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Pyörny J, Karelson M, Sletten IN, Ukkola A, Jokihaara J. Patient-reported significant disability after major traumatic upper extremity amputation. J Hand Surg Eur Vol 2024; 49:1017-1022. [PMID: 37994012 PMCID: PMC11382439 DOI: 10.1177/17531934231215791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.
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Affiliation(s)
- Joonas Pyörny
- Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Margit Karelson
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | | | - Anniina Ukkola
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Jarkko Jokihaara
- Faculty of Medicine and Health Technology, Tampere University, Finland
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
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Barbat P, Henry AS, Pop A, Claudic Y, Saraoui W, Hu W. [Macroreplantation of the upper extremity: Inventory in 2024]. ANN CHIR PLAST ESTH 2024; 69:355-375. [PMID: 38997852 DOI: 10.1016/j.anplas.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.
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Affiliation(s)
- Pierre Barbat
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - Anne Sophie Henry
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - Anastasia Pop
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - Yannis Claudic
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - Wyçal Saraoui
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
| | - Weiguo Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de la Cavale Blanche de Brest, université de Brest, boulevard Tanguy-Prigent, 29200 Brest, France.
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Li J, Wu X, Peng S, Guo Q, Liu M, Li S, Shaffrey EC, Zeng W, Pan X, Liao X, Liu H. Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach. Microsurgery 2024; 44:e31210. [PMID: 38984459 DOI: 10.1002/micr.31210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 04/30/2024] [Accepted: 06/28/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT). METHODS A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications. RESULTS Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria. CONCLUSIONS For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.
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Affiliation(s)
- Jianchi Li
- Department of Plastic Surgery, The First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine, Ministry of Education, Guangzhou, China
- Department of Plastic Surgery, Shenzhen Guangming District People's Hospital, Shenzhen, China
| | - Xiang Wu
- Department of Hand and Microsurgery, Shunde Peace Surgery Hospital, Foshan City, Guangdong, China
| | - Songgen Peng
- Department of Hand and Microsurgery, Shunde Peace Surgery Hospital, Foshan City, Guangdong, China
| | - Qiahong Guo
- Department of Hand and Microsurgery, Shunde Peace Surgery Hospital, Foshan City, Guangdong, China
| | - Ming Liu
- Department of Hand and Microsurgery, Shunde Peace Surgery Hospital, Foshan City, Guangdong, China
| | - Shengshan Li
- Department of Hand and Microsurgery, Shunde Peace Surgery Hospital, Foshan City, Guangdong, China
| | - Ellen C Shaffrey
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Weifeng Zeng
- Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Xianhua Pan
- Department of Orthopaedics and Traumatology, People's Hospital of Baoan District of Shenzhen, The Second Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Xuan Liao
- Department of Plastic Surgery, The First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine, Ministry of Education, Guangzhou, China
| | - Hongwei Liu
- Department of Plastic Surgery, The First Affiliated Hospital of Jinan University, Institute of New Technology of Plastic Surgery of Jinan University, Key Laboratory of Regenerative Medicine, Ministry of Education, Guangzhou, China
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Gao C, Wang H, Ju J, Zhang K, Gao Y, Guo S, Yin D, Hou R, Guo Q. Distribution of pathogens and risk factors for post-replantation wound infection in patients with traumatic major limb mutilation. PLoS One 2024; 19:e0301353. [PMID: 38558019 PMCID: PMC10984543 DOI: 10.1371/journal.pone.0301353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE Even though replantation of limb mutilation is increasing, postoperative wound infection can result in increasing the financial and psychological burden of patients. Here, we sought to explore the distribution of pathogens and identify risk factors for postoperative wound infection to help early identification and managements of high-risk patients. METHODS Adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group between November 09, 2014, and September 6, 2022 were included in this retrospective study. Demographic, and clinical characteristics, treatments, and outcomes were collected. Data were used to analyze risk factors for postoperative wound infection. RESULTS Among the 249 patients, 185 (74.3%) were males, the median age was 47.0 years old. Postoperative wound infection in 74 (29.7%) patients, of whom 51 (20.5%) had infection with multi-drug resistant bacteria. Ischemia time (OR 1.31, 95% CI 1.13-1.53, P = 0.001), wound contamination (OR 6.01, 95% CI 2.38-15.19, P <0.001), and stress hyperglycemia (OR 23.37, 95% CI 2.30-236.93, P = 0.008) were independent risk factors, while the albumin level after surgery (OR 0.94, 95% CI 0.89-0.99, P = 0.031) was significant associated with the decrease of postoperative wound infection. Ischemia time (OR 1.21, 95% CI 1.05-1.40, P = 0.010), wound contamination (OR 8.63, 95% CI 2.91-25.57, P <0.001), and MESS (OR 1.32, 95% CI 1.02-1.71, P = 0.037 were independent risk factors for multi-drug resistant bacteria infection. CONCLUSIONS Post-replantation wound infection was common in patients with severe traumatic major limb mutilation, and most were multi-drug resistant bacteria. Ischemia time and wound contamination were associated with the increase of postoperative wound infection, including caused by multi-drug resistant. Positive correction of hypoproteinemia and control of stress hyperglycemia may be beneficial.
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Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Haiyan Wang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shiqi Guo
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Di Yin
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Suzhou Ruihua Orthopaedic Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Retrouvey H, Franks A, Dunn T, Novoa K, Ipaktchi K, Lauder A. Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review. J Hand Surg Am 2023; 48:993-1002. [PMID: 37589622 DOI: 10.1016/j.jhsa.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/17/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. METHODS Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. RESULTS Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. CONCLUSIONS The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapy/Prevention/Etiology/Harm V.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO.
| | - Amy Franks
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Thom Dunn
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kenneth Novoa
- Division of Psychiatry, Denver Health Medical Center, Denver, CO
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
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Kim DH, Jang HS, Kwak SH, Jung SY, Jeon J, Kim HS, Lee SH. How can we reduce the ischemic time for forearm replantation? Tips to simplify the bone fixation. BMC Musculoskelet Disord 2023; 24:740. [PMID: 37723514 PMCID: PMC10506321 DOI: 10.1186/s12891-023-06862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE Ischemic time is a key factor in satisfactory functional results after forearm replantation. In this study, we provide a detailed description of our surgical technique, the temporary screw plate fixation technique, which aims to reduce ischemic time. METHODS From June 2007 to June 2017, we performed a retrospective study of 20 patients who underwent forearm replantation. Eighteen cases involved male patients, and their mean age was 46 years. The mechanism of injury was roller injuries in 5 cases, power saw injuries in 3 cases, traffic accident in 7 cases, rope injuries in 2 cases, machinery injuries in 2 cases, and crushing injuries by rebar beam in 1 case. RESULTS A total of 20 replantation patients survived. According to injury level, there were 3 cases of the proximal type, 11 cases of the middle type, and 6 cases of the distal type. The average time to revascularization was 331 min. The total operation time was, on average, 5.73 h. In the rest of the 18 cases, the temporary screw plate fixation technique was performed, and the average time required for bone shortening and plate fixation was 38.3 min. CONCLUSIONS To reduce ischemic time, we need a plan that progressively reduces time at each stage. Among our tips, temporary screw plate fixation can reduce the initial bone surgical operation to < 40 min, does not have many complications, and can be used as definitive surgery. This method for bone fixation should be considered as a strategy to actively reduce operation time during forearm replantation. LEVEL OF EVIDENCE Retrospective study, Level III.
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Affiliation(s)
- Dong Hee Kim
- Departments of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Hyo Seok Jang
- Department of Orthopaedic Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sang Ho Kwak
- Department of Orthopaedic Surgery, SNU Seoul Hospital, Seoul, Republic of Korea
| | - Sung Yoon Jung
- Department of Orthopaedic Surgery, College of Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Jongmin Jeon
- Departments of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Hak Sang Kim
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Sang Hyun Lee
- Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea.
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Retrouvey H, Lauder A, Ipaktchi K. Is self-inflicted amputation to the upper extremity a contraindication to replantation? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03669-w. [PMID: 37581643 DOI: 10.1007/s00590-023-03669-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. METHODS The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. RESULTS The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. CONCLUSION The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA.
| | - Alexander Lauder
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, University of Colorado School of Medicine, Denver Health Medical Center, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, CO, 80045, Aurora, USA
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Sabapathy SR, Venkatramani H, Dheenadhayalan J, Bhardwaj P, Zhang D, Rajasekaran S. Forequarter Replantation. J Hand Surg Am 2022; 47:1123.e1-1123.e5. [PMID: 34561134 DOI: 10.1016/j.jhsa.2021.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 05/06/2021] [Accepted: 07/16/2021] [Indexed: 02/02/2023]
Abstract
Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.
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Affiliation(s)
- S Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, Tamil Nadu, India.
| | - Hari Venkatramani
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - J Dheenadhayalan
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Praveen Bhardwaj
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - S Rajasekaran
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Gao C, Yang L, Ju J, Gao Y, Zhang K, Wu M, Yang L, Lu X, Hou R, Guo Q. Risk and prognostic factors of replantation failure in patients with severe traumatic major limb mutilation. Eur J Trauma Emerg Surg 2022; 48:3203-3210. [PMID: 35050386 PMCID: PMC9360147 DOI: 10.1007/s00068-021-01876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/04/2021] [Indexed: 11/06/2022]
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. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01876-w.
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Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ling Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Mingming Wu
- Department of Critical Care Rehabilitation Medicine, Suzhou Ruisheng Rehabilitation Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Lijuan Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Xiaoting Lu
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China.
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China.
- Medical Center of Soochow University, Suzhou, Jiangsu, China.
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Follow-up. Strategies Trauma Limb Reconstr 2022; 16:179-183. [PMID: 35111259 PMCID: PMC8778723 DOI: 10.5005/jp-journals-10080-1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Amputation in the upper extremities influenced the quality of life a lot adversely. So, replantation was tried in many cases of amputation. Especially, due to good plasticity and healing capacity, replantation in children should be actively attempted. On the contrary, owing to growth potential in children, there are several late complications to happen like shortening and synostosis. There are only a few longterm follow-up reports of paediatric patients after replantation of upper extremities. We report a case of successful distal forearm replantation in a 2-year-old child who sustained a wringer injury by a sawing machine with a follow-up of 30 years. Case description A 2-year-old female patient was brought to our institution after a wringer injury to the distal forearm by a sawing machine. She sustained a near-total amputation at the distal forearm level with only a skin tag. Replantation was performed 4 hours after the injury. Radius and ulnar fractures were fixed with Kirschner and roll wires. The radial and ulnar arteries were anastomosed and three veins were anastomosed too. The median, ulnar, and radial nerves were managed by epi-perineurorrhaphy. The muscles were readapted, flexor tendons were performed tenorrhaphy each by each, and extensor tendons were performed grouping tenorrhaphy. Ten years after the replantation, a supination motion block was developed but successfully managed. Conclusion Replantation of upper limbs in children is an eceedingly worthwhile procedure. Though due to growth potential several complications were developed unlikely in adults. But those can be improved with additional procedures. Good plasticity and healing capacity of children make good functional outcomes in long-term follow-up. So, replantation of upper limbs in children should essentially be considered and aggressively performed. How to cite this article Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Followup. Strategies Trauma Limb Reconstr 2021;16(3):179–183.
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Affiliation(s)
- Lee S Hee
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Kim Hyung-Sik
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Lim Hong-Chul
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
- Lim Hong-Chul, Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea, e-mail:
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Major Upper Limb Replantation: An Account of Patient Tenacity. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3005. [PMID: 32983767 PMCID: PMC7489713 DOI: 10.1097/gox.0000000000003005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 11/27/2022]
Abstract
Supplemental Digital Content is available in the text.
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Riccelli V, Pontell M, Gabrick K, Drolet BC. Outcomes Following Mangling Upper Extremity Trauma. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Factors Associated with Primary and Secondary Amputation following Limb-Threatening Upper Extremity Trauma. Plast Reconstr Surg 2020; 145:987-999. [DOI: 10.1097/prs.0000000000006644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Woo SH. Practical Tips to Improve Efficiency and Success in Upper Limb Replantation. Plast Reconstr Surg 2020; 144:878e-911e. [PMID: 31688770 DOI: 10.1097/prs.0000000000006134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVES After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation. SUMMARY This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.
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Affiliation(s)
- Sang Hyun Woo
- From the W Institute for Hand and Reconstructive Microsurgery and the Department of Plastic and Reconstructive Surgery, W General Hospital
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15
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Bhat AK, Acharya A, Mishra D. Correlation of HISS and Strickland Score with the Michigan Hand Outcome Questionnaire in hand injuries. J Clin Orthop Trauma 2020; 11:620-625. [PMID: 32684699 PMCID: PMC7355061 DOI: 10.1016/j.jcot.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The widely used Hand Injury Severity Score (HISS) has intrinsic drawbacks like inability to score vascular status and questionable correlation with Disability of Arm, shoulder and Hand. We compared it with the Strickland score which is easier to calculate and has provision for evaluation of vascular status. We assessed correlation of both the scores with the Michigan Hand Outcome Questionnaire (MHQ). METHODS In a prospective study of 1574 patients admitted with hand injuries, we recorded their HISS and Strickland scores and followed them up for a year and later interviewed for MHQ score. Statistical correlation was done comparing the HISS and Strickland score with the MHQ using the SPSS package. RESULTS Majority of these injuries were in manual labourers (47.5%) with agricultural or industrial background with a mean age of 25 years (18-26 years). Using the One-way ANOVA test we found a significant correlation between the HISS and MHQ (P Value < 0.001). Using the Unpaired T-test, statistically significant association (P < 0.001) was seen between the Strickland score and MHQ. The correlation between HISS and Strickland Score done by One-way ANOVA Test was also found to be significant (P Value < 0.001). On evaluating the group of patients with a Strickland score >10, we observed that the MHQ was almost similar between those who underwent amputation with those who underwent a successful salvage, though not statistically significant. CONCLUSION HISS and Strickland score correlated significantly with each other and with the MHQ. Strickland score was easy and quicker to determine the salvagability of hand injury. However, small group of patients who may benefit from salvage in spite of a high Strickland score where factors like patient's age, occupation, comorbid health condition, motivation, expenses, and social environment needs to be taken into account in decision making.
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Affiliation(s)
| | - A.M. Acharya
- Corresponding author. Division of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal, 576104, India.
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Marques E, Maiorino EJ, Tallackson Z, Masoomi H. Self-amputation of the Upper Extremity: A Case Report and Review of the Literature. Cureus 2019; 11:e5858. [PMID: 31763081 PMCID: PMC6834103 DOI: 10.7759/cureus.5858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Indications for upper-extremity replantation include wrist-level and wrist-proximal amputations, due to the devastating loss of function incurred from these severe injuries. Decisions regarding replantation must be made expeditiously at these proximal levels in an effort to minimize ischemia time. This decision-making process becomes more complicated when a patient presents following intentional self-amputation of an extremity, especially in the setting of an associated mood disorder, psychiatric illness, and/or frank psychosis. A case report is presented involving a 28-year-old right-hand dominant male with untreated depression and recent suicidal ideation who sustained a complete left forearm amputation (distal-third forearm-level) from a self-inflicted circular saw injury. We conducted a PubMed literature search of other reported cases of intentional self-amputations of the hand and upper extremity. The patient underwent replantation of the left upper extremity. At six years postoperatively, the patient was extremely satisfied with the appearance and function of the replanted extremity. Dash score was 5.8 with a Chen Grade 1 (excellent) functional recovery. A literature search identified 16 cases of self-inflicted upper extremity amputation. One patient died at the scene. 87% (13/15) of patients presenting to the hospital were diagnosed with a psychiatric disorder (depression n = 6, bipolar n = 2, and schizophrenia n = 5). 67% (10/15) of these patients were also diagnosed with psychosis. Ten patients underwent replantation (nine at hand/wrist level and one at forearm level), all of which were viable postoperatively. Detailed functional outcome data were not reported in any of the cases. Four patients (40%) were pleased or satisfied with the outcome, but subjective outcomes were not reported for the other six patients. Intentional self-amputation of the hand/upper extremity is an extreme and uncommon act, often presenting with complex psychiatric issues. Although replantation is technically feasible in this patient population, long-term subjective and objective functional outcomes are largely unknown. Future study of this unique group of patients is needed to better assess patient-reported outcomes and functional outcomes of replantation, which could help guide decision making at the time of initial injury.
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Affiliation(s)
- Erik Marques
- Plastic and Reconstructive Surgery, University of Texas Health Science Center, Houston, USA
| | - Eric J Maiorino
- Plastic and Reconstructive Surgery, University of Texas Health Science Center, Houston, USA
| | - Zachary Tallackson
- Plastic and Reconstructive Surgery, University of Texas Health Science Center, Houston, USA
| | - Hossein Masoomi
- Plastic and Reconstructive Surgery, University of Texas Health Science Center, Houston, USA
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Mitchell SL, Hayda R, Chen AT, Carlini AR, Ficke JR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma. J Bone Joint Surg Am 2019; 101:1470-1478. [PMID: 31436655 PMCID: PMC7406140 DOI: 10.2106/jbjs.18.00970] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stuart L. Mitchell
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Roman Hayda
- Department of Orthopaedic Surgery, Brown University Warren Alpert School of Medicine, Providence, Rhode Island
| | - Andrew T. Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James R. Ficke
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen J. MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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The safety of one-per-mil tumescent infiltration into tissue that has survived ischemia. Arch Plast Surg 2019; 46:108-113. [PMID: 30934173 PMCID: PMC6446036 DOI: 10.5999/aps.2018.00248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 01/08/2019] [Indexed: 11/29/2022] Open
Abstract
Background The aim of this study was to assess the safety of one-per-mil tumescent injections into viable skin flaps that had survived an ischemic insult, in order to assess the potential suitability of one-per-mil tumescent injections in future secondary reconstructive procedures such as flap revision and refinements after replantation. Methods Forty groin flaps harvested from 20 healthy Wistar rats weighing 220 to 270 g were subjected to acute ischemia by clamping the pedicle for 15 minutes. All flaps showing total survival on the 7th postoperative day were randomly divided into group A (one-per-mil tumescent infiltration; n=14), group B (normal saline infiltration; n=13), and group C (control, with no infiltration; n=13) before being re-elevated. Transcutaneous oxygen tension (TcPO2) was measured before and after infiltration, and changes in TcPO2 were statistically analyzed using analysis of variance, the paired t-test, and the independent t-test. The viability of flaps was also assessed using the Analyzing Digital Images software at 7 days after the second elevation. Results Thirty-nine flaps survived to the final assessment, with the sole exception of a flap from group A that did not survive the first elevation. TcPO2 readings showed significant decreases (P<0.05) following both one-per-mil tumescent (99.9±5.7 mmHg vs. 37.2±6.3 mmHg) and normal saline (103±8.5 mmHg vs. 48.7±5.9 mmHg) infiltration. Moreover, all groin flaps survived with no signs of tissue necrosis. Conclusions One-per-mil tumescent infiltration into groin flap tissue that had survived ischemia did not result in tissue necrosis, although the flaps experienced a significant decrease of cutaneous oxygenation.
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Functional assessment and quality of life in patients following replantation of the distal half of the forearm (except fingers): A review of 11 cases. HAND SURGERY & REHABILITATION 2017; 36:261-267. [DOI: 10.1016/j.hansur.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 02/19/2017] [Accepted: 05/31/2017] [Indexed: 11/22/2022]
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Ursu D, Nedic A, Urbanchek M, Cederna P, Gillespie RB. Adjacent regenerative peripheral nerve interfaces produce phase-antagonist signals during voluntary walking in rats. J Neuroeng Rehabil 2017; 14:33. [PMID: 28438166 PMCID: PMC5404291 DOI: 10.1186/s12984-017-0243-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 04/13/2017] [Indexed: 11/20/2022] Open
Abstract
Background Regenerative Peripheral Nerve Interfaces (RPNIs) are neurotized muscle grafts intended to produce electromyographic signals suitable for motorized prosthesis control. Two RPNIs producing independent agonist/antagonist signals are required for each control axis; however, it is unknown whether signals from adjacent RPNIs are independent. The purpose of this work was to determine signaling characteristics from two adjacent RPNIs, the first neurotized by a foot dorsi-flexor nerve and the second neurotized by a foot plantar-flexor nerve in a rodent model. Methods Two Control group rats had electrodes implanted onto the soleus (tibial nerve) and extensor digitorum longus (peroneal nerve) muscles in the left hind limb. Two Dual-RPNI group rats had two separate muscles grafted to the left thigh and each implanted with electrodes: the extensor digitorum longus was neurotized with a transected fascicle from the tibial nerve, and the tibialis anterior was implanted with a transected peroneal nerve. Four months post-surgery, rats walked on a treadmill, were videographed, and electromyographic signals were recorded. Amplitude and periodicity of all signals relative to gait period were quantified. To facilitate comparisons across groups, electromyographic signals were expressed as a percent of total stepping cycle activity for each stance and swing gait phase. Independence between peroneal and tibial nerve activations were assessed by statistical comparisons between groups during stance and swing. Results Electromyographic activity for Control and Dual-RPNI rats displayed alternating activation patterns coinciding with stance and swing. Significant signal amplitude differences between the peroneal and tibial nerves were found in both the Control and Dual-RPNI groups. Non-inferiority tests performed on Dual-RPNI group signal confidence intervals showed that activation was equivalent to the Control group in all but the peroneal RPNI construct during stance. The similar electromyographic activity obtained for Control and RPNI suggests the latter constructs activate independently during both stance and swing, and contain minimal crosstalk. Conclusions In-vivo myoelectric RPNI activity encodes neural activation patterns associated with gait. Adjacent RPNIs neurotized with agonist/antagonist nerves display activity amplitudes similar to Control during voluntary walking. The distinct and expected activation patterns indicate the RPNI may provide independent signaling in humans, suitable for motorized prosthesis control.
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Affiliation(s)
- Daniel Ursu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA.
| | - Andrej Nedic
- Department of Surgery, Plastic Surgery Section, University of Michigan Health System, Ann Arbor, MI, USA
| | - Melanie Urbanchek
- Department of Surgery, Plastic Surgery Section, University of Michigan Health System, Ann Arbor, MI, USA
| | - Paul Cederna
- Department of Surgery, Plastic Surgery Section, University of Michigan Health System, Ann Arbor, MI, USA
| | - R Brent Gillespie
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
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Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting. World J Surg 2017; 41:1420-1434. [PMID: 28168319 DOI: 10.1007/s00268-017-3902-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability . METHODS Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes. RESULTS MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury. CONCLUSIONS Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.
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Pet MA, Morrison SD, Mack JS, Sears ED, Wright T, Lussiez AD, Means KR, Higgins JP, Ko JH, Cederna PS, Kung TA. Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation. Injury 2016; 47:2783-2788. [PMID: 28029356 DOI: 10.1016/j.injury.2016.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/03/2016] [Accepted: 10/08/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation. METHODS At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain. RESULTS Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08). CONCLUSIONS Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.
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Affiliation(s)
- Mitchell A Pet
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Shane D Morrison
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jacob S Mack
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Erika D Sears
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Thomas Wright
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Alisha D Lussiez
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Kenneth R Means
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Paul S Cederna
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Theodore A Kung
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States.
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Forequarter Replantation and the Lessons Learnt. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e509. [PMID: 26495222 PMCID: PMC4596434 DOI: 10.1097/gox.0000000000000485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/13/2015] [Indexed: 11/25/2022]
Abstract
The literature on major upper limb replantation, especially those proximal to the elbow, is inadequate. An 18-year-old man presented to us with a left forequarter amputation. A replantation was attempted with a view to salvaging function and avoiding prosthesis. The procedure was technically challenging with a number of issues not highlighted in previous reports, particularly bony stabilization. The procedure was initially successful, with good perfusion. However, with time, the limb showed sepsis and had to be abandoned. We report this case to add to the literature on replantation at the shoulder level in the hope that this procedure may be reported successfully in the future.
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Märdian S, Krapohl BD, Roffeis J, Disch AC, Schaser KD, Schwabe P. Complete major amputation of the upper extremity: Early results and initial treatment algorithm. J Trauma Acute Care Surg 2015; 78:586-93. [PMID: 25710431 DOI: 10.1097/ta.0000000000000548] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic major amputations of the upper extremity are devastating injuries. These injuries have a profound impact on patient's quality of life and pose a burden on social economy. The aims of the current study were to report about the initial management of isolated traumatic major upper limb amputation from the time of admission to definitive soft tissue closure and to establish a distinct initial management algorithm. METHODS We recorded data concerning the initial management of the patient and the amputated body part in the emergency department (ED) (time from admission to the operation, Injury Severity Score [ISS], cold ischemia time from injury to ED, and total cold ischemia time). The duration, amount of surgical procedures, the time to definitive soft tissue coverage, and the choice of flap were part of the documentation. All intraoperative and postoperative complications were recorded. RESULTS All patients were successfully replanted (time from injury to ED, 59 ± 4 minutes; ISS16; time from admission to operating room 57 ± 10 minutes; total cold ischemia time 203 ± 20 minutes; total number of procedures 7.3 ± 2.5); definitive soft tissue coverage could be achieved 23 ± 14 days after injury. Two thromboembolic complications occurred, which could be treated by embolectomy during revision surgery, and we saw one early infection, which could be successfully managed by serial debridements in our series. CONCLUSION The management of complete major amputations of the upper extremity should be reserved for large trauma centers with enough resources concerning technical, structural, and personnel infrastructure to meet the demands of surgical reconstruction as well as the postoperative care. Following a distinct treatment algorithm is mandatory to increase the rate of successful major replantations, thus laying the foundation for promising secondary functional reconstructive efforts. LEVEL OF EVIDENCE Therapeutic study, level V.
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Affiliation(s)
- Sven Märdian
- From the Center for Musculoskeletal Surgery, Charite Universitatsmedizin Berlin, Berlin, Germany
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Patel AA, Blount AL, Owens PW, Askari M. Functional outcomes of replantation following radiocarpal amputation. J Hand Surg Am 2015; 40:266-70. [PMID: 25499843 DOI: 10.1016/j.jhsa.2014.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. METHODS We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. RESULTS Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. CONCLUSIONS Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Amar Arun Patel
- Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, University of Miami, Miami, FL; Department of Orthopaedics, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Andrew L Blount
- Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, University of Miami, Miami, FL; Department of Orthopaedics, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Patrick W Owens
- Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, University of Miami, Miami, FL; Department of Orthopaedics, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Morad Askari
- Department of Orthopaedics, Hand, and Microvascular Surgery, Miller School of Medicine, University of Miami, Miami, FL; Department of Orthopaedics, Jackson Memorial Hospital, University of Miami, Miami, FL.
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Andre A, Rongieres M, Laffosse JM, Pailhe R, Lauwers F, Grolleau JL. [Cross-hand replantation in bilateral upper limb amputation: An anatomical emergency]. ANN CHIR PLAST ESTH 2014; 60:340-5. [PMID: 25498535 DOI: 10.1016/j.anplas.2014.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/08/2014] [Indexed: 11/28/2022]
Abstract
Bilateral amputations of upper limbs are excessively rare clinical situations. We report an exceptional clinical case of bilateral amputation of upper limbs at different levels: destruction of the right hand and left transhumeral amputation in a patient after an attempted suicide on train lines. This special situation led us to perform a cross-hand replantation of the left hand to the right forearm. Only 4 other similar cases have been published in the literature. Once the surgical indication had been formulated collectively, and taking into account all the ethical issues surrounding such a decision, we had to solve the issue of inverting anatomical structures in emergency. We have provided a detailed description of our surgical technique. The aim was to save at least one organ used for grasping. The result obtained is presented and reviewed.
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Affiliation(s)
- A Andre
- Institut de l'appareil locomoteur, unité de chirurgie de la main et chirurgie réparatrice des membres, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, place Baylac, 31059 Toulouse cedex, France; Laboratoire d'anatomie, faculté de médecine, 133, route de Narbonne, 31400 Toulouse, France.
| | - M Rongieres
- Institut de l'appareil locomoteur, unité de chirurgie de la main et chirurgie réparatrice des membres, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, place Baylac, 31059 Toulouse cedex, France; Laboratoire d'anatomie, faculté de médecine, 133, route de Narbonne, 31400 Toulouse, France
| | - J-M Laffosse
- Institut de l'appareil locomoteur, unité de chirurgie de la main et chirurgie réparatrice des membres, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, place Baylac, 31059 Toulouse cedex, France
| | - R Pailhe
- Institut de l'appareil locomoteur, unité de chirurgie de la main et chirurgie réparatrice des membres, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, place Baylac, 31059 Toulouse cedex, France
| | - F Lauwers
- Laboratoire d'anatomie, faculté de médecine, 133, route de Narbonne, 31400 Toulouse, France
| | - J-L Grolleau
- Institut de l'appareil locomoteur, unité de chirurgie de la main et chirurgie réparatrice des membres, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, place Baylac, 31059 Toulouse cedex, France
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Gilleard O, Smeets L, Seth R, Jones ME. Successful delayed nose replantation following a dogbite: arterial and venous microanastomosis using interpositional vein grafts. J Plast Reconstr Aesthet Surg 2014; 67:992-4. [PMID: 24559733 DOI: 10.1016/j.bjps.2014.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/26/2014] [Indexed: 11/16/2022]
Abstract
The nose is one of the most important aesthetic units of the face. Following traumatic amputation, although technically very challenging, replantation is undoubtedly the procedure of choice. We present the first successful replantation of a partially amputated nose subjected to an ischaemic time of over 12 h. The injury was sustained following a dog-bite and inter-positional vein grafts were used to re-establish both arterial and venous blood flow.
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Affiliation(s)
- Onur Gilleard
- Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, United Kingdom.
| | - Laurent Smeets
- Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, United Kingdom
| | - Rohit Seth
- Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, United Kingdom
| | - Martin E Jones
- Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, United Kingdom
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Abstract
Appropriate use of microsurgical techniques in the emergency management of injured hands increases the salvage rate of complex upper limb injuries. Over time, the indications for replantation, both major and minor, have expanded and techniques refined to get better functional outcomes. The wide choice of free flaps available has made primary reconstruction possible to obtain a good functional and aesthetic outcome. The benefits microsurgery offers in the emergent management of the injured hand are now firmly established. The challenge is to create and maintain centers which can provide around-the-clock, high quality microsurgery services. The issues of adequate training opportunities, obtaining adequate work load to maintain high skill levels, attracting talent into the field are the challenges faced in maintaining high levels of service. In the developing countries, in addition to these issues, increasing the awareness of the potential of microsurgical services among the medical personal and the public has to be addressed.
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Woo SL, Urbanchek MG, Leach MK, Moon JD, Cederna P, Langhals NB. Quantification of muscle-derived signal interference during monopolar needle electromyography of a peripheral nerve interface in the rat hind limb. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2014; 2014:4382-4385. [PMID: 25570963 DOI: 10.1109/embc.2014.6944595] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
High-fidelity signal acquisition is critical for the fundamental control of a neuroprosthesis. Our group has developed a bio-artificial interface consisting of a muscle graft neurotized by a severed nerve in a rat hind limb model. This regenerative peripheral nerve interface (RPNI) permits nerve signal transmission, amplification, and detection via in situ electromyography (EMG). Our study examined the magnitude of signal interference from simultaneously contracting muscles adjacent to our muscle of interest. In eighteen F344 rats, the extensor digitorum longus (EDL) muscle was used to fabricate simulated RPNI constructs of various sizes in which the neurovascular pedicle was preserved, obviating the need for reinnervation or revascularization. After 3 weeks of recovery, in situ EMG testing was performed using electrical stimulation of the common peroneal nerve. A recording needle was placed in the EDL muscle with a reference/ground electrode in the contralateral toe webspace, comprising a monopolar recording configuration. The superficial peroneal nerve was transected to further isolate stimulation of the anterior compartment. Recordings from the EDL were performed before and after excision of the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles. After TA/EHL excision, EDL compound muscle action potential (CMAP) peak-to-peak amplitudes were significantly lower by an average of 7.4±5.6(SD) mV, or 32±18%, (paired t(17)=-5.7, p<;0.0001). A significant positive linear correlation was seen between CMAP amplitude and EDL mass both before TA/EHL excision (r=0.68, n=18, p<;0.01) and after TA/EHL excision (r=0.79, n=18, p<;0.0001). EDL mass did not correlate with differences in CMAP amplitude or area caused by TA/EHL excision. Monopolar needle EMG recordings from the EDL muscle are significantly, but predictively, contaminated by concomitant muscular contractions in the anterior compartment of the rat hind limb. Further investigation of strategies to reduce this signal interference, including electrode choice or configuration, use of bioelectrical insulators, and filtering methods, is warranted to promote high-fidelity signal acquisition for prosthetic control.
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