LEFT HAND REPLANTATION.
Bashkir State Medical University, Ufa, Russia
Traumatic amputations of the hand and its fingers are not only a personal drama for the patient, but also a serious medical and social problem, with the rate of 5.4 % from the total amount of injuries to the upper extremities and disability in 52.8 % [1, 2, 3]. The problem of replantation of the separated segments of the hand is still actual, despite of multiple various techniques for repairing lost anatomical structures and hand functioning after traumatic avulsion [4, 5, 6, 7]. It is generally admitted that for traumatic avulsion of the hand or its fingers the best functional and esthetic results are achieved with only replantation [5, 6, 7, 8].
The objective of the study – to evaluate the functional outcomes of left hand replantation after traumatic amputation.
The study was approved by the ethical committee of Bashkir State Medical University. The patient gave the written consent for publishing the results of the study.
The patient M., age of 43, suffered from an injury to the left hand as result of manipulation with the circular saw (Fig. 1). The injury happened on November 12, 2009, 5:15 p.m. After realization of primary surgical management in the central regional hospital according to the patient’s place of residence, he was transported to the traumatology and orthopedics clinic, Bashkir State Medical University (11:00 p.m.).
Figure 1. A preoperative photograph of the left hand and the photofluorography image of the left forearm
The clinical diagnosis: “Traumatic avulsion of the left hand”. Fixation with two K-wires was conducted under local anesthesia after removal of the sutures from the wound of the forearm stump. The tendons of the finger extensors and the hand were reconstructed according to Kazakov. The epineural technique was used for suturing the median and ulnar nerves and the superficial branch of the radial nerve. The suture 8.0 and the atraumatic needle were used for reconstruction of three subcutaneous veins on the dorsal surface of the hand. The microsurgical sutures were applied to the radial and ulnar arteries. After initiation of blood flow the perfusion in the replanted hand restored immediately. The surgery lasted for 4.5 hours. There wereno accidents during the operation.
There were not any complications during the early postsurgical period. The sutures were removed on the 12th day. The patient received the complete course of the rehabilitation. At 5 days after the surgery, the magnetic therapy was initiated with passive movements in the fingers with use of Artromot H (30 minutes, 4 times per day). The active movements in the fingers and the course of electrostimulation of the extensors were initiated in 4 weeks. The rehabilitation treatment lasted for 4 months. There was no need for recurrent surgery. The patient was under our observation. The figure 2 shows the long term functional outcomes of the treatment.
Figure 2. The long-term functional outcome of the surgery
The patient estimated the surgical outcome as satisfactory. He works according his profession (carpenter) and takes sports actively. With his replanted hand he is able to hold weight of 36 kg. The motions in the radiocarpal joint are within the full range. The hand muscles are hypotrophic. The tactile and pain sensitivity completely restored in the region of nerve innervation. The hand strength – 18 kg. The appearance of the hand is normal from the esthetic perspective. All main types of handgrip reactivated.
CONCLUSION
Therefore, only replantation of the detached hand and its fingers is appropriate and most efficient. It results in the best functional and esthetic outcomes. The success of replantation for traumatic avulsion of the extremity segments depends on the presence of magnification equipment and microsurgical tools, as well as on the experience of the surgical team.
REFERENCES
1. Петросян К.А., Антонян П.А., Григорян Ч.А. К вопросу о некоторых аспектах стандартных подходов восстановления нервов при реплантациях пальцев и сегментов кисти // Анналы пластической, реконструктивной и эстетической хирургии. 2016. № 1. С. 100-101. Russian (Petrosyan KA, Antonyan PA, Grigoryan ChA. About some aspects of the standard approaches to nerve restoration in replantation of fingers and hand segments. Annals of Plastic, Reconstructive and Aesthetic Surgery. 2016; 1: 100-101
2. Сидоренков Д.А., Сухинин Т.Ю., Чичкин В.Г.Реплантационная хирургия верхней конечности – современное представление о показаниях и противопоказаниях к реплантации // Анналы пластической, реконструктивной и эстетической хирургии. 2015. № 1. С. 82-83. Russian ( Sidorenkov DA, Sukhinin TYu, Chichkin VG. Replantation surgery of the upper extremity – the modern idea of indications and contraindications for replantation. Annals of Plastic, Reconstructive and Aesthetic Surgery. 2015; 1: 82-83.)
3. Beaton DE, Bombardier C, Guillemin F, Bosi Ferraz M. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine. 2000; 25(24): 86-91
4. Афанасьев Л.М., Исаев Е.А., Ежов А.А. Особенности реплантации сегментов конечностей у детей // Политравма. 2015. № 1. С. 55-58. Russian ( Afanasyev LM, Isaev EA, Ezhov AA. Features of replantation of limb segments in children. Polytrauma. 2015; 1: 55-58.)
5. Афанасьев Л.М., Ежов А.А., Гусельников С.С. Возможности компенсаторного ретроградного венозного кровоснабжения конечности при реплантации // Политравма. 2015. № 2. С. 71-76. Russian (Afanasyev LM, Ezhov AA, Guselnikov SS. Features of compensatory retrograde venous blood supply in the limb during replantation at. Polytrauma. 2015; 2: 71-76.)
6. Тимербулатов М.В., Ибрагимов Р.К., Казбулатов С.С., Тимербулатов Р.Ф., Ибрагимов Д.Р. Реплантация блока пальцев кисти после ампутации в результате травмы // Медицинский вестник Башкортостана. 2016. Т. 11, № 2. С. 29-31. Russian ( Timerbulatov MV, Ibragimov RK, Kazbulatov SS, Timerbulatov RF, Ibragimov DR. Replantation of block of fingers after amputation as a result of trauma. Medical Bulletin of Bashkortostan. 2016; 11 (2): 29-31.)
7. Шаповалов В.М., Губочкин Н.Г., Ткаченко М.В. Микрохирургия в современной реконструктивно-восстановительной и ревизионной хирургии конечностей // Травматология и ортопедия России. 2006. № 2. С. 308-309. Russian (Shapovalov VM, Gubochkin NG, Tkachenko MV. Microsurgery in modern reconstructive and revision surgery of limbs. Traumatology and orthopedics Russia. 2006; 2 (40): 308-309)
8. Афанасьев Л.М., Попов К.А. Функциональный исход после реплантации предплечья и последующей реконструкции // Политравма. 2011. № 2. С. 75-79. Russian (Afanasyev LM, Popov KA. Functional outcome after replantation and subsequent reconstruction of the forearm. Polytrauma. 2011; (2): 75-79.)