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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 2023:17531934231215791. [PMID: 37994012 DOI: 10.1177/17531934231215791] [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] [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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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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Ten-Year (2010-2019) Activity Report of the Replantation Service for Hand and Finger Amputations in Poland. HANDCHIR MIKROCHIR P 2023; 55:41-46. [PMID: 34662914 DOI: 10.1055/a-1552-3684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Replantation of amputated hands is now considered a routine procedure in countries representing high standards of medical care. However, organization of care for patients with hand amputations is not uniform and varies from country to country, even in the European Union. This article presents organization of the Replantation Service for hand amputations in Poland, and ten-year activity report of the Service. Data to this report were obtained by mailing questionnaires to seven participating departments.A total of 974 patients, 871 men (89 %) and 103 women (11 %) at a mean age of 40 years with total or subtotal amputations or other severe upper limb-threatening injuries were admitted to the seven units participating in the Service. The most common injury was multidigital amputation - 353 (36 %), followed by the thumb - 282 (29 %), the metacarpal and wrist - 231 (24 %) and the forearm and arm - 108 (11 %) amputations. The most common operation was replantation of totally amputated hands/fingers - 368 cases (38 %), followed by revascularization of subtotal amputated hands/fingers - 344 (35 %). Primary reconstruction of a complex injury to the hand was performed in 135 patients (14 %). The rate of survival of the replanted/revascularized hands/fingers was a mean of 80 %. The report is supported by literature review about replantation services in other countries.
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Ding W, Li X, Chen H, Wang X, Zhou D, Wang X. Nerve merging repair in the replantation of a severed limb with defects in multiple nerves: five cases and long-term follow-up. BMC Surg 2022; 22:222. [PMID: 35681188 PMCID: PMC9185902 DOI: 10.1186/s12893-022-01673-1] [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] [Received: 10/20/2021] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Repairing all nerves is challenging in cases of upper arm avulsion combined with defects in multiple nerves because the donor area for autogenous nerve transplantation is limited and the outcomes of long-segment allogeneic nerve transplantation are poor. Based on the principle of magnified nerve regeneration, we present a method called nerve merging repair, the feasibility of which needs to be confirmed in clinical practice. Methods The nerve merging repair method relies on the use of fewer proximal nerves to innervate more distal nerves and depends mainly on whether the radial nerve (RN) can repair itself. In the case of defects in multiple nerves precluding RN self-repair, median-(median + radial) (M-(M + R)) repair is performed. If the RN can undergo self-repair, median-(median + ulnar) (M-(M + U)) or ulnar-(ulnar + median) (U-(U + M)) is used to repair the three nerves. Five cases were included in the study and involved the analysis of joint motor function, muscle strength and sensory recovery of the affected limb. Results The replanted limb survived in all 5 cases. Follow-up visits were conducted with the patients for 51–80 months, during which they experienced satisfactory recovery of skin sensation, elbow flexion and extension and partial recovery of hand muscle strength. Conclusions To a certain extent, treatment with the nerve merging repair method improved the sensory and motor function of the affected limb and limited the loss of function of the donor nerve area. This intervention provides a new approach for repairing long-segment defects in multiple nerves caused by avulsion amputation of the upper limb.
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Affiliation(s)
- Wenquan Ding
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China
| | - Xueyuan Li
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China
| | - Hong Chen
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China
| | - Xiaofeng Wang
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China
| | - Danya Zhou
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China
| | - Xin Wang
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, 315040, Ningbo, China.
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Stögner VA, Megerle K, Krezdorn N, Vogt PM. Major traumatic amputations and replantations of the upper extremity in Germany – National Quality Reports 2014 – 2018. JPRAS Open 2022; 32:98-110. [PMID: 35345616 PMCID: PMC8956841 DOI: 10.1016/j.jpra.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/07/2022] [Indexed: 11/12/2022] Open
Abstract
The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe. In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period. Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres. The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres. The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care. Level of evidence IV.
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Rosa S, Freitas M, Pegado A, Martins D, Moura M. Rehabilitation after forearm/hand replantation. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm.jisprm_59_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ramji M, Steve AK, Premji Z, Yeung J. Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3071. [PMID: 33173661 PMCID: PMC7647661 DOI: 10.1097/gox.0000000000003071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation.
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Affiliation(s)
- Maleka Ramji
- Section of Plastic Surgery, Department of Surgery, University of Calgary
| | - Anna K Steve
- Section of Plastic Surgery, Department of Surgery, University of Calgary
| | - Zahra Premji
- Libraries and Cultural Resources, University of Calgary
| | - Justin Yeung
- Section of Plastic Surgery, Department of Surgery, University of Calgary
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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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Heineman J, Bueno EM, Kiwanuka H, Carty MJ, Sampson CE, Pribaz JJ, Pomahac B, Talbot SG. All hands on deck: Hand replantation versus transplantation. SAGE Open Med 2020; 8:2050312120926351. [PMID: 32537157 PMCID: PMC7268554 DOI: 10.1177/2050312120926351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 01/07/2023] Open
Abstract
Objectives: Our hands play a remarkable role in our activities of daily living and the
make-up of our identities. In the United States, an estimated 41,000
individuals live with upper limb loss. Our expanding experience in limb
transplantation—including operative techniques, rehabilitation, and expected
outcomes—has often been based on our past experience with replantation.
Here, we undertake a systematic review of replantation with transplantation
in an attempt to better understand the determinants of outcome for each and
to provide a summary of the data to this point. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses
guidelines, we conducted PubMed searches from 1964 to 2013 for articles in
English. In total, 53 primary and secondary source articles were found to
involve surgical repair (either replantation or transplantation) for
complete amputations at the wrist and forearm levels. All were read and
analyzed. Results: Hand replantations and transplantations were compared with respect to
pre-operative considerations, surgical techniques, post-operative
considerations and outcomes, including motor, sensation, cosmesis, patient
satisfaction/quality of life, adverse events/side effects, financial costs,
and overall function. While comparison of data is limited by heterogeneity,
these data support our belief that good outcomes depend on patient
expectations and commitment. Conclusion: When possible, hand replantation remains the primary option after acute
amputation. However, when replantation fails or is not possible, hand
transplantation appears to provide at least equal outcomes. Patient
commitment, realistic expectations, and physician competence must coincide
to achieve the best possible outcomes for both hand replantation and
transplantation.
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Affiliation(s)
- John Heineman
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ericka M Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew J Carty
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Christian E Sampson
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian J Pribaz
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Simon G Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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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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11
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Abstract
BACKGROUND Advances in microsurgery have improved the survival rate of arm replantation. However, the functional outcome of the replanted arms remains unpredictable. The authors performed a systematic review to evaluate the long-term outcome of arm replantation and the secondary reconstructive procedures after replantation. METHODS All available English literature in the PubMed, Embase, and CENTRAL databases was searched for articles reporting functional outcome of successful arm replantation with follow-up period more than 1 yr. Clinical data were extracted including study characteristics, patient demographic information, functional outcome, and the numbers, types, and timing of secondary surgery. Among these, factors identified to influence overall outcome were reviewed and analyzed. RESULTS Twenty-nine studies representing 79 arm replantations met the inclusion criteria. A total of 111 secondary procedures were recorded in 23 studies. The average number of secondary surgical procedures was 2.6 per patient. The most common procedures were nerve repair (23.4%), followed by functioning muscle transfer (19.8%), tendon transfer (17.1%), wound coverage (11.7%), contracture release (10.8%), bone repair (9.9%), arthrodesis (5.4%), and others (1.8%). Procedures involving wound coverage and nerve repair were mainly conducted in the early stage within 4 mos after replantation, whereas functioning muscle transfer, tendon transfer, and arthrodesis were mostly performed after 1 yr postoperatively. The satisfied (Chen I and II) functional outcome was achieved in 49.4% patients. The level of amputation and the type of injury have significant impact on final outcomes, whereas patients' age and timing of nerve repair do not. Patients with amputation at the distal third of the arms had a better outcome than those at the proximal and middle third of the arms (P < 0.05), and patients injured by sharp-cut recovered better than those by crush and avulsion (P < 0.05). CONCLUSIONS Optimal outcomes could be achieved in nearly half of patients with arm replantation, although multiple secondary surgical interventions and long periods of recovery are often required.
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Harrison LM, Anderson SR, Wimalawansa SM. Outcome of Early Motion Protocol for Total Hand Replantation: 1- and 2-Year Postoperative Results. J Hand Microsurg 2019; 12:S70-S74. [PMID: 33335378 DOI: 10.1055/s-0039-1697060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Introduction We review the benefits of early motion protocols following replantation of a total right hand amputation at 1 and 2 years after replantation, and provide recommendations for postoperative management. Materials and Methods Replantation of the entire right hand in zone-4 was performed and supported by rigid external fixation spanning the forearm and hand. An early active "place-and-hold" motion protocol was initiated within the first 3 postoperative days. Metacarpophalangeal joint extensors were tethered by the pins, limiting full excursion. This resulted in stiffness and extensor adhesions that required a staged extensor tenolysis; however, all joints remained supple. The early motion protocol prevented the need for significant flexor tenolysis and joint releases. Results Early motion rehabilitation protocols can produce very successful results in complex replantation. The enhanced stability afforded by external fixation of the wrist allowed us to perform aggressive early rehabilitation. Conclusion This case highlights the benefits of early active motion (limiting the need for complex joint and flexor tendon releases) and demonstrates the degree of extensor adhesions caused by even minor extensor tendon tethering. This aggressive rehabilitation approach can produce excellent range of motion, and likely limit the need for secondary tenolysis and joint release procedures.
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Affiliation(s)
- Lucas M Harrison
- Department of Orthopaedic and Plastic Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States
| | - Spencer R Anderson
- Department of Orthopaedic and Plastic Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States
| | - Sunishka M Wimalawansa
- Department of Orthopaedic and Plastic Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States
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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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Khan N, Rashid M, Ur Rashid H, Ur Rehman Sarwar S, Khalid Choudry U, Khurshid M. Functional Outcomes of Secondary Procedures in Upper Extremity Replantation and Revascularization. Cureus 2019; 11:e5164. [PMID: 31534868 PMCID: PMC6748349 DOI: 10.7759/cureus.5164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction Traumatic amputation of the upper limb has significant associated morbidities and disabilities. After successful replantation surgery, the micro-surgeons’ tasks are far from over. The replanted and revascularized segments have numerous functional restrictions and need various corrective secondary procedures. The aim of our study was to compare the functional results after secondary procedures by administering the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire to patients who had successful upper limb replantation and revascularization. Materials and methods This prospective observational study involved 40 patients who had a partial or complete amputation of the upper limb and underwent secondary procedures to correct function after successful replantation and revascularization surgery. The patients’ functional outcomes after various secondary procedures were recorded using the QuickDASH questionnaire. Results The mean QuickDASH score for thumb injuries was 42.3 pre-surgery but improved to 29.5 after secondary procedures, which was statistically significant (CI 11.12-14.87, p<0.01). The mean difference in the QuickDASH scores for finger injuries was also statistically significant: 45.5 preoperation and 33.7 postoperation (CI 9.89-13.70, p<0.01). For wrist injuries, the mean QuickDASH score was 52.8 presurgery and was 46.3 postoperatively (CI 1.81-6.58, p=0.0023). The QuickDASH scores of the patients with arm and forearm injuries showed no statistically significant improvement, with a preoperation score of 58.3 declining to 55.2 (p=0.98). The overall replantation and revascularization scores were 49.725 and 41.175 pre and postoperation, respectively (CI 8.35-8.75, p<0.01). Conclusion The study finds that the level and mechanism of injury are important predictors of the functional outcomes of the replantation and revascularization of amputated upper-limb appendages. Most replanted and revascularized upper limbs have numerous functional limitations, and achieving good functional results requires one or more secondary procedures, whose type depends on various factors such as the injury type and mechanism. The QuickDASH results for functional outcomes before and after secondary procedures indicate that it is an easy-to-use, reliable, and effective measure of functional outcomes.
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Affiliation(s)
- Nasir Khan
- Plastic Surgery, Shifa International Hospital, Islamabad, PAK
| | - Mamoon Rashid
- Plastic Surgery, Shifa International Hospital, Islamabad, PAK
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Alawi SA, Werner D, Könneker S, Vogt PM, Jokuszies A. Quality of life and reconstructive surgery efforts in severe hand injuries. Innov Surg Sci 2018; 3:147-156. [PMID: 31579778 PMCID: PMC6604571 DOI: 10.1515/iss-2018-0002] [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: 01/11/2018] [Accepted: 03/28/2018] [Indexed: 11/15/2022] Open
Abstract
Introduction: Severe hand trauma, leading to extensive skeletal and tissue defects, requires plastic surgical reconstruction of the highest level aiming at maximizing function and aesthetics. The intention of this study was to investigate clinical parameters and resource consumption connected with severe hand injuries, with specific emphasis on a follow-up evaluation of quality of life after the reconstruction process. Materials and methods: In this retrospective study, we evaluated patients with severe hand injuries from 2013 to 2016 who had completed surgical and non-surgical treatment. Measures included total period of therapy (TPT) in days, total duration of operations including anesthesia (TOA), total duration of all operations (TO), and total number of operations (TNO). We also determined total inpatient stay (TIS), total number of clinic presentations with interventions (TNPI), initial hand injury severity score (iHISS), and inpatient proceeds (IPP) in Euros (€). Correlation was assessed between iHISS and TOA, TNO, and TIS. Finally, these patients were reexamined in a follow-up inquiry and the life quality was assessed with the five-level version of the EuroQol five-dimensional (EQ-5D) descriptive system (EQ-5D-5L). Results: We analyzed 12 patients with an average age of 44 years (min. 24 years, max. 75 years). Patients receiving reconstructive surgery experienced median (x˜\documentclass[10pt]{article}
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) TPT of 175 days [interquartile range (IQR), 51–499], TOA of 13 h (IQR, 6–37), TO of 9 h (IQR, 4–25), and TNO of 5 (IQR, 3–11). Further, the patients’ median TIS was 22 days (IQR, 9–86), TNPI was 4 (IQR, 2–8), and iHISS was 77 (IQR, 44–162). The median IPP was 14.595 € (IQR, 5.541–33.709 €). IHISS was positively correlated with Pearson’s r for TIS (0.817), TOA (0.857), and TNO (0.871). The EQ-5D-5L index value resulted in a high level of life quality with a median of 0.898 (min. 0.8, max. 1). Conclusion: Severe hand injuries are related to high efforts for surgical and functional reconstructions, which result in high quality of life measured with the EQ-5D-5L assessment. However, for a defined collective of patients, myoelectric prosthetic functional replacement should be considered. Further studies are necessary to examine functional outcomes and quality of life after bionic prosthetic replacement. Also, a bionic reconstruction score to define hard criteria for taking an acute treatment decision is necessary.
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Affiliation(s)
- Seyed Arash Alawi
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Dennis Werner
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Sören Könneker
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Peter M. Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Jokuszies
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
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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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Mattiassich G, Rittenschober F, Dorninger L, Rois J, Mittermayr R, Ortmaier R, Ponschab M, Katzensteiner K, Larcher L. Long-term outcome following upper extremity replantation after major traumatic amputation. BMC Musculoskelet Disord 2017; 18:77. [PMID: 28187720 PMCID: PMC5303287 DOI: 10.1186/s12891-017-1442-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 02/03/2017] [Indexed: 11/30/2022] Open
Abstract
Background Amputations in general and amputations of upper extremities, in particular, have a major impact on patients’ lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. Methods Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. Results Twelve male and four female patients with an average age at injury of 40.6 years (range, 14–61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4–32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2–94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120–126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. Conclusions We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.
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Affiliation(s)
- G Mattiassich
- Trauma Center, Unfallkrankenhaus Linz-Teaching Hospital of the Paracelsus Medical University Salzburg, Garnisonstrasse 7, 4010, Linz, Austria. .,Ludwig-Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria. .,Department of Orthopaedic Surgery, Ordensklinikum Linz Barmherzige Schwestern - Teaching hospital of the Paracelcus Medical University Salzburg, Linz, Austria.
| | - F Rittenschober
- Trauma Center, Unfallkrankenhaus Linz-Teaching Hospital of the Paracelsus Medical University Salzburg, Garnisonstrasse 7, 4010, Linz, Austria
| | - L Dorninger
- Trauma Center, Unfallkrankenhaus Linz-Teaching Hospital of the Paracelsus Medical University Salzburg, Garnisonstrasse 7, 4010, Linz, Austria
| | - J Rois
- Trauma Center Vienna Meidling, Vienna, Austria
| | - R Mittermayr
- Ludwig-Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria.,Trauma Center Vienna Meidling, Vienna, Austria
| | - R Ortmaier
- Department of Trauma Surgery, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
| | - M Ponschab
- Trauma Center, Unfallkrankenhaus Linz-Teaching Hospital of the Paracelsus Medical University Salzburg, Garnisonstrasse 7, 4010, Linz, Austria.,Ludwig-Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - K Katzensteiner
- Trauma Center, Unfallkrankenhaus Linz-Teaching Hospital of the Paracelsus Medical University Salzburg, Garnisonstrasse 7, 4010, Linz, Austria
| | - L Larcher
- Trauma Center Salzburg, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Plastic, Aesthetic and Reconstructive Surgery Sanitaetsbetrieb South Tyrol (SABES), Bolzano, Italy
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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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Otto IA, Kon M, Schuurman AH, van Minnen LP. Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review. PLoS One 2015; 10:e0137729. [PMID: 26340003 PMCID: PMC4560425 DOI: 10.1371/journal.pone.0137729] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 08/21/2015] [Indexed: 12/05/2022] Open
Abstract
Background Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation. Methods Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow. Results Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels. Conclusions Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.
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Affiliation(s)
- Iris A. Otto
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Moshe Kon
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arnold H. Schuurman
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- The Hand Clinic, Amsterdam, The Netherlands
| | - L. Paul van Minnen
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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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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Secondary Reconstructive Surgery following Major Upper Extremity Replantation. Plast Reconstr Surg 2014; 134:713-720. [DOI: 10.1097/prs.0000000000000538] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVES Much attention has been given to lower extremity amputations that occur more than 90 days after injury, but little focus has been given to analogous upper extremity amputations. The purpose of this study was to determine the reason(s) for desired amputation and the common complications after amputation for those combat-wounded service members who underwent late upper extremity amputation. DESIGN Retrospective case series. SETTING Tertiary trauma center. PATIENTS/PARTICIPANTS All US service members who sustained major extremity amputations from September 2001 to July 2011 were analyzed. INTERVENTION Late (>90 days after injury) upper extremity amputations. MAIN OUTCOME MEASUREMENTS Amputation level(s), time to amputation, age, number of operations, pre/postoperative complications, reason(s) for desiring amputation, and disability outcomes were analyzed. RESULTS Seven of 218 (3.2%) upper extremity amputees had a late upper extremity amputation (>90 days from injury to amputation). The mean and median number of days from injury to amputation was 689 and 678, respectively. The most common preamputation complications were loss of wrist or finger motion (7, 100%), neurogenic pain (4, 57%), and heterotopic ossification (4, 57%). Three (43%) patients (2 persistent and 1 new onset) had neurogenic pain and 2 (29%) had heterotopic ossification after amputation. Only 57% (4 of 7) of amputees used their prostheses regularly. CONCLUSIONS Service members undergoing late upper extremity amputation seem to have different pre- and postoperative complications than those patients undergoing late lower extremity amputations. It was common for the amputee to not wear their prostheses and to experience similar complications after amputation, albeit in a less severe form.
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Ng WK, Kaur MN, Thoma A. Long-term outcomes of major upper extremity replantations. Plast Surg (Oakv) 2014. [DOI: 10.1177/229255031402200108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Wendy Ky Ng
- Division of Plastic Surgery; Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Manraj Nirmal Kaur
- Division of Plastic Surgery; Faculty of Health Sciences, McMaster University, Hamilton, Ontario
- Surgical Outcomes Research Centre, Department of Surgery; Faculty of Health Sciences, McMaster University, Hamilton, Ontario
| | - Achilleas Thoma
- Division of Plastic Surgery; Faculty of Health Sciences, McMaster University, Hamilton, Ontario
- Surgical Outcomes Research Centre, Department of Surgery; Faculty of Health Sciences, McMaster University, Hamilton, Ontario
- Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario
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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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Malherbe M, Cheval D, Lejacques B, Vaiss L, Kerfant N, Le Nen D. [Major upper limb trauma: patients' outcomes in 22 cases]. ACTA ACUST UNITED AC 2013; 32:219-25. [PMID: 23932768 DOI: 10.1016/j.main.2013.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/06/2013] [Accepted: 06/23/2013] [Indexed: 10/26/2022]
Abstract
In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.
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Affiliation(s)
- M Malherbe
- Département D'orthopédie et Traumatologie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen Cedex 9, France.
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Leclère FM, Mathys L, Juon B, Franz T, Unglaub F, Vögelin E. Macroreplantations of the upper extremity: a series of 11 patients. Arch Orthop Trauma Surg 2012; 132:1797-805. [PMID: 22886169 DOI: 10.1007/s00402-012-1590-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Micro- or macroreplantation is classified depending on the level of amputation, distal or proximal to the wrist. This study was performed to review our experience in macroreplantation of the upper extremity with special attention to technical considerations and outcomes. MATERIALS AND METHODS Between January 1990 and December 2010, 11 patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4 ± 18.2 years (range 19-76 years). There were two elbow, two proximal forearm, four mid-forearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5 ± 6.3 years (range 2-21 years). RESULTS All but one were successfully replanted and regained limb function: Chen I in four cases (36 %), Chen II in three cases (27 %), Chen III in two cases (18 %), and Chen IV in one patient (9 %). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries. CONCLUSION Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at specialist replantation centers. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Franck Marie Leclère
- Department of Plastic and Hand Surgery, University of Bern, Inselspital Bern, Freiburgstrasse, 3010 Bern, Switzerland.
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