Introduction

In 1962, Malt performed the world’s first successful replan-tation in Boston and, in 1963, Ch’em reimplanted a forearm in Shanghai. The vessel’s diameter was greater than 2 milli-meters, and the suture threads were not appropriate. Experimental reports of limb replantation attempts date from the beginning of the last century. In Brazil, Ely et al. reported the first replantation in 1968, in Porto Alegre.¹ The first hand replantation in Latin America took place in 1971, in São Paulo, by the plastic surgeon Marcus Castro Ferreira and his team.² This same team also performed the first finger replantation on the continent, 2 years later. It was sensible that the hand came before the finger: the smaller the limb, the greater the difficulty of replantation.

The hand plays a crucial role as an organ of communica-tion and environmental interaction. Its absence causes irre-versible deficits, even with the use of modern prostheses, in social and professional life activities. Most hand trauma victims in Brazil are male and economically active. Traumatic hand amputation requires skillful surgical treatment to achieve functional recovery and spare the amputated ex-tremity. The medical team must have these goals in mind after saving the patient’s life. Although aesthetics is within the treatment objectives, one should prioritize a functional, useful hand with pincer function.³

Moreover, the physical and psychological sequelae result-ing from amputations can significantly impact patients’ quality of life, requiring medical and multidisciplinary inter-ventions to minimize damage and promote full recovery.

Such interventions entail substantial costs for treatment and rehabilitation. These costs have a significant global dimension, reflecting not only the financial resources direct-ed towards medical care, but also the social and economic burden related to the physical, emotional, and social con-sequences for amputee patients.

Therefore, it is crucial to analyze this replantation case at a referral hospital for a better understanding of the extent of the issue, identifying risk factors, and enhancing treatment strategies.

Objective

The present study aimed to report descriptively the technical approach and outcomes of a patient who underwent hand replantation.

Materials and Methods

This observational, descriptive, cross-sectional, analytical, and retrospective study used forms completed by hand replantation patients, findings from direct interviews, and active data retrieval from medical records in the database of the Instituto Doutor José Frota (IJF), a major tertiary hospital in Fortaleza, Ceará, Brazil.

Results

Case Report

A 56-year-old patient (IPB), male, married, born and living in Fortaleza, was admitted to the hospital following an accident involving a saw in a butcher shop. He presented with a total amputation of his left hand at the wrist level with bone and tendon exposure. The patient arrived with a tourniquet on his left arm and his amputated hand in an ice-filled contain-er. He reported that the accident had occurred approximately 40 minutes before. On examination, he was stable but mod-erately pale due to significant blood loss, with no loss of consciousness, and a heart rate close to 110 bpm, indicating grade 2 hypovolemic shock. There were no signs of abrasions or trauma to other limbs (►Figs. 1-3).

Fig. 1 - Amputated hand.

Fig. 1 - Amputated hand.

Fig. 2 - Proximal stump of the forearm.

Fig. 2 - Proximal stump of the forearm.

Fig. 3 - Preoperative radiograph.

Fig. 3 - Preoperative radiograph.

Fig. 4 - Bone fixation of the radius and wrist arthrodesis.

Fig. 4 - Bone fixation of the radius and wrist arthrodesis.

Fig. 5 - Radial artery anastomosis.

Fig. 5 - Radial artery anastomosis.

Fig. 6 - Dorsal vein anastomosis.

Fig. 6 - Dorsal vein anastomosis.

Fig. 7 - Skin graft over anastomoses.

Fig. 7 - Skin graft over anastomoses.

Fig. 8 - Postoperative monitoring.

Fig. 8 - Postoperative monitoring.

The medical team must ask for the injury location and the time elapsed between the lesion and primary care (clean or contaminated wound).³ The recommended initial step is to wrap the wound (i.e., proximal stump of the amputated extremity) with a clean cloth or sterile compress, followed by local compression with a crepe bandage. The amputated segment should be thoroughly washed with 0.9% saline solution, wrapped in a clean compress, and placed in an ice-filled container. Cooling (4°C) increases the time until tissue damage from 3 to 6 hours under normal conditions to 12 to 24 hours. However, tissue damage may occur earlier depending on the amount of muscle tissue involved. The time between trauma and revascularization should not exceed 6 hours.

After initial measures according to the Advanced Trauma Life Support (ATLS) protocol, we performed the following surgical steps: vascular stump dissection with identification of the radial and ulnar arteries, and the ulnar and median nerves; heparinization of the blood vessels of the amputated extremity; bone fixation of the radius and wrist block with Kirschner wires; primary microvascular anastomoses of the radial and ulnar arteries and three dorsal veins; suture of the median and ulnar nerves under microscope guidance; and, finally, an en bloc flexor tenorrhaphy and skin grafting over the wound due to tissue loss (►Figs. 4-7).⁴

The patient presented with good hand perfusion and required temporary immobilization due to the fragility of the anastomoses. Pulse oximetry was monitored during hospitalization. The patient was cooperative throughout the admission, leading to a better outcome. After 10 days under observation, the patient was discharged from the hospital with instructions for care and outpatient follow-up (►Fig. 8).

During a follow-up outpatient visit, the patient reported significant difficulty in starting physical therapy through the public healthcare system, which delayed rehabilitation. The patient was satisfied with not losing the limb, but he was experiencing difficulty in mobilization even during simple activities (►Figs. 9,10).

Fig. 9 and 10 - Affected limb 2 months after surgery.

Fig. 9 and 10 - Affected limb 2 months after surgery.

After 6 months, the patient underwent a tendon transfer, involving the removal of a segment of the flexor carpi radialis to reconstruct the extensor carpi ulnaris, potentially allow-ing better wrist flexion and range of motion. During outpa-tient follow-up, the range of motion improved, but not enough to support full movements due to inadequate physi-cal therapy assistance (►Figs. 11,12).

Fig. 11 and 12 - Tendon transfer.

Fig. 11 and 12 - Tendon transfer.

Discussion

Several systemic challenges hinder the management of hand replantation cases in Brazil, starting with the logistical challenges of time and distance required for the replantation, the window of opportunity is small, with rapid transport and highly specialized hospital infrastructure often lacking out-side larger centers. The unequal distribution of microsur-geons and multidisciplinary teams, restricted access to referral centers, and the lack of well-defined protocols for triage and transfer only exacerbate this problem.

Economic and political issues further complicate this matter. The high cost of materials, staff, and the lengthy rehabilitation required are often not covered by public budgets or supplementary health insurance plans. As such, many services opt for cheap, quick solutions, like amputation and subsequent prosthesis.

In the United States, the trend of performing fewer replantation procedures in adult patients has also gained momentum. The current focus on cost-effectiveness and postoperative quality of life has led to a more pragmatic paradigm: in many cases, adaptation with a modern pros-thesis is considered to provide functional and psychological outcomes as good as or even better than replantation, especially when the latter is incomplete, has a poor indica-tion, or when rehabilitation is deemed inadequate.

However, this trend requires careful interpretation in countries such as Brazil, where access to quality prosthetics and rehabilitation remains scarce. There is a risk of adopting an economic logic from more developed countries without providing proper treatment for the local population.

Conclusion

Even over 50 years after the first case, we still face difficulties in replantation procedures due to their delicate nature, the unavailability of an emergency microsurgery service due to a lack of specialized personnel capable of providing salvage surgery for a traumatized limb, and the absence of multidis-ciplinary support with physical therapy and psychological support during limb rehabilitation. These are key barriers to successful treatment. With no proper rehabilitation, even the best surgical technique becomes an empty promise.