Management of complex tissue injuries and replantation across the world
Introduction
Severe injures of the upper limb with injury or loss of more than one functional tissue component are termed “complex tissue injuries”. Such injuries if not treated adequately usually result in amputation or severe morbidity. Obtaining consistent good outcome for patients with complex injuries and providing a good quality replantation service challenges most health care systems.
Introduction of the concepts of radical debridement, primary reconstruction and early extensive rehabilitation combined with the advent of microvascular surgery and stable fixation devices have made the salvage of severely injured limbs a definite possibility. A Study from Louisville has confirmed that salvaged upper limbs are functionally better than the best available prosthesis.3 Hence, it is worth going that extra mile in reconstructing an injured upper limb. This paper seeks to study the existing practices across the world and answer the question whether every patient who sustains such an injury gets the best possible medical care irrespective of the place that the patient lives and the person's capacity to pay. When existing practices fall short an attempt is made to consider the likely cause and suggest possible remedies.
Section snippets
The problem
The incidence of complex upper limb injuries and amputated limbs that are replanted are on the decrease through out the developed world. This trend has been obvious since the early 1990s. Accurate statistics of the number of such injuries are difficult to obtain from different parts of the world but a study in 2000 reported that finger replantations are an uncommon operation in the United States even by 1996.2
However, in the developing world these injuries are increasing probably due to an
Indications for salvage
Indications and contraindications have been drawn up for replantations in Europe.5 Most units follow these guidelines. While these serve as a guide for practice in general, leading teaching units should continue to explore the limits of what is possible. This will allow redefinition of indications and contra indications for limb salvage at regular intervals. For example, our view on the management of the ring avulsion injury with amputation or replant has altered. There are now several reports
Who should do this surgery?
Salvage of these injuries depends upon the fortuitous availability of a combination of skilled manpower, appropriate decision making by the surgeon and adequate infrastructure. Complex injuries are usually treated due to patient pressure and secondary amputations are rarely done in most circumstances. In replantation surgery, however, there is a choice to be made and surgeon factors predominantly apply. Availability of a surgeon sufficiently interested and skilled in replantation is the single
Provision of care
The quality of care in many units in developed countries is largely satisfactory. Only exceptionally is prompt referral to the appropriate centre delayed. While the first stage of operations get done irrespective of the reimbursement status, job position and insurance status appear to be the predominant factors influencing the timing of secondary procedures. In developed countries the public awareness about replantation and its possible benefits may still need to be raised.
In developing
Training gap in the west
An analysis of the 136 institutions which performed finger replantations in 1996 in the United States revealed that 60% performed only one case and only 2% performed 10 or more cases.2 Major replantations are rarely performed and many residents may pass through their otherwise busy training programme without ever seeing one.
In the course of time there may not be enough cases to train the next generation of replant surgeons. In the absence of adequate exposure and training, there is the
The future
What about the future? It is difficult to see any clinically applicable major advances occurring in the near future in the management of complex injuries of the upper limb and in replantation. What is important is to make such salvage surgical procedures for mangled and amputated extremities available to many more potential beneficiaries.
In developing countries this will involve education of medical and para medical professionals, increasing public awareness, building up transport systems and
Acknowledgements
The author wishes to thank S. Vilkki (Finland), F. Pinal (Spain), K. Chung, T.M. Sunil, A. Chong (USA), V. Pathmanathan (Malaysia), B.H. Lim and S. Sebastin (Singapore) for their useful suggestions.
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