Crossover Replantation of Carpometacarpal after Traumatic Amputation

Abstract

Sir:FigureIn April of 2009, a 46-year-old man presented with massive injuries after being crushed by playing rig. His right forearm showed severe avulsion-type amputation, and there was extensive skin loss on the right forearm. The wound of the proximal stump was severely contaminated, and his left hand showed extensive crush injury below the second and fifth metacarpophalangeal joint level (Fig. 1). Orthotopic replantation was not possible because of the extensive soft-tissue damage and multiple fractures, but the right palm and second, third, and fourth fingers were well preserved. No additional injury was found. Intensive care to compensate for blood and fluid loss was started immediately at 1 hour after injury.Fig. 1: View of the crushed left upper extremity.After a rapid débridement, the right metacarpal bones were then shortened approximately 5 cm proximal to the wrist, and the vasculars, nerves, and tendons on the right palm were all separated (Fig. 2). The right little finger and left thumb were sutured to a local flap. After the ends of left and right metacarpal bone fixation were established with cross-Kirschner wires, the flexor and extensor tendon ends were repaired with 0/1 pull-out tendon sutures. The stumps of the muscles were sutured respectively. Corresponding fractured vessels and nerves were sutured using 10/0 microscopy without any grafts. Every main artery of the palm was sutured. Hand veins were anastomosed to guarantee adequate venous drainage for each finger. With our technical modification, the soft tissues and bones were repaired successfully, and the replanted palm of the upper limb survived. The total ischemia time was noted as 5.5 hours, and the total operative time was 8 hours.Fig. 2: After débridement of all nonviable tissues, the right palm was prepared for the crossover replantation to the left amputation part.Gentle active finger range-of-motion exercises were started at 4 weeks, and progressive exercise was monitored in occupational therapy. More than 3 years after reconstruction, the patient can perform flexible activities using the metacarpophalangeal joint and is able to perform basic daily activities, such as using chopsticks (Fig. 3).Fig. 3: After 40 months of postoperative follow-up, the patient can perform flexible activities using the metacarpophalangeal joints. The patient is able to perform basic daily activities, such as using chopsticks.Cross-hand replantation has previously been used for traumatic bilateral amputations.1,2 A good example of cross-hand replantation that transferred the right hand to the left distal forearm was reported by Adkins et al.3 It was briefly shown that the replanted side had a better functional evaluation in range of wrist, thumb, and finger motion. There are very few situations to consider a cross-arm transfer replantation. It requires damage to both extremities if ipsilateral replantation is not an option. Cross–lower extremity transfer is chosen when orthotopic replantation is impossible due to bilateral total or subtotal amputation.4 In this case, cross-palm transfer was essential to restore some hand function and to salvage the left-sided amputation. The transfer was done at the metacarpophalangeal joint. Russell et al.5 reported that distal upper limb amputations near the wrist level had better return of function than more high-level injuries. Despite this nonanatomic transfer, our patient did not have transfer reeducation problems after surgery. The patient did not have major postoperative problems. The palm of his hand on the left side exhibits good protective sensation. Despite aesthetic drawbacks, the functional outcome might not have been duplicated with a prosthesis. Yefeng Yin, M.M. Xiulian Si, M.M. Jiangning Wang, Ph.D. Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China PATIENT CONSENT The patient provided written consent for the use of his image. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. All authors contributed equally to this work and should be considered joint first authors.