Late hand replantation with restoration of intrinsic muscle function: a case and review of the literature

Abstract

Limb amputation injuries and their subsequent replantation is a time-critical exercise if function is to be restored. The exact time limit to functional replantation is still poorly defined in the literature owing to the multitude of factors that influence functional recovery. The relative metabolic activity of a tissue is lower under hypothermic conditions, and subsequently, moderate delays in restoring circulation can still achieve good functional outcomes if the amputated part is transported appropriately. Some surgeons have adopted the practice of, in cases where the delay to replantation is beyond 8–10 h, resecting skeletal muscle from the amputated part to avoid the sequelae of its ischaemic period. We report the case of a traumatic trans-carpal hand amputation in a 40-year-old male, with a second-level injury more distally at the metacarpal heads, who was replanted with a total ischaemic time of 19 h and 25 min. The decision was made to retain his intrinsic hand muscles in contradiction to common practice. At 2.5 years follow-up, he has regained a remarkable level of function of his hand including activation of his intrinsic hand muscles. His Semmes Weinstein testing has also shown good sensory recovery of his repaired nerves and he enjoys little, if any, disability as a result of his injury (despite a double-level injury on the dorsal ulna aspect of his forearm). This suggests, in cases of hand amputation with appropriate hypothermic transportation of the amputated part, ischaemia times up to 20 h may be compatible with restoration of intrinsic hand function. Level of Evidence: Level V, risk / prognostic study.