Replantation of amputation at the wrist: challenges of management in sub-Saharan Africa

Abstract

Amputations of the upper limb, in particular, have a major impact on patients’ lives, as loss of function can not only cause reduced autonomy in daily life but also hinder social interactions and capacity for work. Replantation at or proximal to the wrist, referred to as wrist-proximal replantation, remains a daunting challenge that presents the hand surgeon with an array of difficulties distinct from digital replantation. We present our experience with a successful replantation of a near-complete amputation at the non-dominant left wrist in a 25-year-old man managed in sub-Saharan Africa. Two years after replantation, the patient had a Disabilities of the Arm, Shoulder and Hand score of 40 and 2-point discrimination of 6 mm. We also discuss the peculiar challenges which have limited the development of replantation in the tropics. Environmental temperatures, manpower, expertise and technology are possible factors that limit this practice in the tropics.

Background

The first successful upper limb replantation was reported in 1962,^1–3 since then techniques for upper limb replantation have been refined. The continued need for limb replantation is attributable to the fact that limb amputations have significant emotional, social and functional limitations.^{4 5} Amputations of the upper limb, in particular, have a major impact on patients’ lives, as loss of function can not only cause reduced autonomy in daily life but also hinder social interactions and capacity for work.⁴ Comparatively, lesions of the hand are more psychologically upsetting than lesions of the face. This underscores the need for the hand surgeon to replant amputated limbs within the limited window and with acceptable cosmetic and functional outcomes.⁶ Replantation at or proximal to the wrist, referred to as wrist-proximal replantation, remains a daunting challenge that presents the hand surgeon with an array of difficulties distinct from digital replantation.²

Viability of limb remains a key factor determining the outcome of replantation. Hence, efforts should be made to revascularise the amputated wrist within time limits. Half a century of collective experience in replantation and microvascular surgery has provided today’s hand surgeons with enough evidence to guide the decision-making process.⁷ While expertise in this surgery was hitherto believed to have been distributed worldwide,^{2 8} sub-Saharan Africa is only beginning to develop capacity in microvascular surgery.⁹ Environmental expertise and technical challenges peculiar to sub-Saharan Africa may affect the successful management of such cases in tropical Africa.

We aim at reporting a successful replantation of amputation at the wrist and discussing the peculiar challenges that negatively affect the management of such cases in sub-Saharan Africa.

Case presentation

A 25-year-old right-handed man presented to the emergency department with near-complete amputation at the left wrist. His left upper limb had been caught within a rotating machine while working at a mill. He was first seen at the farm’s clinic where the dismembered limb was suspended on a sling. The patient subsequently presented to a primary care physician where he was resuscitated and advised to accept a refashioning of the stump. He was subsequently referred to the tertiary hospital. The interval from accident to the presentation at the tertiary hospital was 8 hours. It was not possible to immediately operate on the patient in the tertiary hospital because of access to the theatre where microvascular surgery could be done. Hence, the surgical team moved with the patient to a nearby reference hospital for emergency replantation.

Treatment

The patient had a replantation done under general anaesthesia. This surgery was undertaken by a vascular surgeon. The interval from injury to initial operation was 10 hours. Intraoperatively, we found a near amputation with a 3 cm intervening segment consisting of skin and subcutaneous tissue on the anteromedial aspect of the wrist. The dismembered hand was cold, dusky and had no evidence of capillary refill. The wound was an avulsion injury at the wrist with the distal radius and ulnar proximally and the carpal bones distally (see figure 1 and video 1).

Figure 1.

Showing near-complete amputation and a flap of skin.

Video 1.

Download video file ^{(8.5MB, mp4)}

DOI: 10.1136/bcr-2020-238393.video01

After debridement, the transected ends of the radial artery, as well as the flexor and extensor tendons, could be identified. The pulsation of the ulnar artery was not palpable. The 3 cm intervening skin and subcutaneous tissue were not explored. This was aimed at preserving any d flow therein. There was a 2 cm segment of the proximal radial artery having a corkscrew appearance. This appearance persisted despite direct application of papaverine. This segment was resected as it was indicative of avulsion injury to the vessel. There was active bleeding from the proximal segment following this resection. Additional length was gained from the proximal segment following mobilisation of the radial artery. The distal radial artery (figure 2) was embolectomised using Forgarty’s catheter and flushed with heparinised saline. The radial artery was repaired primarily with polypropylene 6/0 sutures aided by a ×3 operating loupe. The venous anastomosis was delayed for 5 min following arterial revascularisation.

Figure 2.

Showing distal radial artery.

This allowed for controlled bloodletting to prevent reperfusion injury. During this time, epineural reapposition of the ulnar, radial and median nerves was done. Embolectomy of the veins was also done. Intravenous hydration and mannitol were commenced. Then we proceeded to do a carpal tunnel release to avoid compartment syndrome. Tendons were tagged. The wrist joint was rearticulated and the joint capsule reconstructed. The skin was closed primarily (figure 3) and the construct was held in place by a volar slab in a position of function. We did not have negative pressure wound therapy hence we adopted strict elevation of the hand on a pillow. Anticoagulation was done with low molecular weight heparin 40 mg daily as prophylaxis for anastomotic thrombosis.

Figure 3.

Showing immediate postoperative replantation.

The patient had a secondary reconstruction of tendons done 48 hours after the initial surgery. End-to-end repair of repair tendons was achieved by modified Kessler’s technique. The hand was held in the position of function and stabilised with a plaster of Paris cast.

Outcome and follow-up

He had an uneventful postoperative period with maintained viability of the hand. He received rehabilitative care by commencing with passive then progressed to active hand exercises. On follow-up (see figure 4), he had good sensitivity of the hand and preserved prehensibility. A radiograph which was done 6 months after replantation (figure 5) showed the condition of the wrist. Two years after trauma (see figure 6), he had a Disabilities of the Arm, Shoulder and Hand score of 40 and 2-point discrimination of 6 mm. The patient was very satisfied with the outcome of the surgery.

Figure 4.

Early postoperative follow-up.

Figure 5.

Radiograph of the limb done 6 months after replantation.

Figure 6.

Long-term outcome at 2 years.

Discussion

Limb amputation results not only in the loss of physical integrity but also affects an individual’s psychological, mental and social well-being. The success rate for replantation surgery following upper extremity amputation is reported to be 77%–93%.^{4 10} Despite the significant progress of modern prosthetic devices, high prosthesis rejection rates are still observed in most traumatic amputation patients.^{4 5} Hence, limb replantation is still believed to be superior to an amputation stump fitted with an appropriate prosthesis.¹¹

Wrist proximal amputations² are peculiar because, compared with digital amputations, they involve ischaemia of muscle and require surgical repair of several vascular, neural and musculotendinous structures, with a higher risk of systemic reperfusion injury. The ischaemic tolerance of dismembered upper limbs is variously discussed. Recommendations range from a warm ischaemia time of 8–12 hours for digits and 4–6 hours for major/wrist proximal amputation.^{1 2} However, successful replantation has been reported after ischaemia times of up to 30–40 hours.^{12 13} These were case reports of digital replantation. This prolonged ischaemic time is made possible by the ability of the digit, devoid of muscle, to withstand ischaemia, especially in hypothermic conditions. The warm ischaemic time for wrist proximal amputations is estimated to be 4–6 hours.^{1 10} This ischaemic time may be prolonged by cooling to 10–12 hours.² This prolongation of viability with cooling may be explained by the fact that alteration of temperature causes a change in the reaction rate of all biochemical processes, especially enzymatic reactions. This temperature dependence of reaction rates has been described by the concept of Q10, which is defined as the doubling or halving in metabolic reaction rates with an increase or decrease of temperature by 10°C.¹⁴

This temperature effect on viability is further compounded by the finding that some biochemical processes, especially those localised to cell membranes, show an abrupt change in reaction rates at certain critical temperatures. This has been termed a phase transition and is thought to be the result of a change in the cell membrane from a fluid to a gel state.¹⁵ In mammalian tissues, phase transitions often occur at approximately 25°C–28°C and may disturb cell homeostasis.¹⁴ This is the average room temperature in sub-Saharan Africa. It can be argued that as the limb is amputated, it loses continuous blood supply and hence loses homeothermy. The temperature of the amputated limb drops from the body temperature (36°C) towards the temperature of the environment. In sub-Saharan Africa with an average atmospheric temperature of 26°C, in the absence of cooling, the temperature of the amputated part drops by 10°C, passes through the phase transition and has only a 50% reduction in metabolic reaction rate. We argue that transporting the amputated limb in the tropical environment is precarious because it is transported close to the phase transition temperatures. In contrast, transporting the amputated part in a temperate environment even without the application of ice gives better protection.

In patients with incomplete amputations, it is impracticable to achieve uniform cooling in the presence of collateral blood flow. We argue that the benefit of the collateral circulation outweighs the benefit of cooling and that both should not be used together. Replantation has been noted to be twice as costly as amputation.¹⁶ Most of the cost of replantation is attributable to the cost of rehabilitation and the cost of exemption from work. It is recommended that amputations that would result in more than 15% impairment of the hand would benefit from replantation.¹⁷ Even though these statistics were generated from developed economies, they inform decisions in tropical Africa where the majority of health costs are paid out of pocket, costs of surgeries are lower and there is barely any social compensation for disability. We argue that the economic productivity and social satisfaction following upper limb replantation, particularly wrist proximal replantation, far outweigh the cost of the procedure in tropical Africa. The submission that replantation is valuable not only to the patient but also to the society as well, in terms of cost¹ is particularly valid in sub-Saharan Africa where there is barely any disability compensation. Since the first successful arm replantation by Malt and McKhann in 1962, a lot of experience has been documented on upper extremity replantation surgery techniques. Despite the opinion of worldwide distribution of expertise,^{2 8} skill in this surgery is poorly developed in sub-Saharan Africa. This lack of expertise is a consequence of, and results in, a low rate of replantation surgery done in the region. The prospect of a good cosmetic and functional outcome, as well as the poor availability and the high rejection rate of prosthesis,¹¹ should drive the need for reconstructive surgery.

Half a century of collective experience in replantation and microvascular surgery has provided today’s hand surgeons with enough evidence to guide the decision-making process.⁷ While expertise in this surgery was hitherto believed to have been distributed worldwide,^{2 8} sub-Saharan Africa is only beginning to develop capacity in microvascular surgery.⁹ With a little over 100 plastic/reconstructive surgeons and about 50 vascular surgeons serving a population of 200 million Nigerians, the odds that a patient with an amputated limb would be attended to by a surgeon capable of replanting the limb successfully within the recommended time frame are low. These patients are attended to by a multidisciplinary team consisting of vascular surgeons (whose training background is cardiothoracic/vascular surgery) and reconstructive surgeons (whose training background is burns/plastic surgery).

This is a far cry from the ideal situation where these patients are attended to by an experienced emergency hand surgeon. It is recommended that replantation needed to be done in centres equipped to accommodate its demands and that patients should be evaluated by experienced surgeons.⁶

The situation in tropical Africa where most of these patients present initially to non-specialists who are more likely to do stump refashioning instead of replantation is inimical to skill acquisition. Pecuniary interests may affect referrals for specialist care. The availability of technology necessary for microvascular surgery is also a limiting factor. Most patients, including our index case, are beyond the recommended golden period by the time of presentation to specialists. This delay results mostly from travel time.

Earlier opinions argue that revascularisation beyond the golden hour is still desirable as it will help to prevent limb loss¹⁸ and that limb viability rates following upper extremity replantation have been reported to be as high as 80%–94%.¹⁹ These facts should go a long way to support replantation in borderline patients which are the norm in our environment.

The success of replantation in selected cases is given, hence we encourage the tropical surgeons to dare despite obvious challenges. The training programmes should be unbound to encourage specialisation. Sequel to the scarcity of subspecialty surgeons, general surgeons should be trained in emergency revascularisation. Adoption of air ambulance systems would obviate the delay due to travel time. Provision of technological support for microvascular surgery should be made. Surgeons should be motivated for undertaking replantation. We argue for a paradigm shift from the present norm of stump refashioning for amputated limbs in the tropics to routine replantation. This can be achieved by expediting referral, reorganising training programmes and encouraging occasional surgeons to venture.

Patient’s perspective.

This accident was the most gruesome event in my life. I was working in the farm when my left hand had been trapped in a fast-moving machine and my hand got ripped at the wrist. When I got to the clinic in our farm, I was told that I had lost the hand. There I had my hand tied to my neck and I was transferred a private health facility where I was almost convinced to accept that the hand be completely cut off and the wound closed. This was too much for me to accept too soon. So, I asked that I be given time to think about it. The doctor working in our farm clinic suggested that we should travel to the city while I make up my mind. There was quite some back and forth at the city hospital. However, when the doctor spoke to me about my chances, I told him that I was going to take, even the slimmest chance at joining my hand and that in the event of failure, I would not hold it against them. I am extremely satisfied with the outcome of the surgery and would recommend replantation to anyone who seeks my opinion.

Learning points.

• Wrist proximal amputations are peculiar because, compared with digital amputations, they involve ischaemia of muscle and require surgical repair of several vascular, neural and musculotendinous structures, with a higher risk of systemic reperfusion injury.

• In sub-Saharan Africa with an average atmospheric temperature of 26°C, in the absence of cooling, the temperature of the amputated part drops by 10°C, passes through the phase transition and has only a 50% reduction in metabolic reaction rate. This compromises viability.

• The lack of expertise in replantation in the tropics is a consequence of, and results in, a low rate of replantation surgery done in the region. The occasional surgeon is encouraged to dare.