This week, a man whose hand was cut off in a sword attack is recovering in hospital after microsurgery. But what is involved in reattaching a severed limb, asks Dr Claire O'Connell.
Peter Rogers's left hand grabbed the headlines this week when it was chopped off during a brutal sword attack in a Dublin pub last Sunday night. A surgical team at St James's Hospital operated for 11 hours to reattach the 27-year-old's severed hand, and Rogers was later reported as being in a stable condition.
But how exactly does one put a severed hand back on? In this case it would have been relatively straightforward because of the clean cut, according to Mr Kevin Cronin, a consultant plastic surgeon at the Mater Misericordiae and Temple Street Hospitals. "[ That] injury is one of the more favourable ones because it was done with a very sharp blade and it's a clean cut and a narrow zone of injury," he says.
While the loss of a whole hand at the wrist is rare, many people lose fingers and even limbs through accidents, particularly in industry, and these cases can be more complicated because the injuries tend not to be as neat.
"Most of these types of injuries are not clean cuts or guillotine amputations, they happen with saws and industrial stampers," says Cronin, who is secretary of the Irish Hand Surgery Society. "There's usually a much wider zone of injury and sometimes the tissues are torn apart, and even if you can restore blood circulation it doesn't always survive. With this sharper injury it's more favourable because the tissues in the part that's amputated are very healthy once you restore circulation." But before starting to restore anything, the doctors must weigh up whether it's worth trying at all. "The first thing you need to do is establish that it's worthwhile to attempt to put it back on, and very many cases are not.
"You'd be very selective because, even if you put them back on successfully, they are often so damaged and painful that you are not actually doing the patient a service at all," says Cronin.
As well as the nature and position of the injury, age is a consideration.
Younger people are better able to regenerate tissue after an injury, notes Cronin. "In children you would nearly always consider putting something back on. And you would always put the thumb back on, even in an adult. And if there are multiple fingers gone you would always try because you have to give them something back." It's also important that the patient is healthy enough to undergo the reattachment, he adds. "If someone has had an accident, sometimes the focus is the amputated part whereas in fact you will survive an amputation but you won't survive things like a dislocation of your neck or a very bad head injury. So you need to be absolutely sure the patient is completely well otherwise. There's no point in reattaching their hand if you don't look after them properly."
ONCE THE OPERATION starts, the first target is the bone, which may need to be pinned back into place. Once the bone is stable, the surgeons reattach the arteries and veins, followed by nerves, tendons and finally the skin. The procedure can take several hours, particularly if the patient is having fingers reattached; these contain small blood vessels and are technically challenging to repair, notes Cronin.
Restoring blood circulation to the amputated body part is central to its survival. The tissue survives in more than 80 per cent of cases, says Cronin, but even then the patient may still have problems with pain and loss of function.
"The final arbiter of recovery is the nerves," he says. "And nerve recovery is very slow. For six weeks there's no recovery and then the nerves can progress from the amputation stump into the amputated part at a rate of a millimetre a day." So in general, patients tend to recover better from amputations at sites farther down the arm, hand and fingers. "The higher the injury the further the nerves have to go and the longer it takes. And the problem there is that muscles waste during the time when they don't have nerves in them," says Cronin.
FOLLOWING A REATTACHMENT, a patient would need physiotherapy and possibly psychological support, and recovery would be assessed over several years, he adds.
Such a reattachment or "replant" of a patient's own tissue is possible for many different body parts - even the face - as long as there is a blood supply, says Irish consultant plastic surgeon Peter Butler from the Royal Free Hospital at Hampstead in London.
Butler was on a surgical team at St James's Hospital in 1993 that sewed both of Nigel Crabbe's hands back on after a factory accident in Wicklow. He has also reattached fingers, limbs, ears, noses and even a penis during his career.
The surgical techniques used to replant a person's own body parts are similar to those used for transplants that graft donor tissue on to the patient, says Butler. But while replants often take place unexpectedly and quickly after an accident, there's more scope with transplant patients to assess them beforehand and make sure they are physically and psychologically suited to the undertaking.
Butler heads the 30-strong UK facial transplant team and is currently working with a number of potential recipients for the world's first full face transplant, which he hopes to carry out in London later this year. "We have been offered faces already by donor families. There's a lot of positive feeling out there about it," he says.