Hand Replantation

15 Jun 2022

Case Report

Hospital MetroHealth Medical Center, Cleveland, OH

Following complex replantation and laceration repair, NovoSorb® BTM was applied to two defects that could not be closed primarily due to edema.

While using a saw at work, the patient sustained a transmetacarpal amputation of their left non-dominant hand and a forearm laceration. A successful replantation was performed and the patient was left with two defects: one to the dorsal hand and the other to the volar forearm. Due to edema, the defects could not be closed primarily. NovoSorb BTM was chosen as an alternative over a more complex tissue flap reconstruction to offer immediate coverage and to minimize surgical time. For the dorsal wound, NovoSorb BTM was applied directly over the exposed extensor tendon and vein grafts; and for the volar wound, over the median nerve and flexor tendons. Both wounds re-epithelialized without requiring skin grafting or additional revision surgery.

Figure 1: Traumatic amputation prior to replantation and volar defect of exposed median nerve and tendon.

Figure 2: NovoSorb BTM applied to both volar and dorsal wounds.

Figure 3: Day 7 post NovoSorb BTM application; no evidence of fluid collection and fingers remain viable.

Figure 4: 61 days post NovoSorb BTM application; well integrated and sealing membrane intact – apart from distal dorsal area trimmed at day 28.

Figure 5: 1 month post delamination; dorsal wound is re epithelialized and volar wound is progressing.

Figure 6: 5 months post NovoSorb BTM application; volar wound closure achieved

    Background

    A 59-year-old male with no significant past medical history endured a workplace traumatic injury to the left non-dominant hand, causing a transmetacarpal amputation through the palmar arch necessitating vein grafts for reconstruction of veins and arteries. In addition, he sustained a distal forearm laceration with transection of all finger and wrist flexor tendons, radial artery, and median nerve (Fig 1). Palm skin was able to be re-approximated over arterial grafts, but due to soft-tissue edema, the dorsal skin and forearm laceration could not be closed primarily.

    Treatment

    Following replantation, immediate reconstruction of the dorsal hand was required because of exposed bone and the need for vein grafts. A range of traditional reconstructive options were initially considered for the wound defects including a full-thickness skin graft, regional flap, distant flap, or free flap. NovoSorb BTM was chosen as a suitable option to offer immediate coverage, allow further discussion of reconstructive options, and minimized surgical time.

    NovoSorb BTM was applied over the exposed extensor tendon and vein grafts (dorsal wound) as well as the median nerve and flexor tendons (volar wound) (Fig 2). NovoSorb BTM was secured with staples, and a bulky dressing was applied and left in place until the first post-operative visit (Fig 3). All wounds were treated with bacitracin, petrolatum impregnated gauze, and a light wrap secured with a custom thermoplastic splint.

    28 days post-application, a purulent fluid collection was noted under the distal dorsal area of the matrix and drained in the clinical office. NovoSorb BTM’s sealing membrane was removed in this area and silver sulfadiazine was applied topically for one week. Six days later, 34 days post NovoSorb BTM application, the matrix demonstrated healthy revascularization with no further fluid collection. The patient resumed previous wound care at that time.

    Outcome

    At two months following replantation, NovoSorb BTM’s matrix was fully integrated providing a robust neodermis over exposed tendons and deep structures. Re-epithelialization was evident at the wound margins and the sealing membrane was removed while the patient continued local wound care (Fig 4).

    One month post-delamination, the dorsal wound was completely re-epithelialized (Fig 5). Five months after replantation and application of NovoSorb BTM, the volar portion of the wound healed without complications or the need for revision surgery (Fig 6). Considering the complexity of both the transmetacarpal amputation and forearm laceration, the goal of this surgery was to create a ‘helper’ hand able to assist the right hand in efforts requiring bimanual tasks. Additionally, the patient was able to obtain limited motion of the thumb
    and small finger.

    A 59-year-old male with no significant past medical history endured a workplace traumatic injury to the left non-dominant hand, causing a transmetacarpal amputation through the palmar arch necessitating vein grafts for reconstruction of veins and arteries. In addition, he sustained a distal forearm laceration with transection of all finger and wrist flexor tendons, radial artery, and median nerve (Fig 1). Palm skin was able to be re-approximated over arterial grafts, but due to soft-tissue edema, the dorsal skin and forearm laceration could not be closed primarily.

    Following replantation, immediate reconstruction of the dorsal hand was required because of exposed bone and the need for vein grafts. A range of traditional reconstructive options were initially considered for the wound defects including a full-thickness skin graft, regional flap, distant flap, or free flap. NovoSorb BTM was chosen as a suitable option to offer immediate coverage, allow further discussion of reconstructive options, and minimized surgical time.

    NovoSorb BTM was applied over the exposed extensor tendon and vein grafts (dorsal wound) as well as the median nerve and flexor tendons (volar wound) (Fig 2). NovoSorb BTM was secured with staples, and a bulky dressing was applied and left in place until the first post-operative visit (Fig 3). All wounds were treated with bacitracin, petrolatum impregnated gauze, and a light wrap secured with a custom thermoplastic splint.

    28 days post-application, a purulent fluid collection was noted under the distal dorsal area of the matrix and drained in the clinical office. NovoSorb BTM’s sealing membrane was removed in this area and silver sulfadiazine was applied topically for one week. Six days later, 34 days post NovoSorb BTM application, the matrix demonstrated healthy revascularization with no further fluid collection. The patient resumed previous wound care at that time.

    At two months following replantation, NovoSorb BTM’s matrix was fully integrated providing a robust neodermis over exposed tendons and deep structures. Re-epithelialization was evident at the wound margins and the sealing membrane was removed while the patient continued local wound care (Fig 4).

    One month post-delamination, the dorsal wound was completely re-epithelialized (Fig 5). Five months after replantation and application of NovoSorb BTM, the volar portion of the wound healed without complications or the need for revision surgery (Fig 6). Considering the complexity of both the transmetacarpal amputation and forearm laceration, the goal of this surgery was to create a ‘helper’ hand able to assist the right hand in efforts requiring bimanual tasks. Additionally, the patient was able to obtain limited motion of the thumb
    and small finger.