Please use this identifier to cite or link to this item: http://hdl.handle.net/1942/44495
Title: Advantages of saving carpal height in hand replantation surgery
Authors: Decramer, Arne
VANMIERLO, Bert 
Lattre, Tom
Issue Date: 2024
Publisher: ELSEVIER
Source: Journal of Hand and Microsurgery, 16 (3) (Art N° 100057)
Abstract: A wrist-level amputation is often referred to as a good indication for replantation surgery and the functional outcome mainly depends on the amputation mechanism. 1 Should one preserve the proximal carpal row in replantation surgery after a wrist-level amputation? Bone shortening, usually performed by a proximal row carpectomy is generally considered to be a critical step in wrist replantation, since it facilitates radical debridement of the soft tissues and direct repair of the neurovascular structures. 2 This dilemma became eminent when we successfully replanted a trans scaphoid midcarpal guillotine-type amputation of the right hand in a right-dominant female of 29 years old in 2011. In our opinion, clear cut amputations at the level of the wrist, whether they occurred through the radiocarpal or the midcarpal joint, are the exception to this rule! The amputation was caused by a direct blow of the front loader of a tractor and replantation surgery was initiated 2 h after trauma while the revascularization occurred within a four-hour time frame. The bony fixation was performed with a headless compression screw to the scaphoid and an external fixation device to the wrist. The post-operative recovery was uneventful, and an intensive, functional rehabilitation was given by experienced hand therapists. After six months, a surgical tenolysis was necessary to improve further functional finger motion of the fifth finger. The recovery of the ulnar nerve occurred surprisingly quick, while thenar atrophy persisted. Remarkable, repeated electro-myographic examinations of the median and ulnar nerve revealed near normal motor nerve conduction. From an osteo-articular point of view, radiographic consolidation of the scaphoid occurred within 3 months after surgery. In the decade following the initial trauma, progressive narrowing of the midcarpal joint space-especially at the level of the capito-lunate joint-was seen on regular X-rays and was confirmed by CAT scan examination (Fig. 1(c-d-i)). A plausible explanation of this inevitable evolution was that of an obvious mid-carpal instability. Since the patient experienced no discomfort, pain or functional deterioration no surgical intervention was proposed. The range of motion, functional recovery and painless neurovascular state were striking. Our patient was tested 10 years postoperatively by an experienced hand therapist (not involved in the postoperative rehab). The active wrist mobility was 60 palmar flexion, 40 dorsal extension 20 radial, 10 ulnar deviation and the pro/supination were 90. The total active range of motion for the thumb was 65 and 215 on average for the long fingers. The maximum grip force was 18 kg (10 kg less than the contralateral side), and the pinch positions showed a maximum force between 1.5kg and 3.25kg (54%-70% less than the healthy side). The full DASH demonstrated a score of 31.6. The MHQ for the overall hand function was 20%, the activities of daily living for the injured hand scored 5% while it was 67% for both hands. The scores for work performance and pain were respectively 80% and 60%. The aesthetics and satisfaction of the injured hand scored respectively 93% and 33%. The surgical strategy proved to obtain a long-lasting result! Currently, there is no agreement about shortening or fixing the bone in wrist replantation. 3,4 For amputations at the distal forearm, plate and screw fixation is advocated, Kirschner wire fixation is preferred at radi-ocarpal joint level and in cases of a midcarpal amputation, a proximal row carpectomy is recommended. A critical footnote is appropriate when considering the consensus about the necessity to shorten in replantation surgery. Restoring the original bony anatomy is more straight forward and an acceptable long-term outcome is to be expected. Moreover, if eventual evolutive degeneration of the midcarpal joint with consequen-tial functional deterioration occurs, options are available to preserve wrist motion. Secondary procedures like a four-corner fusion and even a proximal row carpectomy, can be considered to deal with the installing instability and arthritis and postpone the necessity to perform more radical procedures like a wrist arthrodesis. We believe that in a guillotine-type amputation through the midcarpal joint, avoiding bone shortening and thus preserving length, is the better option!
Notes: Lattre, T (corresponding author), HandReva Tom Lattre, Schietstr 10, B-8900 Ieper, Belgium.
tom@handrevalidatie.be
Keywords: Wrist;Replantation;Amputation;Shortening
Document URI: http://hdl.handle.net/1942/44495
ISSN: 0974-3227
e-ISSN: 0974-6897
DOI: 10.1016/j.jham.2024.100057
ISI #: WOS:001321120100001
Rights: 2024 Society for Indian Hand Surgery and Micro Surgeons. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Category: A1
Type: Journal Contribution
Appears in Collections:Research publications

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