Post-operative critical care and outcomes of limb replantation: Experience in a developing country
Introduction
Traumatic amputation of a limb carries a significant morbidity and disability. These severed extremities may be saved by replantation. Since William Balfour's first successful fingertip reattachment in 1814, much progress has been made in replantation procedures especially following the development of the operating microscope in the early 1960s.9
Several microsurgical centres around the world now achieve success rates greater than 80% in replanting severed digits, hands and limbs. Replantation at the wrist and proximal upper extremity is particularly challenging.6 Mounting clinical experience, improved micro-vascular anastomosis techniques, ultra-fine needles, micro-vascular suture material and instruments, better microscopes, improved anaesthesia and post-operative management have made replantation the procedure of choice in the management of many traumatic amputations.
This paper constitutes an assessment of our experience in limb replantation, their post-operative critical care and outcomes in a regional centre of a developing country.
Section snippets
Patients and methods
All patients who underwent replantation surgery between September 2000 and May 2003 were identified via the operating theatre register and their hospital records were traced. The data were collected from hospital medical and intensive care records of those patients using a structured form in 2003. Subsequently, in 2007, patients who had viable grafts at discharge from hospital were reviewed for a functional assessment using Ch’en criteria (see Table 1).
The demographic data, injury pattern, the
Results
Eleven replantations had been performed during the 2 years and 8 months study period and complete medical and nursing records were available in 6 cases (3 male, median age 32 years, range 3–59) and they were included in the study (see Table 3). The median warm ischaemia time of the severed limb in these cases was 4.5 h (range 1–13.5 h).
Of the 6 studied, 1 graft was lost due to severe wound infection and another due to vascular compromise, 10 and 7 days following surgery, respectively. Failed
Discussion
Replantation aims to restore the amputated part to its anatomical site, preserving function and appearance. Outcome depends on factors intrinsic to the patient and to the nature of the injury as observed in our series also. Crush and avulsion injuries are relative contraindications for replantation4 and this was reiterated in our failures. Meticulous microsurgical technique, dedicated operative and post-operative care, comprehensive occupational therapy and perseverance are needed for success.
Conclusion
Aggressive hydration pre-operatively and post-operatively contributes to graft survival and minimises reperfusion injury to the host. A reduction in platelet count and its recovery post-operatively seems to provide a useful guide to assess the ongoing reperfusion injury. Pulse oximetry is a useful tool to assess graft perfusion. Amputations resulting from guillotine type of injuries have a better chance of survival after replantation. Public education on methods of transporting severed body
Conflicts of interest
None.
Acknowledgements
The authors appreciate the help and support provided by all medical and nursing staff of Peradeniya Teaching Hospital in the clinical management of these cases and Mr. Mahes Salgado for assistance with manuscript preparation.
References (15)
- et al.
Revascularization of digits after thirty-three hours of warm ischaemia time: a case report
J Hand Surg [Am]
(1984) - et al.
Pulse oximetry for vascular monitoring in upper extremity replantation surgery
J Hand Surg [Am]
(1986) - et al.
Wrist level and proximal-upper extremity replantation
Hand Clin
(2007) - et al.
Experimental digital replantation after prolonged cooling
Hand
(1974) - et al.
Pathogenesis of renal ischaemia/reperfusion injury: lessons from knockout mice
Life Sci
(2003) - et al.
Replantation outcomes
Clin Plast Surg
(2007) Replantation surgery
Clin Plast Surg
(1974)
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