Critical analysis of upper limb replantations Análise crítica dos reimplantes no membro superior (original) (raw)
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Optimization of the surgical treatment in replantation of extremity segments
Medical and Health Science Journal, 2010
The article discusses problem of replantation of extremity segments in different trauma mechanisms. While studying the outcomes of the replantation operations for full or partial amputation of limbs or their segments in the 495 patients (363-men, 132-women) the dependency on conditions and duration of their transportation, adequacy anti shock actions, anaesthetic provision, and correctional treatment after the operation is determined. Replantation and reconstructive operations were performed in 191 cases, of them in 7-replantation of big segments. Simultaneous traumatic amputations of two and more segments were noted in 54 cases. Extended skin and soft tissue defects were found in 9 patients. Good outcomes were noted in 77.2% of cases. As Bogomolov and Sedov (2003) showed, a direct relationship was revealed between the anoxia period and the rate of arterial thrombosis.
Since the first successful salvage of an amputated finger using microsurgical anastomoses in 1965, replan-tation has been widely used in these decades and is now firmly established as a viable treatment option in traumatic limb amputation. The current concepts of replantation surgery for upper limb amputation are discussed in this review article in terms of history of replantation, present indications for the procedure, pre-theater care, technical refinements, postoperative management and functional outcome. In this article , we demonstrated that the advent of microsurgery has led to replantation of almost every amputated part of the upper limb possible. Replantation of digits and the hand can restore not only circulation but also function and cosmetic appearance. However, major amputations remain a challenge and the functional outcome is often disappointing, albeit the success rate of replantation exceeds 80%. Proper patient selection, adequate pre-theater preservation, good operative skill and postoperative care, as well as tight cooperation among the patient, the surgeon, and the rehabilitation therapist will help to achieve a better final functional outcome.
Replantation in the mutilated hand
Hand Clinics, 2003
With the evolution of surgical techniques and scientific technology, replantation has become more refined, establishing specific indications for replantation, rituals for preparation, efficient techniques to ultimately minimize ischemia times, improved survival rates, guidelines for postoperative care, strategies for treating complications, and goals for outcomes. Patient satisfaction hinges on their level of expectation as defined and explained in the preoperative discussion and informed consent. Studies have demonstrated patients can be expected to achieve 50% function and 50% sensation of the replanted part. Initially all that was amputated was replanted, as surgeons adopted the philosophy of George C. Ross (1843-1892): "Any fool can cut off an arm or leg but it takes a surgeon to save one." Forty years after the first replant (1962-2002), however, we recognize the ultimate goal: not merely to preserve all living tissue through nonselective replantation, but rather to preserve one's quality of life by improving their function and appearance. This objective to care for the patient with the intent to optimize function and appearance is important not only to the replantation of amputations but to all mutilated hand injuries.
Management of Upper Limb Amputations
The Journal of Hand Surgery, 2011
Acquired upper extremity amputations beyond the finger can have substantial physical, psychological, social, and economic consequences for the patient. The hand surgeon is one of a team of specialists in the care of these patients, but the surgeon plays a critical role in the surgical management of these wounds. The execution of a successful amputation at each level of the limb allows maximum use of the residual extremity, with or without a prosthesis, and minimizes the known complications of these injuries. This article reviews current surgical options in performing and managing upper extremity amputations proximal to the
Actualities in big segments replantation surgery
Replantation of an amputation is no longer a difficult technical problem. Indeed, the experience gathered over the last few decades, right from the first concepts posed by the pioneers up to the present era and the improved technical aids, all go to suggest that the majority of amputated segments may now be reconstructed. However, what we really want from a replant is not just survival but function. Indications for replantations must follow careful and objective patient selection together with the evaluation of type and site of lesion and possible complications. Furthermore, the important role of emergency organization in this type of surgery is to be emphasized. Nowadays, clean cut injuries are rarer and are being substituted by high energy trauma which may produce extensive tissue lesions that increase complications and lead to poor functional results. Consequently, some authors were induced to describe evaluation systems for decision making which still present problems which are in part due to the large number of parameters to be taken into consideration as well as to the complex functionality of the upper limb. This led us to evaluate our case series of 52 major replantations of the upper limb over the last 10 years and to compare it with other published series. The best form of reconstruction following total amputation of a major limb segment is still its replantation. The highly significant increase in the quality of life is able to justify the higher social costs and the number of operations required.
Cold Injury of Amputated Digits
Cooling of amputated parts during transportation delays the onset of ischaemic tissue damage and contributes to successful replantation. The most common error in preservation of amputated parts is exposing them to temperatures, which may cause cold injury, and thus render them unusable. Two case reports will be presented, which illustrate how freezing cold injury (FCI) of amputated digits may decrease the viability of such digits following replantation, and discuss the potential benefit of hyperbaric oxygen therapy (HBOT) in treating FCI of amputated digits following replantation. During the period 1998 to 2002, 124 injured individuals with severed digits were admitted to the Department of Plastic Surgery and Burns at the Ljubljana Clinical Centre. During this period, the number of attempted replantations increased from 29% in 1998 to 48% in 2002. The success rate of these replantations was 81%. Cold injury to the amputated parts was a significant factor affecting the replantation success rate in six patients. In all these cases, all fingers with the exception of the thumb were severed, and placed on ice for preservation during the transportation to the hospital. In all cases, the amputated digits suffered FCI, which was noted after successful replantation. In one patient we assessed the benefit of administering HBOT to treat FCI of the replanted digits. Signs of FCI appeared three days after replantation. One patient received HBOT 7 days after replantation, whereas the others did not. Due to oedema and progressive necrosis observed in the replanted fingers of these patients, reamputation was necessary in most cases. The detrimental consequences of inappropriate preservation of the severed fingers at subzero temperatures were: non-freezing tissue damage, arterial and venous thrombosis during the microsurgical procedure, and longer operations. Post-operatively, improper preservation during transport caused complications associated with freezing-and non-freezing cold injury, despite successful reinstatement of perfusion to the replanted digits. Proper preservation of amputated body parts is essential for successful replantation. Hypothermic preservation is appropriate, if conducted properly. Since digits contain no muscle tissue, irreversible damage appears after significantly longer periods of ischaemia than in other types of tissue. Although we did not observe any benefit of HBOT in one patient, this is most likely due to the delay in initiating the treatment. HBOT should be administered immediately post-surgery, both to minimise reperfusion injury and freezing/non-freezing cold injury.
Critical analysis of upper limb replantations
2006
Objective: The authors analyze the follow-up of results in 62 adult patients who had traumatic amputations in the upper limb and who underwent successful replantation procedures from 1994 to 2004. Methods: The levels of amputation were in fingers or thumb in 48, hand in 5, wrist in 4, forearm in 2 and arm in 3 patients. All patients were treated in a rehabilitation program of specialized hand therapy. A simplified questionnaire was used to evaluate the return to work activities using the operated limb, either in the formal or informal economy, and the patient’s satisfaction rate concerning the surgical procedure. Results: It was noted that 85.5% of patients returned to some work activity using the operated limb and 96.8% of patients are satisfied with the results. Conclusions: Patients submitted to successful replantation present a high rate of satisfaction and return to work activities.
Successful Replantation Despite Improper Storage of Amputated Thumb: A Case Report
Malaysian orthopaedic journal, 2022
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.
Replantation of upper extremity, hand and digits
Acta chirurgica iugoslavica, 2013
Replantation is defined as reattachment of the part that has been completely amputated and there is no connection between the severed part and the patient. In Boston in 1962 Malt successfully replanted a completely amputated arm of a 12-yearold boy. Komatsu and Tamai reported the first successful replantation of an amputated digit by microvascular technique. There are no strict indications and contraindications for replantation. It?s on surgeon to explain to the patient the chances of success of viability, expected function, length of operation, hospitalization and long rehabilitation protocol. Survival and useful function in replantation of upper extremity amputations is questionable. Success depends on microvascular anastomoses, but the final function is related with tendon, nerve, bone and joint repair.