Abstract
In February 1958, I treated an 8-year-old Ojibway boy (DS) who had injured his left index finger with a hatchet as he was cutting wood. It was attached by only 1/8 inch of lateral skin on its ulnar aspect, with sharp severance of all remaining structures of the finger—bone, tendons, and blood vessels.
Using only ophthalmologist “loupes” for magnification, with the smallest suture material available being 5-0 plain catgut and 5-0 nylon, I proceeded to approximate the ends of the ulnar digital artery and nerve, and then the radial digital artery and nerve with 5-0 plain catgut. Only the tissues adjacent to the nerves and arteries were sewn to precisely approximate the neurovascular bundles.
5-0 nylon was used to accurately match the digital skin rugae of the proximal and distal digital portions. Neither bone fixation nor venous or tendon repair was attempted. A volar plaster splint was incorporated into the dressing of the digits, hand, and wrist.
At 24 hours, the digit had a dark purple color, but daily over the ensuing 5 days, the digit did not turn “black,” but gradually became more “pink.” The digit survived. A nearby general surgeon advised by telephone to not attempt tendon repair. As I had no photographs, the case is still not reported.
Harold Kleinert, MD, 1 using microsurgical techniques, later reported in 1965 that he had “replanted” an incompletely amputated finger, one he described that “would not have survived.” He claimed that this was the first digital “replantation” in the United States. Later, other reconstructive hand surgeons redefined the word replantation to include only those digits with complete detachment.
Between 1966 and 1972, I had 5 years of general and plastic surgical residency, the latter at Columbia-Presbyterian Hospital followed by a hand surgery fellowship under Dr J. William Littler of Roosevelt Hospital in New York.
In October 1972, Drs Berish Strauch and Avron Daniller held their first instructional course in microsurgical technique for surgeons in the United States.
I had been appointed as Director of Hand Surgery in the Departments of Plastic and Orthopedic Surgery at Rush University in August l972. My first clinical microsurgical case was done at Rush University in November 1972—replanting a hand traumatically amputated at the transmetacarpal level.
Dr Boonmee Chunprapaph 2 of Cook County Hospital reported in the New England Journal of Medicine. He used 3 different techniques: arterial and venous anastomosis, arterial anastomosis only, and composite graft as reported by Douglas.
I later read the privately published Bibliography of Dr Beverly Douglas of Nashville, TN, Chief of Plastic Surgery at Vanderbilt University. I learned that he had first performed successful experimental surgery, with a 50% success rate, replacing toes and digits of monkeys as “composite grafts,” without an operating microscope, by using by an exacting approximation technique, sewing near the vessels and nerves, and precisely aligning the overlying skin rugae.3-5
The publications by Dr Douglas, in any event, postdated my clinical case success in l958.
I followed up the patient, DS, 25 years later in 1983 at the Red Lake Indian Hospital, MN. Testing revealed the digit had full sensation, with 5 mm 2-point discrimination bilaterally in the digit. The digit’s passive range of motion was full, but, as one would expect without tendon repair, there was no active interphalangeal flexion.
Several initial factors were in his favor at the time of original injury. The original hatchet blade injury had produced noncrushed wound surfaces of a sharp or guillotine nature. Favorable too was his young age of 8 years, which helped the digit to regain circulation and normal sensation.
This case demonstrates the wonderful ability of small nerves and vessels to resume their original function if they are accurately approximated and immobilized, even without placement of sutures. Of course, the availability today of an operating microscope and use of more delicate sutures would now give an even greater guarantee of consistent success.