[Radical tumour resection in the upper extremity and heterotopic replantation of the hand. Analyses of functional results in two patients].
We describe here two cases treated 17 years apart from each other. The patients were young males with malignant soft tissue tumours of the forearm and elbow joint. Radical tumour resection involved removal of the elbow joint. Neither of the patients consented to upper arm amputation, but agreed to undergo heterotopic replantation of the amputated distal third of the forearm together with the hand to the stump of the upper arm. The tendons of the forearm were attached to the three muscles of the upper arm, and the distal nerves were coapted with the nerve trunks of the upper arm. However, the reconstructive procedures carried out in these two patients were anatomically different. In the first patient, for technical reasons, only the deep flexor tendons were sutured. Furthermore, development of a postoperative haematoma necessitated revision surgery with split-thickness skin graft to cover the defect of the forearm. Long-term immobilisation together with a conservative approach to mobility had resulted in less than optimal results so that it appeared meaningful to re-operate the patient even 17 years after the primary operation to help him gain improved sensibility as well as motor function. These goals were achieved to a surprising extent by scar release, Z-plasty, removal of split-thickness skin graft, neurolysis, arthrodesis of the IP joint of the thumb, and tendon transposition together with intensive early postoperative sensibility and mobility training. In the second patient, longitudinal division of the muscles of the upper arm into different compartments and interweaving of the long tendons of the forearm into these muscles as well as early intensive mobility training and reintegration of the replanted hand in the body scheme resulted in the rapid gain of extremely good functional results so that the patient is now able to employs his heterotopically replanted hand quite effectively in his activities of daily living as a farmer. We believe that the differences in the surgical techniques employed and intensive postoperative training may explain the varying functional outcomes of these two patients. What is surprising is that it was possible to achieve marked functional improvement even after an interval of 17 years.
Piza-Katzer
H
H
Klinik für Plastische und Wiederherstellungschirurgie, Medizinische Universität Innsbruck, Osterreich. hildegunde.piza@i-med.ac.at
Baur
E-M
EM
Estermann
D
D
D000203:Activities of Daily Living; D000328:Adult; D004551:Elbow Joint / Q000601:surgery*; D005500:Follow-Up Studies; D005542:Forearm / Q000601:surgery*; D006225:Hand / Q000502:physiology / Q000601:surgery*; D006801:Humans; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D020127:Recovery of Function; D012086:Reoperation; D012092:Replantation; D012509:Sarcoma / Q000175:diagnosis / Q000601:surgery*; D013584:Sarcoma, Synovial / Q000601:surgery*; D016038:Skin Transplantation; D012983:Soft Tissue Neoplasms / Q000175:diagnosis / Q000601:surgery*; D013710:Tendons / Q000601:surgery; D013997:Time Factors; D016042:Transplantation, Heterotopic; D016896:Treatment Outcome