[Macroreplantation of the upper extremity: Inventory in 2024]

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.

Psychological sequelae of hand injuries: an integrative review

This integrative review investigated reports of psychological impact and sequelae of traumatic hand injuries. A systematic search using Medline, PsychINFO, PubMed, EMBASE, CINAHL and hand-searching methods was conducted from 2008 to 2020. Nine included articles with a total of 503 participants were reported in prospective cross-sectional or longitudinal cohort studies. Depression and anxiety were common, affecting between 7% and 71% and between 23% and 71% of patients, respectively. Post-traumatic stress disorder affected between 3% and 95% of patients. Factors reported predicting psychological sequelae of hand injuries included injury severity, pain, limb dysfunction, negative perceptions of injured limbs, suboptimal coping mechanisms and limited social support. Symptoms persisted for protracted periods of follow-up but broadly attenuated after 3 months. We conclude that the high prevalence and enduring nature of psychological symptoms demonstrate an urgent need for further research to optimize treatment.Level of evidence: III.

A qualitative study of the long-term consequences and adaptation in daily life after replantation surgery at a young age

Introduction

Impaired functioning is seen in patients following replantation surgery to the thumb or fingers. Our aim was to explore long-term consequences and adaptation in daily life after a thumb and/or multiple finger amputation followed by replantation surgery during young age.

Methods

Semi-structured interviews were conducted with nine recruited individuals and analysed using content analysis. The participants were asked to describe their hand function, pain, appearance, emotional consequences, impact on daily life and strategies for overcoming daily challenges.

Results

The interviews revealed five main categories: memories of the injury and concerns for the future; hand function, pain and cold sensitivity; feelings about having a visibly different hand; adaptation to impairments and challenges in daily life; and key messages to healthcare professions and advice to future patients.The circumstances of the injury were well remembered. Pain at rest was rare but occurred when grasping. Cold sensitivity was a major issue. Appearance-related concerns varied from none to a major problem. Despite impaired hand function, solutions were found to challenges in daily life. Compensatory strategies, personal resources and support from others were important in this adaptation process.

Conclusions

Patients with replantation surgery after an amputation during young age adapt to challenges in daily life over time. Healthcare professionals should offer adequate support to enable emotional processing of trauma experience. Appearance-related concerns should be addressed to prevent distress. Information about alleviating strategies to overcome long-term problems with cold sensitivity should be emphasized.

Outcome of Early Motion Protocol for Total Hand Replantation: 1- and 2-Year Postoperative Results

Introduction  We review the benefits of early motion protocols following replantation of a total right hand amputation at 1 and 2 years after replantation, and provide recommendations for postoperative management. Materials and Methods  Replantation of the entire right hand in zone-4 was performed and supported by rigid external fixation spanning the forearm and hand. An early active "place-and-hold" motion protocol was initiated within the first 3 postoperative days. Metacarpophalangeal joint extensors were tethered by the pins, limiting full excursion. This resulted in stiffness and extensor adhesions that required a staged extensor tenolysis; however, all joints remained supple. The early motion protocol prevented the need for significant flexor tenolysis and joint releases. Results  Early motion rehabilitation protocols can produce very successful results in complex replantation. The enhanced stability afforded by external fixation of the wrist allowed us to perform aggressive early rehabilitation. Conclusion  This case highlights the benefits of early active motion (limiting the need for complex joint and flexor tendon releases) and demonstrates the degree of extensor adhesions caused by even minor extensor tendon tethering. This aggressive rehabilitation approach can produce excellent range of motion, and likely limit the need for secondary tenolysis and joint release procedures.

Revascularization and Replantation in the Hand: Ectopic Banking and Replantation

Traumatic amputation of the upper extremity remains a challenging problem for reconstructive hand surgeons. Temporary ectopic banking of amputated parts for subsequent replantation is an innovative and valuable surgical technique for patients who would otherwise be poor candidates for replantation. The applications of ectopic banking have evolved and expanded to include various clinical scenarios. Although there is considerable variability within the literature, this article summarizes the optimal banking locations and duration, while also highlighting several treatment considerations when performing this technique.

Systematic review: Predicting adverse psychological outcomes after hand trauma

STUDY DESIGN

Systematic review.

INTRODUCTION AND PURPOSE OF THE STUDY

After traumatic hand injury, extensive physical and psychological adaptation is required following surgical reconstruction. Recovery from injury can understandably be emotionally challenging, which may result in impaired quality of life and delayed physical recovery. However, the evidence base for identifying high-risk patients is limited.

METHODS

A PROSPERO-registered literature search of MEDLINE (1946-present), EMBASE (1980-present), PsychInfo, and CINAHL electronic databases identified 5156 results for studies reporting psychological outcomes after acute hand trauma. Subsequent review and selection by 2 independent reviewers identified 19 studies for inclusion. These were poor quality level 2 prognostic studies, cross sectional or cohort in design, and varied widely in methodology, sample sizes, diagnostic methods, and cutoff values used to identify psychological symptoms. Data regarding symptoms, predisposing factors, and questionnaires used to identify them were extracted and analyzed.

RESULTS

Patients with amputations or a tendency to catastrophize suffered highest pain ratings. Persisting symptom presence at 3 months was the best predictor of chronicity. Many different questionnaires were used for symptom detection, but none had been specifically validated in a hand trauma population of patients. Few studies assessed the ability of selection tools to predict patients at high risk of developing adverse psychological outcomes.

DISCUSSION AND CONCLUSION

Despite a limited evidence base, screening at 3 months may detect post-traumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes.

LEVEL OF EVIDENCE

Level 4.

Contribution of patient-advisors during rehabilitation for replantation of digits improves patient-reported functional outcomes: A presentation of concept

Clinical approach to surgical patients has evolved to include previous patients as part of the treating team in the role of "patient-advisors". Knowing that compliance to rehabilitation protocols is significant for a successful functional hand replantation, we set out to quantify functional patient-reported outcomes in individuals enrolled in a Patient-Advisor Program (PAP). We performed a prospective cohort pilot study of all patients admitted for a finger replantation between July 2015 to January 2016. All patients were offered to partake in the PAP, or else they would constitute the control group. Primary endpoints were functional outcomes as reported by patients at 6-8weeks and 4-6months of follow-up. Secondary endpoints were patient-reported pain and quality of life questionnaires. In total, 62 patients were admitted for finger replantation in the studied period, in which 50 agreed to participate in the study, including 7 in the patient-advisors group and 43 in the control group. Patients from the patient-advisors group fared better on mean scores of the Disabilities of the Arm, Shoulder and Hand than controls (29.6 vs 34.8 respectively at 4-6months). Improvements in the McGill Pain Questionnaire were also greater in the studied group (19.9 vs 33.3 at 4-6months). Replantation patients benefiting from the PAP demonstrated superior functional outcomes on self-reported questionnaires, which could be explained by a better understanding of rehabilitation protocols and compliance when previous patients are active members of the treating team.

Case report and literature review of the outcome following reimplantation of the arm

The following case report and literature review will detail the management of a traumatic amputation of the arm in a 12-year-old boy. Compared with lower limbs, upper limb prosthesis usually results in significant suboptimal function by any measure. While the literature lacks high-quality evidence with regard to functional outcomes following proximal amputations of the upper limb, especially in children, it is known that children generally have superior functional outcomes compared with their adult counterparts. The mechanism of injury, transportation of the amputated part, type of ischemia, timing of surgery, surgical techniques/factors and postoperative rehabilitation will be discussed as factors affecting outcome of reimplantation.

LEVEL OF EVIDENCE

V.

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation

BACKGROUND

After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.

METHODS

At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.

RESULTS

Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08).

CONCLUSIONS

Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.

Elective amputation and bionic substitution restore functional hand use after critical soft tissue injuries

Critical soft tissue injuries may lead to a non-functional and insensate limb. In these cases standard reconstructive techniques will not suffice to provide a useful outcome, and solutions outside the biological arena must be considered and offered to these patients. We propose a concept which, after all reconstructive options have been exhausted, involves an elective amputation along with a bionic substitution, implementing an actuated prosthetic hand via a structured tech-neuro-rehabilitation program. Here, three patients are presented in whom this concept has been successfully applied after mutilating hand injuries. Clinical tests conducted before, during and after the procedure, evaluating both functional and psychometric parameters, document the benefits of this approach. Additionally, in one of the patients, we show the possibility of implementing a highly functional and natural control of an advanced prosthesis providing both proportional and simultaneous movements of the wrist and hand for completing tasks of daily living with substantially less compensatory movements compared to the traditional systems. It is concluded that the proposed procedure is a viable solution for re-gaining highly functional hand use following critical soft tissue injuries when existing surgical measures fail. Our results are clinically applicable and can be extended to institutions with similar resources.