macroreplantations refer to amputations proximal to wrist or ankle joints . when there is evidence of a residual circulation the term revascularisation is used . since the first successful replantation of an arm in 1962 by malt and mckhann in boston and forearm in 1963 by chen et al . in shanghai , the procedure has become common in developed countries . replantation and revascularisation surgery requires the existence of a specialised centre , well - trained teams and microsurgeons , something that is not always available in sub - saharan countries where refashioning and closure of the amputation stump are the common surgical procedures . to the best of our knowledge , except in the republic of south africa , no case of hand replantation has been reported in a sub - saharan country till now . a 17-year - old right - hand dominant male student was transferred to our traumatology emergency department ( ed ) on the 13 december 2012 , 5 h after his left hand had been amputated in a knife fight . his left hand had been sharply amputated at the level of zone v with only a skin bridge at the lateral border of the wrist . x - ray showed that the amputation was through the distal third of scaphoid , capitate , hamate and base of the fifth metacarpal [ figure 1 ] . we immediately wrapped the hand in a fabric - containing ice to minimize warm ischaemia after we put a vascular shunt on the radial artery ( use of a venous catheter 14-gauge ) in the ed . ( a ) subtotal non - viable left - hand amputation , ( b ) pre - operative x - ray showing fracture of scaphoid , capitate , hamate and parcelar articular fracture of the base of the fifth metacarpal as the patient desired to keep his hand and his mother signed the consent form , the decision to attempt replantation was taken at the 7 h. the team consisted of plastic surgeon , anaesthesiologist and two theatre nurses . the patient was kept in a warm room with a postoperative orthosis and the hand elevated . we started low molecular weight heparin intraoperatively which was continued for 1 week , and aspirin ( 100 mg ) was given for 1 month . broad - spectrum antibiotique ( cephalosporin and aminoside ) were given intravenously for 5 days . on the 30 postoperative day , a superficial infection appeared at one k - wire site and was treated with broad - spectrum antibiotics and k - wire removal . on the third post - operative day passive motion of the shoulder , elbow and digits was commenced . on the 10 day , the active motion of the wrist and digits was initiated within the confines of the orthosis by physiotherapy . at 3 weeks , the orthosis was removed for exercises and put for the rest of the day . at 6 weeks , the splint was totally removed . however , it was difficult to maintain this regularly for the next 6 months because of the patient 's uncontrolled seizure disorder and social condition . the patient recovered static two - point discrimination of 20 mm in all three peripheral nerves . his pinch strength was 50% , and grip strength was 40% of the opposite side . he had 45 of the active wrist with flexion and 35 of active wrist extension . active range of motion in all fingers was 200 and thumb active range of motion was 130. intrinsic muscle function was good . the patient used the replanted hand for most daily tasks and some precise activities without pain or instability . ( a ) pollicidigital pinch , ( b ) thumb opposition , ( c ) grip strength , ( d ) wrist extension and ( e ) wrist flexion in sub - saharan countries , treatment of the majority of upper limb amputations is stump closure . reasons include ignorance , poverty , late presentation to the hospital , lack of proper care of amputated parts , lack of proper supplies at the hospital such as microsurgical sutures , instruments and magnification . other relevant factors in africa are the scarcity of hand surgeons , poor experience of surgeons and lack of a trained replantation team . the sequence of repair is directly influenced by the amount of muscle mass in the amputated part and ischaemia time . in our case , warm ischaemia time was 5 h supported by a vascular shunt by the 6 h. psychological or neurologic illness has been cited as a contraindication to replantation . although our patient was epileptic , he did not develop any complication as a consequence of this . we achieved a functional hand replantation in a sub - saharan country just similar to other countries probably because of the age the patient , the use of arterial shunt to reduce the ischaemia time and meticulous reparation of all tissues and hard work of physiotherapist . through this first experience , we can state that hand replantation can be performed successfully both in survival and function in a non - specialised hospital of a sub - saharan african country . this may be the beginning of a replantation team and populations need to be educated about conditions in order for replantation to be attempted .
fifty years after chen has performed the first forearm replantation , we report our first case of hand replantation in a sub - saharan african country . the etiology of the amputation was machete due to interpersonal violence . 
 the amputation was trans - carpal , guillotine - type , subtotal non - viable maintained with a small skin bridge . 
 the replantation procedure was successful . 
 at one year follow - up , the functional result according to chen 's criteria was excellent . through this first experience 
 , we can state that hand replantation can be performed successfully both in survival and function in a non - specialized hospital of a sub - saharan african country .