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CASE REPORT
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1192-1195

Revascularization of near total amputation of the hand: A viable salvage procedure in a resource-constraint setting


1 Department of Surgery, Plastic Surgery Unit, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
2 Department of Surgery, Plastic Surgery Unit, LAUTECH Teaching Hospital, Ogbomoso, Oyo-State, Nigeria
3 Department of Surgery, National Orthopaedic Hospital, Dala, Kano, Nigeria

Date of Submission03-Nov-2021
Date of Acceptance05-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. O S Ilori
Department of Surgery, LAUTECH Teaching Hospital, Ogbomoso, Oyo-State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1922_21

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   Abstract 


Traumatic near total amputation of the hand with major vascular injury may lead to loss of the hand with dire consequences to the patient. A prompt attempt at salvaging the hand is key to prevent the untoward consequences. In addition, the awareness of the possibility of salvage in our environment should be spread among health care personnel as well as the need for multispecialty approach to the management. We report 2 patients with near total unilateral amputation of their hands proximal to the wrist who underwent salvage procedures.

Keywords: Amputated hand, reimplantation, revascularization


How to cite this article:
Ajani A, Ilori O S, Adesina A A, Salihu M N, Yunusa R, Wadanas U. Revascularization of near total amputation of the hand: A viable salvage procedure in a resource-constraint setting. Niger J Clin Pract 2022;25:1192-5

How to cite this URL:
Ajani A, Ilori O S, Adesina A A, Salihu M N, Yunusa R, Wadanas U. Revascularization of near total amputation of the hand: A viable salvage procedure in a resource-constraint setting. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 8];25:1192-5. Available from: https://www.njcponline.com/text.asp?2022/25/7/1192/351464




   Introduction Top


The hand plays an extremely vital role in body image, self-identity, and activities of daily living; thus, the loss of the hand will cause tremendous functional and psychological problems in such individuals.[1] Attempt at revascularization of the severed or nearly severed hand is, however, germane in order to prevent such untoward consequences. Replantation is defined as reattachment of severed body part using the neurovascular and musculoskeletal structures in order to obtain the recovery of the limb.[2] Revascularization on the other hand is the repair of a body part that has been incompletely amputated from the body and requires vascular repair.[2]

In the last 4 decades, technological advances and innovation in the field of microsurgery have made salvage procedures possible. Replantation/revascularization centers of excellence have been established in many developed countries where such cases are referred for prompt-specialized surgical intervention with overall success rate of more than 70%.[3] However, this success rate has not been replicated in many resource constraint countries. Ironically, cases requiring replantation/revascularization are reportedly higher in the resource constraint nations.[3] In addition, most of the injuries occur far away from any hospital setting where it can be done making it difficult to salvage the limbs due to prolonged ischemia time.

The goal of revascularization after near total traumatic amputation is the successful salvage of the limb in both form and function. The decision to attempt salvage in such injury is influenced by many factors such as the level of injury, expected return of function, and mechanism of injury. The mechanism of injury may, however, be the most predictive variable for success.[4]

In addition, the outcome of revascularization has improved in the last 3 decades due to the understanding of the pathophysiology of the injury, early referral to multispecialty center, and better preservation of the hand to reduce warm ischemia time. Other factors include the following: advanced microsurgical technique, close monitoring in postoperative period, and a dedicated follow-up with appropriate secondary procedures if required.[5]

In this case series, we described 2 male patients with near total amputation of the dominant and nondominant hands, respectively, just proximal to the level of the wrist. Both presented at different times (one year apart) and underwent revascularization with successful limb salvage.


   Case Presentation Top


Case 1

A 16-year-old right-handed adolescent who was assaulted with a machete by his relative for alleged stealing. He sustained near total amputation of the right hand at the level of the wrist [Figure 1]. He got to the Accident and Emergency 6 hours after the injury.
Figure 1: Preoperative picture showing the right near amputated hand

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At presentation, he was conscious but pale; the blood pressure was 100/70 mm Hg.

There was a circumferential laceration at the level of the right wrist joint (zone v) with exposed transected superficial and deep flexor tendons. The median nerve, ulnar nerve, and ulnar artery were transected [Figure 2]. In addition, the extensor tendons (zone 7) were transected and exposed with radial deviation of the wrist and subluxation of the distal radioulnar and radiocarpal joint; the radial artery was, however, spared.
Figure 2: Intraoperative picture showing transected tendons and neurovascular structures

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X-ray of the right wrist showed widening and dorsal displacement of the distal radioulnar joint.

He had an emergency wound exploration following the initial resuscitation. Intraoperative findings included a complete transection of the right ulnar artery, right ulnar nerve, right median nerve, the superficial and deep flexor tendon, and the extensor tendons. There was also transection of the triangular fibrocartilage complex at the wrist with subluxation of the proximal carpal bones.

The patient had perineural repair of the median and ulnar nerve and revascularization of the ulnar artery. He also had modified Kessler repair of all the deep flexor tendons, the extensor tendons as well as the repair of the volar radioulnar and ulnar-lunate ligaments. The right upper limb was immobilized in a below elbow back slab and a Kleinert dynamic traction was applied.

He was subsequently discharged home and he is currently undergoing hand rehabilitation on outpatient basis. At the follow-up clinic, a year postsurgery, the patient had acceptable aesthetic and functional outcome [Figure 3].
Figure 3: A year postoperative picture of the patient's right upper limb

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Case 2

A 25-year-old right-handed farmer/cattle rearer with multiple injuries to the left forearm and back following an assault. He was attacked by his assailant inside a bush with a machete and he sustained near total amputation of the left hand just proximal to the wrist; [Figure 4] there was associated pain and deformity. He got to the Accident and Emergency 9 hours after the injury.
Figure 4: Preoperative picture showing the near amputated left hand of the second patient

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At presentation, he was in painful distress and pale; the blood pressure was 90/60 mm Hg.

On the left upper limb, there was a circumferential laceration 5 cm proximal to the wrist with the hand held only by a lateral skin paddle. Distally the fingers were pale and cold with no capillary refill; sensation was also absent. There was transection of the flexor and extensor tendons, the ulnar, median, and radial nerves, and the ulnar artery. The radial artery was also transected with a 5 cm gap. In addition, there was associated transverse fracture of both the radius and ulnar bones [Figure 5].
Figure 5: Plain radiograph of the left hand and forearm showing fractured radius and ulnar bones

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He had an emergency wound exploration following the initial resuscitation. Perineural repair of the median, ulnar, and radial nerves were done after open reduction and internal fixation of the fractured ulna and radius with plate and screws [Figure 6]. The ulnar artery was directly apposed, while the radial artery was repaired with a reversed great saphenous vein graft [Figure 7]. He also had modified Kessler repair of all the deep flexor tendons and the extensor tendons. His left upper limb was immobilized in a below elbow cast (back slab). He has been discharged home and he is also currently undergoing rehabilitation on outpatient basis [Figure 8].
Figure 6: Plain radiograph of the left forearm showing the fixation of the fractured bone with plate and screws

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Figure 7: Intraoperative picture showing the vein graft sutured proximally

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Figure 8: The patient's hand on the sixth postoperative day

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   Discussion Top


Once limb-threatening amputation injuries are identified, appropriate interventions must be performed swiftly to optimize functional outcomes.[6] Constant improvement and innovations in surgical techniques has resulted in increased efficacy of trauma surgeons in salvaging the patient's limb, which are affected by severe injuries and hence amputation can be prevented ultimately.[6] It is important to assess the level of injury and the exact type and an early and thorough assessment of the outcome before performing the surgery. This will enable the surgeon to decide which treatment option is best in the interest of the patient's well-being.

The most important factors that play a role in outcomes are age, the presence of multiple levels of injury, the mechanism of injury, and the ischemia time.[7] It has been established that the success rate of revascularization/replantation in guillotine or sharp-cut injury is much higher when compared with crush/avulsion injuries.[8] Both index cases presented with sharp cut injuries and they also belong to a younger age group with no comorbidities; those favorable factors might have been responsible for the good outcome recorded in the patients.

In 2005, the American College of Surgeons Committee on Trauma concluded that vascular injuries should be treated within 6 hours of injury to maximize the success of limb salvage. Contraindications for surgery are a warm ischemia time of >6 hours and a cold ischemia time of >12 hours. When it comes to the hand, attempting replantation or revascularization even with a poor prognosis due to prolonged ischemia time is warranted.[9] In this case series, however, the patients presented with warm ischemia time of 6 hours and 9 hours, respectively, with successful hand salvage. In addition, the outcome might also have been further improved in both cases if the nearly severed parts were appropriately preserved to improve the cold ischemia time. Shalima et al.[10] described that the nearly amputated segment hanging by a sliver of skin can be preserved by wrapping it in a saline-moistened guaze. A plastic bag sealed with ice in it should be placed adjacent to the nearly severed limb and then the whole area bandaged to keep the ice in place.[10] A public enlightenment on the possibility of limb salvage in our environment and what to do with nearly severed limb parts when bringing such patients to the hospital will also help increase the number of successful limb salvage procedures done in the resource constraint settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Francois CG, Breidenbach WC, Maldonado C, Kakoulidis TP, Hodges A, Dubernard JM, et al. Hand transplantation: comparisons and observations of the first four clinical cases. Microsurgery 2000;20:360-71.  Back to cited text no. 1
    
2.
Mahajan RK, Mittal S. Functional outcome of patients undergoing replantation of hand at wrist level-7 year experience. Indian J Plast Surg 2013;46:555-60.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Nangole FW, Khainga SO, Mogire T, Ogallo JP, Ajujo M, Okello O, et al. Is reimplantation surgery an option in resource constrained countries? Orthoplastic Surg 2021;5:1-5. doi: 10.1016/j.orthop.2021.05.001.  Back to cited text no. 3
    
4.
Nanda V, Alsafy T, Jacob J, Mohan L. Successful revascularization of near total amputation at Sultan Qaboos Hospital, Salalah. Oman Med J 2009;24:44-8.  Back to cited text no. 4
    
5.
Korompilias AV, Beris AE, Lykissas MG, Vekris MD, Kontogeorgakos VA, Soucacos PN. The mangled extremity and attempt for limb salvage. J Orthop Surg Res 2009;4:4.  Back to cited text no. 5
    
6.
Langer V. Management of major limb injuries. ScientificWorldJournal 2014;2014:640430.  Back to cited text no. 6
    
7.
Sulaiman SM, Alkhodair AA, Sulaiman S, Sulaiman LM, Elkafafy AS. Successful hand transplantation in a case of total avusion without vein graft. Plast Reconstr Surg Glob Open 2018;6:e1637.  Back to cited text no. 7
    
8.
Khan N, Rashid M, Ur Rashid H, Ur Rehman Sarwar S, Khalid Choudry U, Khurshid M. Functional outcomes of secondary procedures in upper extremity replantation and revascularization. Cureus 2019;11:e5164. doi: 10.7759/cureus.5164.  Back to cited text no. 8
    
9.
Stranger K, Horch RE, Dragu A. Severe mutilating injuries with complex macroamputations of the upper extremity—is it worth the effort? World J Emerg Surg 2015;10:30.  Back to cited text no. 9
    
10.
Shalimar A, William H, Levin KB, Parminder GS, Nur Azuatul AK, Tan JA, et al. A black finger does not equal a dead finger. Med Heal 2018;13:229-34.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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