Late hand replantation with restoration of intrinsic muscle function: a case and review of the literature

  • Luke Watson
  • Henry Beem
  • Kieran Rowe
  • Shireen Senewiratne
Case Report


Limb amputation injuries and their subsequent replantation is a time-critical exercise if function is to be restored. The exact time limit to functional replantation is still poorly defined in the literature owing to the multitude of factors that influence functional recovery. The relative metabolic activity of a tissue is lower under hypothermic conditions, and subsequently, moderate delays in restoring circulation can still achieve good functional outcomes if the amputated part is transported appropriately. Some surgeons have adopted the practice of, in cases where the delay to replantation is beyond 8–10 h, resecting skeletal muscle from the amputated part to avoid the sequelae of its ischaemic period. We report the case of a traumatic trans-carpal hand amputation in a 40-year-old male, with a second-level injury more distally at the metacarpal heads, who was replanted with a total ischaemic time of 19 h and 25 min. The decision was made to retain his intrinsic hand muscles in contradiction to common practice. At 2.5 years follow-up, he has regained a remarkable level of function of his hand including activation of his intrinsic hand muscles. His Semmes Weinstein testing has also shown good sensory recovery of his repaired nerves and he enjoys little, if any, disability as a result of his injury (despite a double-level injury on the dorsal ulna aspect of his forearm). This suggests, in cases of hand amputation with appropriate hypothermic transportation of the amputated part, ischaemia times up to 20 h may be compatible with restoration of intrinsic hand function.

Level of Evidence: Level V, risk / prognostic study.


Hand replantation Amputation Upper limb Intrinsic muscles 


Compliance with ethical standards

Conflict of interest

Luke Watson, Henry Beem, Kieran Rowe and Shireen Senewiratne declare that they have no conflict of interest.

Ethical approval

Formal human research ethics committee approval is not required for this type of unit auditing.

Patient consent

Written consent was obtained from the patient to include her clinical information and clinical photographs and images in this study.



Supplementary material (167.4 mb)
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  1. 1.
    Kaye AR, Sheena Y, Chester DL (2015) Results of upper limb digital and hand replant and revascularisation at a UK Hand Centre. Eur J Plast Surg 38(2):127–132CrossRefGoogle Scholar
  2. 2.
    Kleinert JM, Graham B (1990) Macroreplantation: an overview. Microsurgery 11(3):229–233CrossRefPubMedGoogle Scholar
  3. 3.
    VanderWilde RS, Wood MB, Zu ZG (1992) Hand replantation after 54 hours of cold ischemia: a case report. J Hand Surg Am 17(2):217–220CrossRefPubMedGoogle Scholar
  4. 4.
    Woo SH, Cheon HJ, Kim YW, Kang DH, Nam HJ (2015) Delayed and suspended replantation for complete amputation of digits and hands. J Hand Surg Am. 40(5):883–889CrossRefPubMedGoogle Scholar
  5. 5.
    Vanstraelen P, Papini RP, Sykes PJ, Milling MA (1993) The functional results of hand replantation. The Chepstow experience J Hand Surg Br 18(5):556–564CrossRefPubMedGoogle Scholar
  6. 6.
    Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29(6):602–608Google Scholar
  7. 7.
    Hoang NT (2006) Hand replantations following complete amputations at the wrist joint: first experiences in Hanoi, Vietnam. J Hand Surg Br 31(1):9–17CrossRefPubMedGoogle Scholar
  8. 8.
    Russell RC, O’Brien BM, Morrison WA, Pamamull G, MacLeod A (1984) The late functional results of upper limb revascularization and replantation. J Hand Surg Am. 9(5):623–633CrossRefPubMedGoogle Scholar
  9. 9.
    Mahajan RK, Mittal S (2013) Functional outcome of patients undergoing replantation of hand at wrist level—7 year experience. Indian J Plast Surg 46(3):555–560CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Levinson H, Garcia RM, Miller KJ, Levin LS (2014) Major hand replantation after an extended search for the missing part. Current Orthopaedic Practice 25(3):302–304CrossRefGoogle Scholar
  11. 11.
    Chen ZW, Yu HL (1987) Current procedures in China on replantation of severed limbs and digits. Clin Orthop Relat Res 215:15–23Google Scholar
  12. 12.
    Sabapathy SR, Venkatramani H, Bharathi RR, Dheenadhayalan J, Bhat VR, Rajasekaran S (2007) Technical considerations and functional outcome of 22 major replantations (the BSSH Douglas Lamb Lecture, 2005). J Hand Surg Eur Vol 32(5):488–501CrossRefPubMedGoogle Scholar
  13. 13.
    Brunelli G, Vigasio A, Brunelli F (1985) Muscular elementarization in the “borderline” replantation and revascularization of the forearm. Ann Chir Main 4(4):337–339CrossRefPubMedGoogle Scholar
  14. 14.
    Sturm SM, Oxley SB, Van Zant RS. Rehabilitation of a patient following hand replantation after near-complete distal forearm amputation. J Hand Ther 2014;27(3):217–223; quiz 24Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Plastic and Reconstructive SurgeryRoyal Brisbane and Women’s Hospital (RBWH)HerstonAustralia

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