed to improve the rate of regeneration in the small number of cases in which it was used. Snyder (1964) and Williams (1966) also reported on the function of replanted dog limbs. All the dogs had some degree of foot drop occasionally complicated by a flexed knee. A S S E S S M E N T OF R E P L A N T A T I O N OF LIMBS I N M A N

In man there have been thirty-nine cases in which successful limb replacement has been carried out following complete or near complete amputation. Twenty-three of the cases have been reported in sufficient detail and followed up for a sufficient length of time to allow an appraisal of the results. Group I (a) Upper A r m : Six patients followed up for over two years revealed poor sensa-

tion in two cases. Weakness in fingers and wrist extension in three cases, and one case of claw hand. (b) Upper A r m : Three patients followed up for over one year. Assessment showed one case of poor sensory recovery and all had weakness of wrist and finger extension. There was one case of claw hand. Group H E l b o w : Five patients followed up for over one year. Two patients showed poor

sensory recovery. There was some weakness of finger extension which was improved in two cases by tendon transfers, Group HI Distal Forearm: Nine patients were followed up for over six months. Sensory

recovery was poor in three cases. There was weakness of finger extension and one claw hand; the thumb required arthrodesis in one case. No author claimed full sensory and motor recovery in the limb. The quality of sensation, even in the cases classed as a good result, judged by two point discrimination would only be fair; a pinch grip was achieved in many cases, but the power grip was weak. 152

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With the exception of two cases (personally communicated), all the patients were satisfied with their limbs. There were, however, a further two cases recorded in the group of failures of limb replantation where the limb was amputated because of poor nerve regeneration. Paletta (1968), Halmagyi et al (1969). DISCUSSION

The case material consisted of one patient with an amputated thumb and another with amputated index finger. A third patient had a near total amputation at the level of the elbow. Treatment demanded a period of hospitalization and withdrawal from employment at a critical age. In no case was the result entirely satisfactory, but we did achieve considerable hand function, the ability to use a knife and fork, to write with the hand, and return to work. In distal amputations, replacement is indicated either in the patient with a cleanly amputated thumb or with an intact thumb associated with amputation of all the other digits. The use of a skin pedicle to restore the blood supply to an autogenous bony skeleton is too slow to maintain joint function and adequate sensation is not realised unless a neuro-vascular island flap is incorporated in the repair. Replantation of digits by small vessel anastomosis even using micro-surgical techniques still presents problems, although advances are being made, and several workers are regularly achieving success in the suture of divided blood vessels of digital artery calibre. However, we must contrast the results of either method, not with an absent finger, or with a prosthesis, but with the other orthodox methods of repair. Treatment by pollicisation, or tube-pedicle bone graft and neuro-vascular island flap technique, are safe methods for the restoration of at least partial hand function. In proximal amputations the reported results of fifty-one cases of replantation of the arm or hand by vascular anastomosis reveal that given the correct circumstances the parts can be successfully replaced without endangering the patient. Complications are fortunately not such a problem in human replantation as they are in the animal, although they should be circumvented or promptly recognised and treated if they occur. The factors in assessing a case for replantation a r e : (a) Replantation should not be attempted more than six hours after separation. (b) The patient should not have any other serious injury. (c) There should be a limited amount of soft tissue destruction, the type of injury being a cut rather than a crush. (d) No concomitant traction injury of the brachial plexus or additional damage to the subclavian vessels. (e) The most important single factor is the age of the patient. Analysis of the cases of replantation reveals that the younger the patient the better the ulimate result. Probably no patient over thirty years should be considered as a candidate. (f) Vol. 2

Finally, the patient must personally express a desire for replantation after the procedure with all its difficulties has been discussed. No. 2

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Some Observations on the Autogra[ting o / D i g i t s and Upper Limb Replantation --J. S. P. Wilson, 1. F. McNeill CONCLUSION

T h e f u n d a m e n t a l p r o b l e m is to i m p r o v e the nerve repair, a l t h o u g h in Case I I I the return of sensation a n d function was g o o d because the m e d i a n a n d ulnar nerves were a n a t o m i c a l l y intact, although from the time of the course of recovery they h a d o b v i o u s l y suffered c o m p l e t e axonotmesis. Thus, it is of interest to note that the physiologically a m p u t a t e d limb presented w h a t might be c o n s i d e r e d a " R e s e a r c h Module". I n m a n y of the cases of r e p l a n t a t i o n reviewed, the loss of the r a d i a l nerve was the most crippling of the defects encountered a n d t e n d o n transplants m a y well have i m p r o v e d the outcome. H o w e v e r , the s t a n d a r d of c o m p a r i s o n in this group is not the n o r m a l hand, but an insensitive highly technical prosthesis. T h e fact remains that some m e a n s of hastening a n d i m p r o v i n g nerve regeneration m u s t be found, if the r e p l a c e m e n t of limbs by a u t o g r a f t i n g a n d in the future, homografting, is not to be a "surgical d r e a m " . E x p e r i e n c e m u s t be gained in the technique of limb or p a r t a n a s t o m o s i s with a critical assessment of the results. I f this m e t h o d is not to fall into disrepute, clear indications that the p a t i e n t ' s h a n d function will be greatly e n h a n c d b y these m a j o r a n d time consuming p r o c e d u r e s should be our first consideration. ACKNOWLEDGMENTS Figs. 1 (a) (b) and (c) are reproduced from the Transactions of the 3rd International Congress of Plastic Surgery, 1964 by the permission of the Editors of the Excerpta Medica Foundation, Amsterdam. Figs. 2 (b) and (c) are reproduced by permission of the Editor of the British Journal of Surgery. BIBLIOGRAPHY

BORA, F. W. and DESANT1S, D. (1967) Replantation of a Hand. Pennsylvania Medicine. 70, 2: 53. BLALOCK, A. (1930) Experimental Shock. Archives of Surgery, 20: 959. CARREL, A. (1908) Results of the Transplantation of Blood Vessels, Organs and Limbs Journal of the American Medical Association, 51: 1662. CARREL, A. and GUTHRIE, C. C. (1906) Science, 23: 393. CAVE, E. F. (1958) Injuries to Peripheral Nerves. In Fractures and Other Injuries. Chicago. Yearbook Medical Publishers, 769. CH'EN, C. W. (1967) Reattachment of Traumatic Amputations. China's Medicine, 5: 392. CH'EN, C. W., CH'IEN, Y. C. and PAO, Y. S. (1963) Salvage of the Forearm following Complete Traumatic Amputation. Chinese Medical Journal, 82: 632. CH'EN, C. W., CH'IEN, Y. C., PAO, Y. S. and LIM, C. T. Further experiences in the Restoration of Amputated Limbs. Chinese Medical Journal, 84: 225. EIKEN, O., NABSETH, D. C., MAYER, R. F. and DETERLING, R. A. (1964) Limb Replantation, The Technique and Immediate Results. Archives of Surgery, 88: 48. EIKEN, O., MAYER, R. F., NABSETH, D. C., APOSTOLOU, K. and DETERLING, R. A. (1964) Limb Replantation: Long Term Evaluation. Archives of Surgery, 88: 66. EIKEN, O., NABSETH, D. C., MAYER, R. F. and DETERLING, R. A. (1964) Limb Replantation, The Pathophysiological Effects. Archives of Surgery, 88: 54. GILLIES, H. (1940) Autograft of Amputated Digit. Lancet, 1: 1002. HALMAGYI, A. F., BAKER, C. B., CAMPBELL, H. H., EVANS, J. G., MAHONEY, L. J. (1969) Replantation of a Completely Severed Arm, Followed by Reamputation because of Failure of Innervation. Canadian Iournal of Surgery, 12, 2: 222. HAMEL, A. L. and MOE, J. H. (1964) Effect of total ischaemia on hind limbs of dogs subjected to hypothermia. Surgery, 55: 274. HARDIN, C. A. (1967) Salvage of Severed or Near-Severed Arms. Annals of Surgery, 166: 137. HERBSMAN, H., LAFER, D. J. and SHAFTAN, G. W. (1966) Successful Replantation of an Amputated Hand. Annals of Surgery, 163: 137. HOPFNER, E. (1903) Ueber Gefiissnaht, Gefiisstransplantationen und Replantation yon amputirten Extremit~iten. Archives for Klinische Chirurgie, 70: 417. 154

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INOUE, T., TOYOSHIMA, Y., FUKUSUM1, H., UEMECHI, A., INUI, K., HARADA, S., HIROHASHI, K., KOTANI, T. and SHIRAYA, Y. (1967)a. Replantation of Severed Limbs. Journal of Cardiovascular Surgery, 8: 31. INOUE, T., TOYOSHIMA, Y., FUKUSUMI, H., UEMECHI, A., INUI, K., HARADA, S., HIROHASHI, K., KOTANI, T. and SHIRAHA, Y. (1967)b. Factors Necessary for Successful Replantation of Upper Extremities. Annals of Surgery, 165: 225. KLEINERT, H. E., KASDAN, M. L. and ROMERO, J. L. (1963) Small Blood-Vessel Anastomosis for Salvage of Severely Injured Upper Extremity, Journal of Bone and Joint Surgery, 45A 788. LAPCHINSKY, A. G. (1960) Recent Results of Experimental Transplantation of Preserved Limbs and Kidneys. Annals of the New York Academy of Sciences, 87: 539. LINDHOLM, R. and KIUSMAN, A. (1967) Accidental Near Severance of the Upper Arm. Actac Chirurgica Scandinavica, 133: 423. LINDSAY, W. K., WALKER, F. G. and FARMER, A. W.-(1962) .Traumatic Peripheral Nerve Injuries in Children. Plastic and Reconstructive Surgery, 30: 462. MACDONALD, G. L. (1964) Reported by Eiken et al. Archives of Surgery, 88: 54. MeNEILL, I. F. and WILSON, J. S. P. (1970) The Problems of Limb Replacement. British Journal of Surgery, 57: 365. MALT, R. A. and McKHANN, C. F. (1964) Replantation of Severed Arms. Journal of the American Medical Association, 189: 716. MATHIESEN, F. R. and GAMMELGAARD, A. (1963) Traumatic Arterial Injuries. Journal of Cardiovascular Surgery, 4: 308. MEHL, R. L., PAUL, H. A., SHOREY, W., SCHNEEWlND, J. H. and BEATYIE, E. J. (1964) Treatment of "Toxaemia" after Extremity Replacement. Archives of Surgery, 89: 871. MEHL, R. L., PAUL, H. A., SCHNEEWlND, J. and BEATTIE, F. J. (1964) Journal of Trauma, 4: 495. NIGST, H. (1968) Basel, Personal Communication. NOLAN, B. (1968) Edinburgh, Personal Communication. PALETTA, F. X. (1968) Replantation of the Amputated Extremity. Annals of Surgery, 168: 720. RAMIREZ, M. A., DUQUE, M., HERNANDEZ, L., LONDONO, A. and CADAVID, G. (1967) Replantation of Limbs. Plastic and Reconstructive Surgery, 40: 315. REICHERT, F. L. (1926) The Regeneration of the Lymphatics. Archives of Surgery 13: 871. ROSENCRANTZ, J. G., SULLIVAN, R. C., WELCH, K., MILES, J. S., SADLER, K. M. and PATON, B. C. (1967) Replantation of an Infant's Arm. New England Journal of Medicine, 276: 609. SALESSES, M., MOUSSU, M. and AUPECLE, M. (1962) Deux observations "princeps" de section traumatique quasi complete du bras suivie d'op6ration restauratrice et de conservation du membre. M6moires de l'Acad6mie de Chirurgie, 88: 930. SHAFTAN, G. (1965) Replantation of Limbs. Minnesota Medicine, 48: 1645. SHOREY, W. D., SCHNEEWlND, J. H. and PAUL, H. A. (1965) Significant factors in the reimplantation of an amputated hand. Bulletin International Society of Surgery, 1: 44. SKOOG, T. (1968) Uppsala, Personal Communication. SNYDER, C. C. and KNOWLES, R. P. (1963) Autoplantation of Extremities. Clinical Orthopaedics and Related Research, 29: 113. STEINMAN, C. In discussion. Mehl et al. (1964) Treatment of "Toxaemia" after Extremity Replantation. Archives of Surgery, 89: 871. THOMPSON, J. E. In discussion. Williams et al. (1966) Replantation of Amputated Extremity. Annals of Surgery, 163: 788. TOSE, L. (1961) Autotransplantation of Limbs. M.S. Thesis, Tufts University, Boston, Mass. VOGT, B. P. (1967) Replantation of a Completely Amputated Arm. Proceedings of the British Club for Surgery of the Hand, Lausanne, May 1967, 46. VOGT, B. P. (1969) Successful Replantation of the Completely Amputated Arm. Surgical Therapeutics (Osaka), 21, 1: 124. WILFLINGSEDER, P. (1967) In discussion on Autografting Amputated Thumbs. Proceedings of the British Club for Surgery of the Hand, Lausanne, May 1967: 27. WILLIAMS, G. R., CARTER, D. R., FRANK, G. R. and PRICE, W. F. (1966) Replantation of Amlautated Extremities. Annals of Surgery, 163: 788. WILSON, H. and ROOME, N. W. (1936) The Effects of Constriction and Release of an Extremity. Archives of Surgery, 32: 334. WILSON, J. S. P. and BRAITHWAITE, F. (1964) The Autografting of an Amputated Thumb. Transactions of the International Society of Plastic Surgery, 3rd Congress, Ed., T. R. Broadbent. Amsterdam, Excerpta Medica Foundation, 1012. WORMAN, L. W., DARIN, J. C. and KRITTER, A. E. (1965) The Anatomy of a Limb Replacement Failure. Archives of Surgery, 91: 211. Vol. 2

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