Perioperative Evaluation and Outcomes of Major Limb Replantations with Ischemia Periods of More Than 6 Hours

Abstract

Early revascularization is cardinal for successful replantation of proximal limb amputations. Prolonged ischemia time potentially leads to reperfusion syndrome and morbidity. The dilemma persists regarding safe duration of cold ischemia time for replantation. The study was conducted to evaluate retrospectively the outcomes of major replantation in terms of limb survival, reperfusion events, morbidity, and potential mortality with respect to the ischemia time and level of amputations. Fourteen patients with proximal amputations at the arm, elbow, and forearm with total ischemia time beyond 6 hours were replanted. All had warm ischemia time of less than 2 hours and were closely monitored to record and correct reperfusion events. Nine out of 14 limbs survived. Five patients had reperfusion events. Proximal limb amputations with larger muscle mass were at higher risk of developing reperfusion syndrome and such events had higher chances of limb loss. Major limb amputations within 2 hours of warm ischemia time even with prolonged cold ischemia can be successfully replanted with closed perioperative monitoring.

Complete major amputation of the upper extremity

“…10 In contrast to other algorithms, 16 we prioritize the initial reestablishment of bony integrity (either by plating or external fixation) to ensure an optimal environment for vessel reconstruction 16,19,26 and to protect the anastomoses against shear and traction forces during further management. 12,15 The sequence of reconstruction (bone before vessel and vice versa) is controversially discussed in the literature. 6,10 Primary shortening is advocated by several authors as prerequisite for successful replantation and it is better tolerated in the upper than in the lower limb.…”

“…In the present series, this was not necessary. 12 Dermatofasciotomy is suggested if total ischemia time exceeds 6 hours. 2,14,27 The saphenous vein was used because of its good long-term performance (Fig.…”

“…10 Upper extremity amputations are defined as ''major'' when they occur through or proximal to the radiocarpal joint and include transections at the level of the wrist, forearm, elbow, humerus, or shoulder. 12 During the last decades' improvements in reconstructive microsurgical care, anesthesia and critical care have drastically altered the outlook for the replantation of amputated limbs. 6 Traumatic amputations of the upper extremity are less common than those of the lower extremity, but the literature reveals an increasing number of patients experiencing these injuries.…”

“…11 Because of the important function of the hand in daily living activities, replantation of amputated hands and forearms/arms has been considered to be an absolute indication if the patient's general status does not reflect a contraindication. 12 A great body of literature is dealing with digital and midhand replantations. 12 During the last decades' improvements in reconstructive microsurgical care, anesthesia and critical care have drastically altered the outlook for the replantation of amputated limbs.…”

Reconstrucción funcional de brazo en fractura abierta III C de húmero

“…Es muy importante la cobertura de los defectos de tejidos blandos, ya que ésta brinda una fuente de vascularización al sitio de fractura y favorece su consolidación, los mecanismos de defensa y el suministro antibiótico precoz. Por lo tanto, la selección del procedimiento reconstructivo de cobertura dependerá de la localización y la magnitud del defecto a reconstruir (5,6).…”