Successful Replantation Despite Improper Storage of Amputated Thumb: A Case Report

Replantation of fingers is highly complex and technically challenging. Surgeons are serious with their selection criteria as many factors are involved in determining good surgical outcome. Improper storages of amputated parts are usually denied the option for replantation. We report a 42-year-old lady who was assaulted with a machete and presented with total amputation of left thumb. The amputated thumb was stored in a plastic bag directly on ice cubes which eventually melted; thumb immersed in water for two hours. On examination, the amputated thumb was neither macerated nor frozen. Replantation was attempted and was successful. There are limited reports on proper methods of storage of amputated fingers pertaining to daily practical scenario. Yet, it is a strict criterion for surgeons in attempting replantation. Direct contact of amputated fingers on ice and immersion in hypotonic solutions leads to irreversible tissue damage. In our case, two hours of unfavourable storage did not affect surgical outcome. In conclusion, clinical assessment of the amputated part is essential in deciding for replantation. Combination of direct contact with ice and immersion in hypotonic solution for two hours should not be a contraindication for replantation.


INTRODUCTION
Replantation of fingers is highly complex, delicate, and technically challenging. Surgeons are serious with their selection criteria as many factors are involved in determining good surgical outcome. Success of replantation depends on the level and nature of injury itself, age and vascular condition of patients, quality of micro anastomosis and postoperative care [1][2][3] .
Storage of the amputated digit under low temperature is an important factor in determining good surgical outcome 1 . Thus, surgeons frequently hesitate to attempt replantation if the storage is not physiological. There are two basic methods proposed on storage of amputated fingers; either wrap it with moistened cloth with normal saline or Ringer's lactate solution, place it in a plastic bag and keep it on ice; or immerse it into normal saline or Ringer's lactate solution in a plastic bag and keep it on ice 4 . We report a case of successful replantation despite unfavourable storage conditions.

CASE REPORT
A 42-year-old lady was assaulted with a machete and presented with total amputation of left thumb at base of proximal phalanx. The amputated thumb was found on the road. A passerby helped to wash it under tap water and placed it in a plastic bag with ice cubes. She presented at Emergency Unit about two hours later where the ice cubes had melted, and the thumb was completely immersed in ice water. The thumb was immediately rewashed with normal saline. The edges appeared sharply cut with minimal soft tissue damage. There was neither maceration nor frostbite (Fig. 1). The amputated thumb was wrapped with moist gauze and stored in ice box. We hesitated to replant due to improper storage. After careful patient counselling, we decided to proceed with surgery with patient's consent.
After general anaesthesia, left upper limb was prepped and tourniquet was inflated. Two teams of surgeons debrided and explored both the stump and the amputated part simultaneously; fusion of metacarpophalangeal joint performed with K-wires (Fig. 2). Flexor pollicis longus and digital arteries were repaired. Torniquet was released within two hours and veins were allowed to ooze. A stat dose heparin 5000 IU was given intravenously. Subsequently,  Post-operatively, patient was well-hydrated. Heparin infusion and aspirin were started and the thumb was kept warm under a heat lamp. Heparin was discontinued after five days and allowed discharge with aspirin for two weeks. Antibiotics were completed for a week. Wound healed well at two weeks post-surgery (Fig. 3) and passive range of motion exercises were started. Radiographs showed union after two months; thus, K-wires were removed and active range of motion exercises commenced. At one year followup, she could oppose her fingers despite shortening of 1cm. Active range of motion at interphalangeal joint was 5° to 45°. Grip strength was 22kg and pinch strength was 4kg; almost similar to the opposite hand. Sensation at fingertip on radial aspect was normal, ulna aspect was reduced with intact protective sensation (3.61/0.4g Semmes-Weinstein monofilament). She expressed her utmost gratitude for the treatment received. If the digit appears neither frozen nor macerated, replantation can be attempted. Our replantation was successful despite the unfavourable condition and patient achieved satisfaction functionally and aesthetically.

DISCUSSION
In conclusion, clinical assessment of the amputated part is essential in deciding for replantation. Combination of direct contact with ice and immersion in hypotonic solution for two hours should not be a contraindication for replantation.