|Year : 2021 | Volume
| Issue : 4 | Page : 198-200
Rehabilitation after forearm/hand replantation
Susana Rosa1, Margarida Freitas2, Afonso Pegado2, Diogo Martins1, Mário Moura1
1 Physical and Rehabilitation Medicine Department, Central Lisbon University Hospital Centre, Lisbon, Portugal
2 Physical and Rehabilitation Medicine Department, Garcia de Orta Hospital, Almada, Portugal
|Date of Submission||20-Jan-2021|
|Date of Decision||29-Mar-2021|
|Date of Acceptance||10-May-2021|
|Date of Web Publication||18-Nov-2021|
Dr. Susana Rosa
Physical and Rehabilitation Medicine Department, Central Lisbon University Hospital Centre, Beneficencia Street no 8, 1069-166 Lisbon
Source of Support: None, Conflict of Interest: None
Currently, the challenge of replantation of the upper limb after amputation has become an achievable and meticulously perfected reality in recent decades and is in constant evolution. The surgical option for replantation should take into account not only a comprehensive analysis of the viability of the replantation but fundamentally its potential for long-term functional recovery. We present the clinical case of a 40-year-old man, victim of a work accident, with cut trauma, which resulted in distal amputation of his right forearm. The warm ischemia time was 5 h, having been submitted to joint replantation surgery. Following the surgery, physical medicine and rehabilitation (PMR) was referred early, carrying out a sequential functional rehabilitation program. This work aims to emphasize the importance of the role of PMR in an early, careful, and extensive rehabilitation program, a fundamental factor in the functional recovery and long-term prognosis of these injuries and prevention of complications.
Keywords: Amputation, forearm, hand, rehabilitation, replantation
|How to cite this article:|
Rosa S, Freitas M, Pegado A, Martins D, Moura M. Rehabilitation after forearm/hand replantation. J Int Soc Phys Rehabil Med 2021;4:198-200
|How to cite this URL:|
Rosa S, Freitas M, Pegado A, Martins D, Moura M. Rehabilitation after forearm/hand replantation. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2022 May 22];4:198-200. Available from: https://www.jisprm.org/text.asp?2021/4/4/198/330659
| Introduction|| |
Replantation is defined as a surgical procedure of reconstruction of neurovascular and musculoskeletal structures, seeking the recovery of an amputee segment of the body. Traumatic limb amputation is a catastrophic injury, which is sudden and emotionally devastating for the victims. Although a number of major traumatic amputations have been declining over the years as a result of continuous progress in occupational safety activities, major amputations of upper extremities are reported to have an average prevalence of 11.6/100.000 individuals in Europe. Nowadays, the challenge of upper-limb replantation after amputation became an achievable reality, thoroughly improved in the last decades and in constant evolution. The surgical option for replantation should take into account not only the patient-tailored analysis of the feasibility of replantation but especially the potential of long-term hand functional recovery.
Survival of the replanted extremity is the most common parameter for which the success or failure of this procedure has been evaluated. It has been reported to be between 80% and 94%., However, this outcome measure only indicates that the replanted limb is viable at the follow-up visit. More useful outcome measures are those assessing the functional outcome of the surgery such as Chen's criteria, the ability to resume work, range of motion relative to normal, sensibility, and power. Ideal assessments are those that include patient-reported quality of life, as well as functional outcomes.
When a surgeon is considering whether or not to perform a replantation surgery, the patients' age and general health, the total of time of ischemia, and the level, type, and extent of tissue damage need to be taken into consideration. Traditionally, up to 6-h warm ischemia or 12-h cold ischemia is the limit when considering replantation. One recommended criterion for replantation is that the outcome of surgery should yield a level of function higher than that possible with the use of a prosthesis. Some authors use Chen's Scoring System [Table 1] to follow up the functional recovery after replantation. In Chen's system, the results are classified into four grades. Complications of replantation include bone nonunion, bone infection, skin and muscle necrosis, and bleeding.
|Table 1: Chen's Scoring System for evaluation of functional outcome after replantation of amputated extremity|
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| Case Report|| |
The authors report a case of a healthy 40-year-old man, left-handed, metalworker. The patient was asked to carefully read and sign an informed consent. Researchers ensured data confidentiality. He suffered a clean-cut traumatic amputation of the right distal forearm/hand, while working, and was quickly transferred from a tertiary-care hospital. Warm ischemia time was 5 h, he was operated on by a multidisciplinary team of orthopedic and plastic and reconstructive surgeons, with successful replantation. One week after, the patient was reoperated due to an infectious intercurrence of the skin flap [Figure 1].
|Figure 1: Images of the right upper-limb extremity. (a)The right hand. (b) Three days after replantation. (c)Five days after replantation. (d) Seven days after replantation, before being reoperated.|
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Subsequently, he was referred to physical medicine and rehabilitation, to perform a sequential program of rehabilitation.
The patient had generalized edema of the entire replanted hand. The surgical scars had no inflammatory signs but were in an early stage of healing. He referred moderate pain in the scar and wrist area, hypoesthesia of the whole hand, and paresthesia on the palmar side. He presented active wrist flexion movements, with a range of motion of 0°–10° and flexion of the fingers with a range of motion of 0°–20° of the metacarpal-phalangeal joints. The overall muscle strength was Grade I according to the Medical Research Council (MRC) scale.
A custom palmar wrist hand protective orthosis was fabricated, which included the metacarpophalangeal (MTC-P) joints. The orthosis positioned the forearm and wrist in neutral position, the MTC-P joints in 50° flexion, and interphalangeal joints in 20° flexion. The patient was instructed to elevate the right arm above the elbow for edema control.
Hand therapy began 10 days post replantation surgery [Figure 2].
|Figure 2: Images of the custom palmar wrist hard orthosis (a) The right hand. (b) Three days after replantation. (c) Five days after replantation. (d) Seven days after replantation, before being reoperated|
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The patient participated in an intense course of hand therapy consisting of:
- First phase (1–4 weeks): Positioning, raising hand above the elbow for edema reduction, wound care, soft massage, exercises to improve active range of motion of the left upper limb and right shoulder, and elbow. The patient was also instructed to start compensatory techniques with the right upper limb to assist in activities of daily living. He wore a forearm-palmar splint to prevent fingers and wrist flexion contractures between therapy sessions
- Second phase (5–12 weeks): Desensitizing and scar massage, exercises to improve passive range of motion of his right fingers, thumb, and wrist. He also started hydromassage. Finally, he started muscle-strengthening exercises with light load of the right forearm, wrist, and fingers
- Third phase (13–35 week): Phase 2 exercises, sensory reeducation, increase of load in muscle-strengthening exercises, and functional practice of daily living activities.
Around 8 months after the surgery, the patient was classified in Grade III using Chen's Scoring System, which means moderate but satisfactory and worthwhile function: He was able to carry on daily life, ROM exceeded 30% of normal, he recovered most of the sensitivity, and he had a global Grade III muscle strength (MRC scale) of the wrist, hand, and finger muscles.
All previous edema had regressed, and the patient denied pain at rest and during mobilization. Pain and vibratory sensation were similar to that of the contralateral hand. The thermal and tactile sensations were slightly decreased but improved from the initial assessment. Paresthesia of the palmar side of the hand got less intense. He could use the hand to grab a glass and to help in some daily living activities. At that time, the patient was highly satisfied with the result [Figure 3].
|Figure 3: Images of the right hand after forearm/hand replantation. (a) Active range of motion of the right hand 5 months after surgery. (b) Active range of motion of the right hand 8 months after surgery|
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| Discussion|| |
Replantation surgery of the upper limb may be considered for the arm, forearm, hand, and fingers. We must consider some factors, related to the patient and to the type of lesion, that may contraindicate this procedure. Primary contraindications include severe crush injuries, multilevel amputations, concomitant life-threatening injuries, patients unable to comply with rehabilitation program, and prolonged normothermic ischemia time (>6 h). Relative contraindications can be medically unstable patient, disabling psychiatric illness, and tissue contamination.,
Currently, there is no standard protocol for rehabilitation following replantation surgeries. There is no agreed-upon timeline for these interventions to occur; however, early mobilization beginning in the 1st week is considered essential for a positive outcome.,
The main aims of the rehabilitation program are to achieve a hand that can help carry, hold, and oppose the contralateral extremity. Furthermore, preventing limb deformities is another goal of rehabilitation treatment.
In this case, we present a healthy patient who suffered a clean cut of the nondominant distal forearm. The warm ischemia time was 5 h. He did not have an absolute contraindication and was truly motivated for surgery and all the rehabilitation processes. The patient has been fulfilling the rehabilitation program with good functional outcomes.
The main limitations of this clinical case are that only the Chen scale, physical examination, ROMs, and muscle strength have been measured. The team could have applied quality of life scales, pain assessment scales, or even a specific instrument to access the functionality of the replanted hand.
The development of surgical techniques associated to multidisciplinary teamwork, promotes better outcomes and decreases complication rate.
| Conclusion|| |
The aim of this work is to emphasize the importance of an early, thorough, and extensive rehabilitation program as a key of functional recovery and long-term good prognosis in hand replantation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ostlie K, Skjeldal O, Garfelt B, Magnus P. Adult acquired major upper limb amputation in Norway: Prevalence, demographic features and amputation specific features. A population-based survey. Disabil Rehabil 2011;33:1636-49.
Buncke HJ Jr. Microvascular hand surgery-transplants and replants-over the past 25 years. J Hand Surg Am 2000;25:415-28.
Gulgonen A, Ozer K. Long-term results of major upper extremity replantations. J Hand Surg Eur Vol 2012;37:225-32.
Battiston B, Tos P, Clemente A, Pontini I. Actualities in big segments replantation surgery. J Plast Reconstr Aesthet Surg 2007;60:849-55.
Chew WY, Tsai TM. Major upper limb replantation. Hand Clin 2001;17:395-410.
Atzei A, Pignatti M, Baldrighi C, Maranzano M, Cugola L. Long-term results of replantation of the proximal forearm following avulsion amputation. Microsurgery 2005;25:293-8.
Raimondi PL, Petrolati M, Delaria G. Replantation of large segments in children. Hand Clin 2000;16:547-61.
Prucz RB, Friedrich JB. Upper extremity replantation: Current concepts. Plast Reconstr Surg 2014;133:333-42.
Wolfe VM, Wang AA. Replantation of the upper extremity: Current concepts. J Am Acad Orthop Surg 2015;23:373-81.
Papanastasiou S. Rehabilitation of the replanted upper extremity. Plast Reconstr Surg 2002;109:978-81.
Chan SW, LaStayo P. Hand therapy management following mutilating hand injuries. Hand Clin 2003;19:133-48.
Scheker LR, Hodges A. Brace and rehabilitation after replantation and revascularization. Hand Clin 2001;17:473-80.
[Figure 1], [Figure 2], [Figure 3]