Risk and prognostic factors of replantation failure in patients with severe traumatic major limb mutilation

Abstract

Purpose Traumatic mutilation of major limbs can result in limb loss, motor disability, or death. Patients who had replantation failure needed to undergo additional surgeries (even amputation) and had a longer length of hospital stay. Here, we determined the risk and prognostic factors of replantation failure in patients with traumatic major limb mutilation. Methods This retrospective study included adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group from October 18, 2016 to July 31, 2020. Demographic, and clinical characteristics including traumatic conditions, laboratory findings, mangled extremity severity scores (MESS), treatments, and outcomes of the patients were collected. Data were used to analyze predictors and risk factors for replantation failure. Results Among the 66 patients, 48 (72.7%) were males, the median age was 47.0 years old. Replantation failure occurred in 48 patients (72.7%). The area under the curve of the joint prediction of lactic acid on admission, 72-h cumulative fluid balance, and albumin level immediately postoperatively was 0.838 (95% confidence interval [CI], 0.722–0.954; P < 0.001) with a sensitivity of 89.7% and a specificity of 69.2%. Lower limb trauma (odds ratio [OR] 8.65, 95% CI 1.64–45.56, P = 0.011), mangled extremity severity scores (OR 2.24, 95% CI 1.25–4.01, P = 0.007), and first 72-h cumulative fluid balance > 4885.6 mL (OR 10.25, 95% CI 1.37–76.93, P = 0.024) were independent risk factors for replantation failure. Conclusions Lower limb trauma, mangled extremity severity scores, and cumulative water balance were associated with replantation failure, implying that fluid management is necessary for major limb salvage. More studies are needed to explore the predictive power of indicators related to tissue oxygenation and wound healing for replantation failure.

Distribution of pathogens and risk factors for post-replantation wound infection in patients with traumatic major limb mutilation

“…Data were accessed for research purposes on May 1, 2021, data on patients admitted after this date were still collected retrospectively. Ruixing medical group includes Level III specialized hospitals, rehabilitation hospitals, and an institute of applied technology in hand surgery [ 21 ]. Orthopedic trauma, amputated limbs (fingers and toes) replantation, and rehabilitation are the focus medical programs of the group, with an average annual operation volume of more than 10,000, which increasing yearly.…”

“…All of the mutilation limbs were accompanied by discontinuous vessels, nerves, muscles, and bone structures to varying degrees. Patients with severe limb damage that could not be replanted or had first-stage amputations were excluded, which were detailed in our previous study [ 21 ]. Identify patients who receive reimplantation by reviewing and analyzing admission logs and histories from all available electronic medical records and patient care resources.…”

“…Indications for replantation of severed limb: (1) Relatively complete distal limb and mild skin contusion, (2) The tissue structure of the proximal limb is relatively complete, and the bone and joint injury does not seriously affect the appearance and function of the limb, (3) No avulsive nerve injury or only minor local contusion, (4) Patients could tolerate microsurgery with stable physical signs and without serious complications[ 21 ]. Gustilo-Anderson classification of open fractures were defined as follows [ 22 ]: type I, open fracture with a wound less than 1 cm long, low energy, without gross contamination; type II, open fracture with a wound 1–10 cm long, low energy, without gross contamination or extensive soft-tissue damage, flaps, or avulsions; type III A, open fracture with a wound greater than 10 cm with adequate soft-tissue coverage, or any open fracture due to high-energy trauma or with gross contamination, regardless of the size of the wound; type III B, open fracture with extensive soft-tissue injury or loss, with periosteal stripping and bone exposure that requires soft-tissue coverage in the form of muscle rotation or transfer; type III C, open fracture associated with arterial injury requiring repair.…”