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An unusual Case of a segmental composite Hand ReplantationEin ungewöhnlicher Fall einer Replantation an der Hand
A 31-year-old man with an unremarkable medical history presented with segmental composite amputation of the left hand. He informed us that the incident had occurred due to injury caused by a log cutting saw. The ischemia time was 4 h, and the amputated part was transported for surgery.
Examination revealed that the amputated part included partial segments of the trapezium, scaphoid, the 1st, 2nd, and 3 rd metacarpals, tendons of the 1st, 2nd, 3 rd, and 4th extensor compartments, 1st and 2nd dorsal interosseous muscles, and the superficial radial nerve ([ Fig. 1a–Fig. 1c ]). The amputated segment also demonstrated signs of crush injury. However, all the fingers including the thumb were viable.
The patient underwent surgery under general anesthesia. In the first stage, three K-wires were inserted through the metacarpals of the amputated part like a “shish kebab”. Thereafter, bone fixation of the 1st, 2nd, and 3 rd metacarpals was performed ([ Fig. 2a ]). This was followed by the resection of the segment of the scaphoid. Subsequently, the arterial repair was performed proximal to the respective ends of the radial artery. A flow-through anastomosis was not required due to sufficient circulation of the hand. The venous repair was performed proximal to the respective ends of the cephalic vein. All the extensor tendons were repaired, and the superficial radial nerve was primarily repaired. Microsurgical sutures of 9–0 and 8–0 nylon were used for vessel anastomosis and nerve coaptation, respectively. The replanted segment was replaced with interrupted sutures radially, proximally, and distally. At the ulnar side of the replant, no sutures were applied ([ Fig. 2b ]) to provide a “fasciotomy defect” for the injured hand. After the surgery, the patient was prescribed 2 × 0.4 cc low molecular weight heparin for 14 days and 500 mg aspirin per day for 1 month.
The postoperative recovery period was uneventful. The replant remained pink and viable, without any vascular compromise. On the 7th postoperative day, a posterior interosseous artery (PIA) flap for the fasciotomy defect was planned. The PIA flap was viable, and the patient was discharged from the hospital on the 15th day.
A follow-up visit after 4 years demonstrated excellent aesthetic results and good bone healing assessed using plain radiography ([ Fig. 3a ] and [ Fig. 3b ]). The functional result, however, was not as impressive. The patient had a good sense of touch on the radiodorsal side of the hand. The left wrist had radial deviation due to a scaphoid bone defect. Extansor pollicis longus, extensor indicis, and the 2nd and 3 rd extensor digitorum tendons had an extension lag. Nevertheless, the patient was able to continue work in his field of choice and was capable of pinching and grasping materials. He denied any further corrective surgeries.
Article published online:
28 January 2022
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