Invited Discussion

“Difficulties are opportunities!” Albert Einstein

This case report of an unfortunate 15-year-old suicidal youngster illustrates the instinct of the microsurgeon to save all potential spare parts until the last possible minute. Who can forget Marko Godina's patient, whose wrist and hand were banked orthotopically in the axilla (splint and all) prior to return to the distal portion of a crushed forearm? This case dramatically ushered in the wave of ectopic, temporary reattachment of amputated parts, which could then be used for functional reconstruction of the damaged upper limb(s). In this boy, the parts of the crushed hands were not useable; the left foot was attached to the right leg at the ankle level, and a primary closure performed on the left BK amputation stump. Open wounds were wisely covered with skin grafts. Secondary reconstruction was then performed when the patient was completely stabilized and healthy. Several points are worth emphasis.

Surgeon experience Late night, early morning, holiday and weekend call often lands in the lap of the most junior faculty member, the hand/microvascular fellow, or the senior orthopedic or plastic surgical resident, all of whom may not have much experience with secondary hand reconstruction. It is crucial that the more experienced hand surgeon(s) on the faculty or within the community make themselves available for either consultation or participation whenever opportunities for orthotopic reattachment arise. A simple phone call by the treating surgeon to a colleague can make a tremendous difference. Older, experienced microsurgeons, who understandably have drifted away from this demanding and labor-intensive work, can and should be a tremendous resource for both decision-making and provision of technical expertise. Often, the senior surgeon may think of a useful application for an intact portion of the amputation specimen, which would either be discarded initially or, as illustrated in this case, ultimately lost in a failed reattachment effort. Figure 1 illustrates a case in which an intact digit remained in the amputated portion of an extremity severed as a result of a crush/avulsion injury. This intact digit was reattached on the radial side of the distal forearm, specifically to motor a myoelectric prosthesis and to provide a rudimentary pinch mechanism. Figure 1 Digit salvage. (A) The postoperative appearance of a young female whose hands had been amputated at the middle third of the right and distal third of the left forearm. A massive crush/avulsion injury made hand reattachment impossible. However, at the time of injury, an intact digit from the right hand was reattached on the radial side of the left radius, and primary closure of the forearm performed. The more proximal right forearm injury was initially debrided and closed with local tissue. The radiograph of the left forearm shows the insertion of the metacarpal on the radial side of the forearm. (B, C) The motion of this radial digit was effective in triggering her myoelectric prosthesis. Initial injury One unusual aspect of this particular case is that there were no other devastating associated injuries sustained when the train ran over all four extremities. Once the initial resuscitation for hypovolemia and shock had been completed, this young, healthy patient was an excellent candidate for reattachment surgery under tourniquet control. Often, an associated liver or spleen laceration, a bowel disruption, a pneumothorax, or serious head injury eliminates the opportunity to reattach amputated parts. Young patients, especially, will rebound very quickly from fluid resuscitation and tolerate a long procedure under a combined regional block and intravenous sedation. In this case report, it was the temporary reattachment of the left foot at the level of the right ankle. However, nothing is lost if the amputated part is properly cleansed, wrapped, and maintained in a cold water bath for 12 to 24 hr, at which time the patient may be reassessed for a possible transplantation effort. (Fig. 2) Figure 2 Spare parts transplantation. (A) The right hand of a young college student is seen following a near lethal accident with a subway car. The hand was simply debrided under anesthesia after the general surgeons performed a laparotomy for liver, spleen, and intestional lacerations, the urologists repaired a ruptured bladder, the neurosurgeons completed a craniotomy for intracranial bleeding, and the orthopedists placed an external fixation device on a fractured right leg. (B) The left leg, amputated at the mid thigh level, is seen on the back table. It was wrapped and placed in an ice bath and stored in the OR overnight. (C) After the patient had been resuscitated and was stable on a ventilator in the critical care unit, a revascularization procedure was performed under wrist block in the ICU. The dorsal skin from the foot supplied by the dorsalis pedis pedicle and several large dorsal veins were harvested and prepared in the operating room and then taken to the ICU, where two surgeons anastomosed six vessels, three veins, and three nerves without difficulty. The degloved dorsum of the hand was covered with a thick STSG. (D) The flap and two remaining digits are well-preserved. (E) The same hand is seen 1 year later prior to syndactyly release between the two digits and multiple Z-plasties within the first web space. Electrolysis was used to eliminate the troublesome hair follicles. Static two-point discrimination in both digits was 7.0 mm. The thumb digital nerves were initially intact. In older people with associated diseases and morbidity, attempts to salvage amputated parts can be very dangerous and are often not warranted. In our experience, middle-aged and elderly patients with a previous history of peripheral vascular disease, cardiac dysfunction, pulmonary disease, and chronic diseases such as diabetes mellitus or collagen vascular diseases, carry a markedly increased chance of developing an intraoperative or postoperative complication which may become as serious as the traumatic amputation itself. In addition, adequate sensory return to the reattached part becomes another critical consideration. Double toe transfer The “basic hand” consists of a mobile ray on the radial side, a stable post on the ulnar side, and an intervening web space. Fortunately, both thumbs were not injured. The ulnar post of the right hand consisted of a double toe transfer from the left foot. This is one of the few instances in which large dorsal and plantar flaps are transferred with the toes. In normal toe-to-hand transfers, it is wise to keep this tissue on the foot, where open skin-grafted regions are not tolerated as well as on the hand. In this case, it is unfortunate that the remaining portions of the foot could not be utilized. However, the osteocutaneous fibular flap did provide s stable post covered with full-thickness, sensate skin. In the future, unstable, floppy skin may require some debulking and firm fixation with deep dermal-to-periosteal sutures. Amputees Both plastic and orthopedic surgeons receive very little training in the use of prosthetics for the lower and upper limb. Those of us who have had the opportunity to serve the US military as orthopedic surgeons during the past 34 to 40 years can readily appreciate how well young, healthy men tolerate unilateral and, to a lesser extent, bilateral below-knee amputations. Recent feature articles on those amputees presently serving in Iraq and Afghanistan serve to underscore this point. Most prosthetists would argue that it would be a lot easier to fit a below-knee stump with adequate length than a short limb with the opposite foot attached distally. Psychiatric evaluation No one involved in this patient's care should fail to recognize that this boy's major problem lies north of his clavicles. His most significant problem is not physical, and this malady should be treated as aggressively and creatively as necessary and possible.