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Limb replantation and transplantation is the optimal treatment for traumatic limb amputation. Safe and effective limb preservation is the key factor to determine the success of limb replantation and transplantation. Currently, static cold storage is the gold standard of limb preservation. However, the preservation time is short, which may no longer meet clinical requirements. With rapid development of organ preservation in recent years, novel preservation technologies, such as ultra-low temperature preservation, supercooling preservation and mechanical perfusion preservation, have successively emerged. However, at present, these techniques are primarily applied to the preservation of solid organs rather than composite tissue allografts with blood vessels including limbs. In this article, research status and progress on the application of static cold storage and mechanical perfusion preservation in limb preservation were reviewed, aiming to provide reference for clinical application of limb preservation technology and promote the development of limb replantation and transplantation.
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The development of microsurgical techniques has also increased the success rate of replantation surgery. This paper reports the results of limb replantation performed on a lower extremity amputation that was associated with crush amputation and an ipsilateral comminuted fracture in and elderly patient. A 68-year-old female presented with a right distal tibia amputation due to a traffic accident. At that time, with a comminuted fracture in the distal femoral condyle, simple wound repair was recommended, but the caregivers strongly wanted replantation. Three years after surgery, normal walking was possible without a cane and the patient was satisfied with the function and aesthetics. What used to be contraindicated in limb replantation in the past are now indications due to the development of microsurgical techniques, surgical experience, and postoperative rehabilitation treatment. If the patient is willing to be treated, good results in contraindications can be obtained.
Subject(s)
Aged , Female , Humans , Accidents, Traffic , Amputation, Surgical , Canes , Caregivers , Esthetics , Extremities , Fractures, Comminuted , Leg , Lower Extremity , Rehabilitation , Replantation , Tibia , Walking , Wounds and InjuriesABSTRACT
Results: All 12 patients recovered the same lengths of both lower extremities after shortened replantation and limb lengthening. The lengthened segments gained good bone mineralization, bony union was achieved at lengthened segments and broken end of fracture at 7-16 months (mean, 11.3 months). All patients were followed up 6 months to 5 years (mean, 2 years and 5 months). The range of motion of the knee joint were 0-5° (mean, 3°) in hyperextension and 110-140° (mean, 120°) in flexion. Except for 2 cases of ankle arthrodesis, plantar flexion angles were 15-45° (mean, 26°) and dorsiflexion angles were 10-25° (mean, 15°) in the other cases. The plantar sensation was restored to the S 3 + level in 4 cases, S 3 level in 6 cases, and S 2 level in 2 cases. At last follow-up, the affected limb function were excellent in 7 cases, good in 3 cases, fair in 2 cases according to Kofoed functional evaluation criteria.
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Objective To analyze the relative factors of functional recovery after upper limbs replantation. Methods From September, 2009 to March, 2014, 24 consecutive patients after upper limb replantation for amputation were retrospectively analyzed. The Disability of Arm Shoulder and Hand (DASH) was used to assess the functional recovery of the upper limbs at the last follow-up. The non-conditional Logistic regression was used to analyze the correlation of gender, age, time from injury to surgery, amputated level, amputated method, isch-emia hours, dominant hand or not, rehabilitation treatment, rehabilitation duration, and the DASH scores. Results The DASH score was>28.50 in 15 patients, while ≤28.50 in 9 patients. The Logistic regression analysis demonstrated that amputated method and rehabilitation treatment correlated with the functional recovery of upper limbs (χ2>7.360, P0.05). Conclusion The amputated method and rehabilitation treatment after operation are the factors related to the func-tional recovery after upper limb replantation.
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Objective To observe the contribution of acute normovolemic hemodilution ( ANH) in experiment of cryopreserved dog limb replantation.Methods Sixteen healthy Beagle dogs (male:female=1:1) were divided into two groups.Dogs in the experiment group ( Group B) received ANH in the limb replantation, and dogs in the control group ( Group A) received the same amount of lactate Ringer’ s solution intravenously during the surgical operation.We recorded and compared the hemodynamic indexes, HB, HCT, the resuscitation time, the first rising head time, the first standing time and the first eating and drinking time between the two groups.Results ( 1 ) During the operation, both PaO2 and PCO2 in the two groups were normal, as well as the breathing rate.The heart rate in the group B was lower than that in the group A.Before blood transfusion, there was no statistically significant difference in HB and HCT between the two groups, but after transfusion they were significantly higher in the group B than in the group A.(2) The resuscitation time, the first rising head time, the first standing time and the first eating and drinking time of the group B were all better than those in the group A.Conclusions In cryopreserved dog limb replantation experiments, acute normovolemic hemodilution is helpful to improve the general condition and facilitate the recovery of animals after limb replantation.
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RESUMO Introdução: As indicações de reimplante de membros inferiores em crianças são ainda controversas na literatura e, comparadas com os reimplantes de membros superiores, são mais seletivas. Os reimplantes de membro inferior são menos frequentes por várias razões, haja vista que os traumas que provocam amputações ao nível do membro inferior geralmente são de alta energia cinética e provocam grave lesão tecidual, além da associação frequente de lesões de outros órgãos que contraindicam o procedimento. Associada à frequência de complicações graves no pós-operatório e os resultados medíocres de alguns casos, muitos cirurgiões se sentem desencorajados a reimplantar estes segmentos. Existem poucos relatos de reimplantes de membros inferiores com sucesso funcional na literatura. Relato de Caso: Paciente E.S.S., sexo feminino, quatro anos de idade, vítima de atropelamento por trem em julho de 1997, que resultou em esmagamento do terço inferior da perna esquerda e amputação ao nível do tornozelo esquerdo. A paciente deu entrada na emergência da Santa Casa de Campo Grande-MS, apresentando boas condições gerais, sendo indicado o reimplante do membro amputado. Foi então transferida à sala de operação (S.O), e após oito horas de isquemia foi reimplantado o pé esquerdo. Conclusão: Fica claro que em casos selecionados, como o da paciente acima, o reimplante microcirúrgico é uma opção válida e extremamente valiosa, não só do ponto de vista funcional, mas estético.
ABSTRACT Introduction: The indications for lower limb replantation in children are still controversial in the literature. Furthermore, they are more selective than those for upper limb replantation. Replantations of lower limbs are less frequent for various reasons, including that the traumas leading to amputations at the lower limb level are usually high-kinetic-energy injuries and involve severe tissue damage, in addition to their frequent association with other organ damage that discourage the use of the procedure. Because of the association with frequent serious postoperative complications and unsatisfactory outcomes in some cases, many surgeons feel discouraged to replant these segments. There are few literature reports on lower limb replantations with functional success. Case Report: Patient E.S.S. is a 4-year-old girl who was run over by a train in July 1997. The accident resulted in the crushing of the lower third of her left leg and the amputation of her left ankle. She was admitted to the emergency room of Santa Casa de Campo Grande-MS, in good overall condition. Replantation of the amputated limb was recommended. She was then transferred to the operating room, and her left foot was replanted after 8 h of ischemia. Conclusion: Clearly, in selected cases, such as the patient reported here, microsurgical replantation is a valid and extremely valuable option, both from a functional and an aesthetic point of view.
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Objective To study the injuries of avulsion and severance of upper extremity caused by flexion and rotation and application of tissues of chest side and back in functional reconstruction of the upper extremity. Methods The primary or fosterage replantations were performed from 2000 July to 2003 September for 6 cases of the injuries of avulsion and severance of upper extremity caused by flexion and rotation. After the operation, the shoulder joint was immobilized at abduction of 90 degrees and elbow joint was fixated at inflexion of 100 degrees. 4 weeks later, the fixation was removed and the regular functional training was started. Results Follow-ups ranging from 3 months to 2 years revealed that all the cases of replantation were successful. After operation, the shoulder joint could abduct 50?～90?, anteflect 50?～70?, extend backwards 20?～30?, and adduct 20?～40?. The elbow joint could flex 100?～140?and extend -20?～0?. 3 months after reconstruction, the muscle strength of elbow flexion recovered to Ⅳ～Ⅴdegrees. Conclusion Application of tissues of chest side and back to repair avulsion and severance of upper extremity stage by stages and layer by layer is an ideal method to resolve the contradiction between wound coverage and functional reconstruction because it can restore both the function and appearance.
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Objective To evaluate the functional outcome and long-term problems of a patient 39 years after forearm replantation.Methods The methods and criteria of the China Hand Surgery Association for limb replanta- tion were used to evaluate motion,muscle strength,sensation,cosmesis,and subjective symptoms.Dexterity in vo- cational and daily living activities was also assessed.Results The final evaluation score was 71,and the activities of daily living score was 14.Conclusion The replanted forearm was functioning well.Protective sensation had re- turned,but fine discriminative ability had not,nor had cold tolerance.
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Objective To study the feasibility of adopting temporary revascularization during the course of limb replantation in order to shorten ischemia time and accelerate functional restoration of the severed limb. Methods Temporary revascularization was firstly established with various kinds of canals before the routine replantation was conducted. A statistical comparison of objective indexes was carried out between the revascularization method and the routine method. Results The method of adopting temporary revascularization during the course of limb replantation resulted in more satisfactory clinic effects than the routine method. Conclusion Temporary revascularization during the course of limb replantation plays an important role in accelerating functional restoration of the severed limb, and therefore is practically recommendable in clinics.
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Objective To explore feasibility of monitoring the extremital arterial blood supply and venous blood circulation in rabbits with replanted limb by Na~(99m)TcO_4 trace imaging(TTI). Methods TTI was performed on 6 normal control rabbits and 30 rabbits with replanted limb at 24～36h after replantation. The radioactivity uptake ratio of replanted limb/normal limb(T/NT) was analyzed. Imaging was classified into ?,Ⅰ,Ⅱand Ⅲ scales according to the accumulation amount of extremital radionuclide. Then an exploratory operation was performed on each rabbit. Results Rabbits with ?,Ⅰ,Ⅱand Ⅳ scales had 8,6,15(including 6 normal control rabbits),and 7 animals, respectively, and their T/NT were 0.178?0.072, 0.461?0.046, 0.816?0.074, 1.14?0.086(P1.05) may serve as a qualitative and semiquantitative diagnostic standard for venous blood circulation block. Conclusion TTI was feasible in monitoring the extremital arterial blood supply and venous blood circulation in patients with replanted limb(finger).