Reabilitação do polegar reimplantado: avaliação dos resultados funcionais em uma unidade de saúde no Rio de Janeiro / Rehabilitation of the replanted thumb: evaluation of functional results in a health unit in Rio de Janeiro

Introdução: O polegar é o dedo de maior importância funcional da mão, por isso a justificativa de reimplantação e reabilitação do mesmo. Objetivo: Realizar uma análise retrospectiva dos resultados, via revisão de prontuários de pacientes submetidos à reimplante de polegar, realizados pelo Serviço SOS-Reimplante do Hospital Estadual Adão Pereira Nunes. Metodologia: Trata-se de um estudo retrospectivo com amostra de conveniência, abrangendo o período entre janeiro de 2010 a dezembro de 2015, realizado através de prontuários de pacientes submetidos a processo de reimplante de polegar, atendidos no Serviço de Terapia Ocupacional/TO-Mão no Hospital estadual Adão Pereira Nunes, em Duque de Caxias, Rio de Janeiro. Foram coletadas informações sociodemográficas, além de força muscular, sensibilidade e tempo de reabilitação. Resultados: Foram revisados 63 prontuários de pacientes submetidos a procedimento de reimplante de polegar, na faixa etária de 18 a 65 anos. Quanto ao local do acidente, 76,1% dos casos foi decorrente de acidente de trabalho e 23,2% acidentes domésticos. Ao observamos à lateralidade da lesão, 92% dos pacientes eram destros, enquanto o polegar com maior número de lesões foi o esquerdo, com um total de 82,5% pacientes. Quanto ao nível da lesão, 25,3% pacientes sofreram lesão na falange proximal, 20,8% pacientes sofreram lesão na região da interfalangeana, e 53,9% dos pacientes apresentaram lesão na falange distal. Dentre os reencaminhados para nova avaliação, 28,5% pacientes, foram submetidos a outros procedimentos cirúrgicos. Houve ganho de força em global em 88,2% dos pacientes em de sensibilidade. Conclusão: A maioria dos pacientes que sofreram reimplante do polegar conseguiram obter ganho de força muscular e sensibilidade, conseguirem retornar as suas atividades laborais, com um tempo de reabilitação que variou de 4 a 14 meses. (AU)

Introduction: The thumb is the greatest functional finger of the hand, which is justifies its replantation and rehabilitation. Objective: To carry out a retrospective analysis of the medical records of patients undergoing thumb reimplantation, performed by the SOS-Reimplantation Service of the State Hospital Adão Pereira Nunes. Methodology: This is a retrospective study with a convenience sample, covering the period between January 2010 and December 2015, conducted thorough medical records of patients undergoing the process of thumb replantation, attended at the Occupational Therapy Service / TO - Hand at the Adão Pereira Nunes State Hospital, in Duque de Caxias, Rio de Janeiro. Sociodemographic information was collected, in addition to muscle strength, sensitivity, and rehabilitation time. Results: 63 medical records of patients who underwent thumb reimplantation procedure, aged 18 to 65 years, were reviewed. As for the accident site, 76.1% of the cases were due to occupational accidents and 23.2% to domestic accidents. When observing the laterality of the lesion, 92% of the patients were righthanded, while the thumb with the largest number of lesions was left, with a total of 82.5% patients. As for the level of the lesion, 25.3% of patients suffered an injury to the proximal phalanx, 20.8% of patients suffered an injury to the interphalangeal region, and 53.9% of the patients had lesions to the distal phalanx. Among those referred for further evaluation, 28.5% of patients underwent other surgical procedures. There was overall strength gain in 88.2% of patients in sensitivity. Conclusion: Most patients who underwent thumb reimplantation were able to obtain gains in muscle strength and sensitivity, being able to return to their work activities, with a rehabilitation time that varied from 4 to 14 months. (AU)

Effect of Health Care and Rehabilitation Nursing and Analysis of Neurovascular Preservation of Patients Undergoing Reconstruction of Severed Finger under X-ray Image Examination.

OBJECTIVE: The study aimed to provide a guideline for continuous rehabilitation nursing for patients with severe finger replantation, and establish a satellite contact point for patients with severe finger replantation after discharge, so as to ensure scientific and effective rehabilitation training after discharge and explore the role of continuous rehabilitation nursing measurement in severe finger rehabilitation and neurovascular preservation. METHODS: A total of 380 patients accepting neurovascular preservation finger replantation in the hand surgery department were divided into an observation group and a control group according to the number of hospitalizations. All patients underwent reconstructive surgery of severed finger. X-ray filming was used to monitor the postoperative nursing effect of neurovascular preservation of severed finger. The discharged patient information questionnaire was filled 3 days before the discharge. Then, a patient information database was established, and rehabilitation training was performed. Finally, sexual rehabilitation nursing follow-up intervention, telephone follow-up, and cross-referring intervention were carried out. Postoperative x-ray images were taken regularly to observe the recovery of reconstructed finger. RESULTS: There was no difference in daily life ability scores and hand function scores between the 2 groups at discharge (P > 0.05). The daily life ability scores and hand function scores of the observation group were better than those of the control group at 1 and 6 months after discharge (P < 0.05), the difference is statistically significant. As the discharge time prolonged, the daily life ability score and hand function score of the 2 groups of patients gradually increased. X-ray images showed that the replanted finger body was well developed, phalanx was in good antithesis, and there was no epiphysis. CONCLUSIONS: Continuous rehabilitation nursing measures should be taken after the replantation of the severed finger after neurovascular preservation, which provides standardized rehabilitation training standards for patients with replantation of severed finger after discharge, improves patient training compliance, promotes hand function recovery as soon as possible, and enables patients to return to society as soon as possible, which is worthy of clinical promotion and application.

Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study.

OBJECTIVE: The aim of this study was to determine the effects of age and body mass index (BMI) on the functional outcomes, satisfaction rates, and recovery time after open debridement and reattachment surgery in non-athletic patients with insertional Achilles tendinopathy (IAT). METHODS: In this retrospective study, 33 non-athletic patients (34 ankles) in whom open debridement and reattachment surgery was performed for IAT from 2006 to 2016 were included. Change in pain intensity was assessed using a Visual Analogue Scale (VAS) preoperatively and at the final follow-up. Functional assessment was done by preoperative and postoperative American Orthopaedics Foot and Ankle Score (AOFAS) and final follow-up Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A). Patient satisfaction was evaluated by Roles - Maudsley score (RMS). The recovery time was defined as the time interval from the first appearance to postoperative relief of symptoms and recording. In addition, the recurrent Haglund's deformity was determined by postoperative control radiographs. RESULTS: The mean age at the time of the operation was 51.19 years. The mean follow-up was 61.75±8.49 months. According to BMI, 5 patients were determined as morbid obese, 19 as obese, 3 as overweight, and 6 as normal. The mean VAS score significantly decreased from 8.5 preoperatively to 1.3 postoperatively (p<0.001). The mean AOFAS score significantly improved from 55.8 preoperatively to 92 postoperatively (p<0.001). Postoperative VISA-A score was 86% (range=32%-100%). According to RMS, 22 patients reported the result as excellent, 8 as good, 2 as fair, and 1 as poor. The mean recovery time was 11.8 (range=2-60) months, but one patient did not reach a symptom free status and thus was not included in the recovery time analysis. Postoperative control radiographs revealed signs of recurrence deformity in four patients. Recovery time showed a negative correlation with the age of the patients (r=-0.65). Postoperative scores and BMI showed no significant correlations with the recovery time on the basis of Spearman's rho test (p=0.196). CONCLUSION: The results of this study have shown that open debridement and reattachment surgery may be an effective surgical method in relieving pain and improving functional status with high satisfaction rate and acceptable recovery time in the management of non-athletic patients with IAT. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Functional outcome using early controlled active motion in rehabilitation of a replanted hand: A case report.

STUDY DESIGN: Case report. INTRODUCTION: This case report details the postsurgical rehabilitation and outcome of a young maintenance man who sustained a complete amputation of his dominant upper limb at the level of the distal forearm. The patient underwent replantation surgery with 2-centimeter bone shortening, followed by early controlled active motion commencing on day 6. PURPOSE OF THE STUDY: To illustrate the use of early motion after replantation. RESULTS: The patient achieved almost full active range of motion of the digits, intrinsic function, 30 seconds on Nine-Hole Peg Test and early return to work without any additional reconstructive procedures. DISCUSSION: Several fairly recently published protocols advocate initiating active range of motion at only 3 or 4 weeks after upper limb replantation. The following therapeutic interventions were considered important contributors to our favorable functional outcome; early controlled active motion, occupation-based therapy in combination with therapeutic exercises and many custom molded orthoses. CONCLUSION: Future research is required to determine if bone shortening, which is an integral part of replantation surgery, reduces tendon repair tension, allowing for early active motion and thereby contributing to a favorable outcome.

Assessment of Somatosensory Reorganization by Functional Magnetic Resonance Imaging After Hand Replantation.

INTRODUCTION: Amputation of the hand is a rare and extremely intense trauma. Replanting and allografting after this type of injury require a major reorganization of the brain. Brain plasticity, though better known in the context of disorders of the central nervous system, is just as indispensable when the extremities are damaged. MATERIALS AND METHODS: A 17-year-old patient underwent replantation of the nondominant hand after transmetaphyseal amputation after traumatic injury. After 18 days in hospital and subsequent treatment in a physical rehabilitation center, the patient attended clinical and radiology follow-up sessions over the next 2 years. RESULTS: The management of this patient led to an excellent functional outcome in conjunction with successful social and professional reintegration. Electromyography at 18 months confirmed nerve regrowth. Functional magnetic resonance imaging was done at 2 years to evaluate cerebral plasticity. Motor function, largely dependent on the primary motor area, is aided by the addition of secondary and accessory motor areas for both simple and complex movements. A change in sensory information is stimulation in its own right hemisphere and increases solicitation of the contralateral precentral and postcentral gyrus. CONCLUSIONS: There seems to be a real reversible dynamic plasticity under the balance of inhibitory and excitatory influences exerted on the cortical neurons. Any disruption of this balance requires the brain to adapt to the new circumstances to reestablish the hand as a functioning part of the body.

Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit.

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.

Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study.

Importance: Optimal treatment for traumatic digit amputation is unknown. Objective: To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. Design, Setting, and Participants: Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. Exposures: Revision amputation or replantation of traumatic digit amputations. Main Outcomes and Measures: The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. Results: Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (-4.29; 95% CI, -8.45 to -0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03). Conclusions and Relevance: When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

Hallmarks of amputation surgery.

PURPOSE: To highlight the most important innovations and milestones in the historical evolution of amputation and disarticulation surgery through the ages, from the early antiquity until the modern era. METHOD: A thorough search of the literature was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize current and classic literature on the hallmarks of the history of amputation surgery in the course of medical history. RESULTS: Amputation of a limb is one of the oldest surgical procedures. Initially, it was fraught with complications and dismal outcome of the patients because of hemorrhage and infection. Due to lack of analgesics and narcotics the operation had to take only a few minutes. Obtaining experience, the surgeons evolved the operative technique and refined the procedure, anesthesia and perioperative analgesia was introduced, instruments were developed, and rehabilitation has enabled functional and social reintegration of amputees. CONCLUSION: From the Hippocratic era until currently, the surgical approach to amputation has changed little. However, the indications for amputations have changed a lot and had been refined, especially in diabetic patients and in those with severe chronic peripheral vascular disease. An exponential decrease in mortality for an operation once fraught with complications was due to the development of the tourniquet, proper vessel ligation and repair, antisepsis, and anesthesia.

Long-term functional, subjective and psychological results after single digit replantation.

OBJECTIVE: The aim of this study was to analyse the long-term functional, subjective, and psychological results after single-digit replantation. METHODS: Thirty cases of digital replantation (14 thumbs, 12 index fingers, 2 middle fingers, 1 ring finger, and 1 little finger) in 30 patients (7 females and 23 males) with a mean age of 44.2 years (20-65 years) were evaluated at the end of a mean follow-up time of 36 months (19-50 months). The active range of motion of joints, grip and pinch strength, cutaneous sensibility, upper-extremity functioning, and subjective satisfaction were determined using the Disability of Arm, Shoulder, and Hand (DASH) questionnaire and the Michigan Hand Outcomes questionnaire (MHQ). Psychological sequelae, including depression, anxiety, and posttraumatic stress disorder (PTSD), were assessed. A correlation analysis among variables was also performed. RESULTS: The mean score for the DASH questionnaire was 6.6 (range: 0-39.2). The symptom of cold intolerance occurred in 53% of the patients. Two patients were diagnosed with depression, and only one patient exhibited PTSD. The DASH score had a good statistical correlation with total grip strength, pinch grip strength, and static two-point discrimination (S-2PD) (P < 0.05). Several aspects of the MHQ were also statistically relevant to some or all of the three objective results. Furthermore, the grip strength showed significant correlation with DASH and most aspects of the MHQ in multivariate logistic regression analysis (P < 0.05). CONCLUSION: Total grip strength is the most important factor positively related to subjective outcomes. The incidence rates of psychological symptoms after digit replantation are very low at long-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Long-Term Health-Related Quality of Life Outcomes in Digital Replantation versus Revision Amputation.

Background Earlier, digit viability judged the success of digital replantation. Now, utility health-related quality of life (HRQOL) measures can better assess the impact of digital replantation. Methods Overall, 264 digital injury patients were sent a regimen of utility measures: Disabilities of the Arm, Shoulder and Hand (DASH) score, European Quality of Life 5 Dimensions, visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). Overall, 51 patients responded completely to all of these-36 replantation patients and 15 revision amputation patients. The utility results of these patients were stratified between replantation versus revision amputation; dominant hand replantation versus nondominant hand replantation; and dominant hand revision amputation versus nondominant hand revision amputation. Results The mean VAS score of replant (0.84) and revision amputation (0.75) groups was significantly different (p = 0.05). The mean DASH score of dominant hand replantations (29.72) and nondominant hand replantations (17.97) was significantly different (p = 0.027). The dominant hand revision amputation had higher anxiety levels in comparison to nondominant hand revision amputation (p = 0.027). Patients with two or more digits replanted showed a significant decrease in VAS, TTO, and SG scores in comparison to patients who only had one digit replanted (p = 0.009, 0.001, and 0.001, respectively). Conclusions This study suggests that HRQOL can offer better indices for outcomes of digital replantation. This shows some specific replantation cohorts have a significantly better quality of life when compared with their specific correlating revision amputation cohort. These findings can be employed to further refine indications and contraindications to replantation and help predict the quality of life outcomes.

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.

Revisión sistemática del tratamiento de fisioterapia en el reimplante de extremidad superior / Systematic review of the physiotherapy treatment in the replantation of upper extremity

Objetivo: Describir las técnicas de fisioterapia implementadas en el tratamiento posquirúrgico de reimplante de extremidad superior y evaluar los resultados funcionales. Estrategia de búsqueda y selección de estudios: Revisión sistemática de las bases de datos Pubmed, Web of Science, Scopus y Cochrane Library desde el 1 de enero de 1990 hasta el 30 de junio de 2015. Dos revisores independientes han examinado, analizado y evaluado los resultados. Se han incluido estudios originales de pacientes con reimplante del miembro superior en los que se describiera y analizara el tratamiento de fisioterapia y los resultados obtenidos. Síntesis de resultados: Se han obtenido 6 publicaciones, todas estudios de casos, sobre 6 reimplantes de antebrazo-mano y uno de todos los dígitos de ambas manos. Las intervenciones planteadas en el postoperatorio inmediato han sido la colocación de ortesis, el control del estado del reimplante, los ejercicios respiratorios, la educación sanitaria, el drenaje del edema, y la movilización controlada del miembro implantado y del resto de la extremidad. En la fase ambulatoria se ha propuesto continuar con la movilización pasiva, asistida y activa controlada; drenaje del edema; masaje de la cicatriz; electroterapia; trabajo de la sensibilidad y reeducación de las actividades de la vida diaria. Hallamos variabilidad en el inicio del tratamiento de fisioterapia y sus técnicas, especialmente en la movilización articular. Conclusiones: Se advierte de la escasez de referencias al tratamiento de fisioterapia en las publicaciones biomédicas, a pesar de ser una parte indispensable y vital para el éxito del reimplante

Objective: Describing the techniques of physiotherapy implemented in post-surgical treatment of upper extremity replantation and evaluate the functional results. Search strategy and article selection: Systematic review of Pubmed, Web of Science, Scopus and Cochrane Library from 1st January 1990 to 30th June 2015. Two independent reviewers have examined, analyzed and evaluated the results. It has included original studies of patients with upper limb replantation, in which is described and analyzed physiotherapy treatment and outcomes. Summary of results: Six publications have been obtained, all of them case studies, about 6 replantations of forearm-hand and one of all digits of both hands. The interventions in immediate postoperative period have been the placement of orthosis, state inspection of the replantation, breathing exercises, health education, drainage of edema, and controlled mobilization of the replanted member and the rest of the limb. In ambulatory phase it has been proposed to continue the passive, assisted and active controlled mobilization; drainage of edema; scar massage; electrotherapy; sensory reeducation and retraining of the activities of daily living. Presence of variability at the start of physical therapy and its techniques, especially in joint mobilization. Conclusions: The study warns of the paucity of references to physical therapy in the biomedical literature, despite being indispensable and vital to successful of the replantation

Rehabilitation of a patient following hand replantation after near-complete distal forearm amputation.

STUDY DESIGN: Case report. INTRODUCTION: Reports of comprehensive rehabilitation following hand replantation are limited. PURPOSE OF THE STUDY: To describe hand therapy of a patient following hand replantation. METHODS: Right hand dominant 55 year-old male assessed 9 days following left hand replantation to treat distal forearm amputation. Patient presented with dorsal blocking orthotic. Initial status: AROM digits and thumb 0-20° extension, 0-40° flexion; absent light touch sensation; 0-1/5 hand strength. Patient underwent 70 hand therapy sessions over 13 months focusing on A/PROM, therapeutic exercise, neuromuscular re-education, and modalities to address functional limitations. RESULTS: Hand therapy discharge status: AROM digits and thumb form composite fist, thumb opposition to digit 3, light touch sensation (monofilament) 4.03 (digits 2, 4) and 4.17 (digits 1, 3, 5); 3- to 4-/5 hand strength. DISCUSSION: Hand therapy allowed for near complete functional return of the hand following replantation. CONCLUSION: Comprehensive Hand therapy aided restoration of adequate sensation and strength for functional use of the replanted hand. LEVEL OF EVIDENCE: 4.

Long-term results of major upper extremity replantations.

We analyzed the long-term functional outcome in patients with major upper extremity replantations. Two patients had amputations proximal to the elbow joint, two had elbow disarticulations and five patients had amputations at the forearm. The mean age was 24 and the mean follow-up time was 18 years. Six patients have undergone secondary operations. The mean grip strength was restored to 34% of the contralateral extremity. Protective sensation was restored in all patients. According to Chen's functional recovery scale, five patients had excellent, two had good, and two had fair results. Grip strength, two-point discrimination, ranges of motion and Chen's scale did not improve after 5 years. However, Semmes-Weinstein monofilament testing and cold intolerance continued to improve up to 10 and 12 years, respectively. Replantation of an upper extremity proximal to the wrist joint satisfactorily restored the upper extremity function.

Correlation of digital sensibility and precision of pinch force modulation in patients with nerve repair.

The outcome measures for patients following peripheral nerve repairs commonly include muscle strength and sensory assessments. However, no significant discussion exists on the impact of nerve injury on sensorimotor control. The objective of this longitudinal study was to explore the effects of nerve regeneration on the control of pinch force in executing functional tasks. Seven patients with digital or median nerve repairs were assessed by a custom-designed pinch device and conventional sensory tools at monthly intervals following nerve repair. These tools measured sensibility, maximum pinch strength, and anticipated pinch force adjustments to movement-induced load fluctuations in a pinch-holding-up activity (PHUA). Six force-related and temporal parameters for sensory measurement were used to determine improvements in pinch performance over time following sensory recovery. The results revealed significant differences in the parameters of peak pinch force, baseline pinch force, force ratio, and the percentage of maximal pinch force output at different points in the course of nerve regeneration. A strong relationship was also found between kinetic data from the PHUA test and the traditional sensibility tests for the nerve repair patients in the present study.

Predicting functional recovery and return to work after mutilating hand injuries: usefulness of Campbell's Hand Injury Severity Score.

PURPOSE: We investigated the effect of severity and form of mutilating hand injuries on functional recovery and return to work, and the usefulness of an injury-severity score in predicting these outcomes. METHODS: We reexamined patients in whom finger amputation or near amputation had been treated with replantation or revascularization at our institution at least 3 years earlier. We evaluated radiographs, sensory recovery, finger range of motion, skin temperature, and current overall hand function to calculate Tamai and Quick Disabilities of the Arm, Shoulder, and Hand scores, and recorded return-to-work status, duration of treatment, and time away from work. We determined injury level, number of involved fingers, type of injury, and Campbell's Hand Injury Severity score (HISS) from the medical record. RESULTS: The average age of the 50 enrolled patients was 43 years (range, 18-69 years); average follow-up was 7.8 years (range, 3.1-15.3 years). More proximal injuries, more involved fingers, and more complicated injury predicted poorer functional recovery. HISS was highly correlated with Tamai's score (r = -0.77; p<.001) and moderately correlated with the Quick Disabilities of the Arm, Shoulder, and Hand score (r = 0.39; p = .009). HISS was only moderately correlated with length of treatment (r = 0.32; p<.05) and with time away from work (r = 0.34; p<.05). Mean HISS among the 3 return-to-work groups differed remarkably. When HISS was <50, 11 of 12 patients returned to their original jobs; when it was between 50 and 150, 17 of 23 patients were able to return; and when it was >150, only 4 of 15 were able to return to work. CONCLUSIONS: Given the current surgical care of patients with mutilated hand injuries, HISS determined at the time of injury can adequately predict functional outcome and return to work status. Larger studies will be necessary to validate these findings.

Reimplantación de miembro superior: presentación de un caso / Superior limb reimplantation: case presentation

La cirugía de reimplante se realiza sólo en centros altamente especializados. Su éxito se encuentra ligado al desarrollo y perfeccionamiento de las técnicas microquirúrgicas y al entrenamiento constante del equipo de profesionales que interviene en su realización. Se presenta el caso de un paciente blanco, de 17 años de edad, que por un accidente laboral sufrió el desprendimiento total de su miembro superior derecho a nivel del hombro, y a ras con el tronco. Recibido en la unidad de urgencias médicas en estado de choque hipovolémico, fue estabilizado para realizar luego la reimplantación del miembro. La evolución postoperatoria fue satisfactoria, lo que demuestra que los reimplantes pueden ser considerados como una opción segura y viable de tratamiento, en heridas complejas o amputaciones que afecten a las extremidades(AU)

Reimplantation surgery is only performed in highly specialized medical institutions. Its success is associateto the development and improvement of microsurgical techniques and to the constant training of the medicalteam. We present the case of a white patient of 17 years of age, who, as a result of an accident at the workingplace, suffered the total detachment of his upper right limb in the shoulder area. He was admitted in theemergency unit presenting hypovolemic shock and was immediately stabilized to perform later the limb reimplantation. The postsurgical development wassatisfactory, proving that reimplantation can be considered a safe and functional practice in complex wounds or amputation affecting limbs(AU)

Replantation of articular composite tissue masses severed from extremities.

SUMMARY: The techniques and outcomes of in situ replantation are discussed for managing 5 cases of articular composite tissue masses severed from an extremity (digit). All 5 cases treated with in situ replantation survived. Rehabilitation was performed after surgery. Follow-ups of 2-5 years showed good appearance, satisfactory functional and sensory recovery. In situ replantation is indicated for an articular composite tissue masses severed from an extremity (digit), if its structure is complete and a blood supply vessel in the mass is available for anastomosis. Replantation can achieve better outcomes than transfer or grafting of adjacent skin or osteocutaneous flaps, or transplantation of a metatarsophalangeal or interphalangeal joint.