Forearm Replantation Research Articles

How can we reduce the ischemic time for forearm replantation? Tips to simplify the bone fixation

PurposeIschemic 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.MethodsFrom 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.ResultsA 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.ConclusionsTo 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 evidenceRetrospective study, Level III.

Forearm replantation: pearls and pitfalls

Forearm replantation is a challenging procedure for both patients and medical professionals. High survival rates are now being achieved owing to developments in microsurgical techniques. However, patient expectations for a “functional hand” are ever-increasing. To obtain satisfacto-ry functional results following major limb replantation, it is important to reduce the ischemic time. During forearm replantation, the time from the beginning of surgery to the anastomosis of the artery should be minimized. This step includes anesthesia, wound debridement, and bone fixation, which are key factors in choosing the most efficient method and reducing the time needed. Herein, we review the prognostic factors and report the general operative procedures for forearm replantation using our proposed surgical technique.

The Effect of Forearm Shortening on Forearm Range of Motion

Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening. A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model. Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2-4 cm of shortening and in pronation at 4-6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow's location. This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm. This information may improve surgeons' and patients' understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.

A serious complication after forearm replantation caused by a cord tightened on the stump during transportation – a case report

Abstract In amputations of an upper extremity, an adequate preservation of the amputated part during its transport to a replantation centre is very important: it needs to be maintained at about 4°C. Providing adequate haemostasis of the extremity stump is also important for the patient’s safety, to avoid bleeding on the journey. The article presents the case of a patient who had sustained a hand amputation at the forearm, in which bleeding from the stump was stopped with a cord that has been tightened on the forearm, 10 cm above the amputation site. Transport for the patient took over 6 h and resulted in a critical ischaemia of the forearm stump. Replantation was successfully performed, but an excessive oedema of the ischaemically injured part of the stump developed in the post-operative course, requiring a fasciotomy, resection of the necrotic muscles, following by coverage of the defects with skin grafts. No complications were observed in the replanted part of the forearm, and the prognosis towards recovery of good hand function is moderate, due to the loss of a portion of the forearm muscles.

Replantation of forearm with abandoned fingers for emergency finger reconstruction

Objective To explore the surgical method and clinical efficacy of emergency finger reconstruction with forearm replantation using abandoned fingers. Methods From February 2003 to February 2019, 15 patients with only 2 or 3 finger intact were treated by forearm replantation using abandoned fingers for finger reconstruction. Among them, 3 fingers were reconstructed in 2 cases and 2 fingers were reconstructed in 13 cases. Results All reconstructed fingers survived and the wounds achieved primary healing. The follow-up time was 3 to 12 months with an average of 6 months. The reconstructed finger was similar to the original finger in shape, with good function, grasping and other basic functions. The pulp sensation recovered well. The two-point discrimination was 5 to 10 mm. The patients were satisfied. According to the evaluation criteria of thumb and finger reconstruction function issued by the Hand Surgery Society of the Chinese Medical Association, the results were rated as excellent in 3 cases, good in 9 cases and fair in 3 cases. Conclusion Emergency replantation of forearm with abandoned fingers to reconstruct finger is an ideal method for emergency treatment of wrist injury, reconstruction and recovery of some hand functions. Key words: Finger injuries; Replantation; Microsurgery; Hand reconstruction

The use of a Gore-Tex prosthesis to stabilise venous drainage in an amputated distal forearm replantation

Venous drainage disorders are one of the common complications after peripheral limb replantation. We report a middle-aged male patient who underwent a macro-amputation of the distal forearm at the wrist as part of an occupational accident. After successful replantation, a postoperative venous drainage disorder develops, which despite multiple revisions and the installation of a wide venous grafts could not be permanently repaired and endangered the preservation of the hand. The use of a Gore-Tex prosthesis allows a sufficient venous drainage and was the last option to preserve the limb. As far as we know, the available sources give no information about the use of Gore-Tex prostheses in venous drainage restoration in a case of hand replantation. The resulting limb drainage was sufficient, exhibiting both stability and minimal complications in healing. Despite significant advances in surgical technique, replanting the amputated hand in the forearm remains a challenge for the reconstructive surgeons’ community.

Odległe wyniki replantacji rąk

ABSTRAKT Wstęp: Celem pracy była ocena wyników czynnościowych u pacjentów, którym wykonano replantacje rąk w Klinice Chirurgii Ogólnej i Chirurgii Ręki Pomorskiego Uniwersytetu Medycznego w Szczecinie, co najmniej przed 5 laty. Materiały i metody: Zebrano dane 54 pacjentów, którym w latach 2009–2012 wykonano udaną replantację amputowanych rąk lub palców. Do tych osób wysłano zestaw kwestionariuszy z pytaniami o sprawność kończyny (kwestionariusz DASH), poziom jakości życia (kwestionariusz SF-36), objawy nadwrażliwości na ochłodzenie i powrót do pracy. Otrzymano 22 wypełnione kwestionariusze (41% wysłanych) i te dane były przedmiotem analizy. W tej grupie było także 5 pacjentów, których zbadano bezpośrednio w szpitalu. Podstawę oceny stanowiły wyniki uzyskane od 22 pacjentów, 20 mężczyzn i 2 kobiet w średniej wieku 43 lat (zakres 20–82), którzy mieli wykonaną replantację ręki/palców średnio 6,5 roku przed badaniem (zakres 5–7). Najwięcej pacjentów miało replantację na wysokości śródręcza (n = 9), palców II–V (n = 8), nadgarstka (n = 2), kciuka (n = 2) i przedramienia (n = 1). Przyczyną urazu w 15 (68%) przypadkach była piła tarczowa, a w pozostałych maszyny przemysłowe i rolnicze. Wyniki: Średnia punktacja kwestionariusza DASH dla całej grupy wynosiła 23 (zakres 2–74), co wskazywało na średnio niewielkie upośledzenie czynności replantowanej ręki. Bardzo dobrą czynność ręki miało 10 (45%) pacjentów (DASH &lt;20), 7 (32%) – niewielkie upośledzenie (DASH 21–40), a 5 (23%) – znaczne upośledzenie (DASH &gt;40). Najlepsze wyniki pod względem czynnościowym wykazywali pacjenci po replantacjach nadgarstka i kciuka (DASH 4), nieco gorsze po replantacjach palców II–V (DASH 16), a najgorsze po replantacji śródręcza i przedramienia (DASH 33). Średnia punktacja kwestionariusza SF-36 w domenie fizycznej wynosiła 61 pkt (dobra jakość życia), a w sferze mentalnej 58 pkt (średnia jakość życia). Dość dokuczliwe objawy nietolerancji zimna miało 20 (91%) pacjentów. Do wcześniej wykonywanej pracy wróciło 12 (54%) osób. Wniosek: Uzyskane wyniki wskazują, że większości pacjentów udało się uzyskać dobrą czynność replantowanych rąk, pozwalającą na dobre funkcjonowanie w życiu codziennym, a części na powrót do pracy.

Forearm Replantation for a Patient Presented with Major Amputation Injury: A Case Report

Forearm Replantation for a Patient Presented with Major Amputation Injury: A Case Report

Negative pressure wound therapy in the early period after hand and forearm replantation, is it safe?

In this study, effectiveness and reliability of negative pressure wound therapy (NPWT) in the early period after replantation will be examined retrospectively in a series of patients. Patients who underwent replantation between 2007 and 2014, and had tissue defect or partial necrosis in the absence of a major circulation problem were included in this retrospective study. Following debridement of necrotic tissues on the postoperative 7-10 days, NPWT was applied to all patients one day later and adjusted as intermittent 75 mmHg pressure. Intermittent phase adjustment was arranged as 5 minutes suction and 2 minutes resting, and resting pressure was adjusted as 35 mmHg. NPWT was applied for six days and dressings were changed in every three days in the first six day period. Open wounds was debrided again and grafted with split-thickness skin graft and NPWT was continued over the graft for 4 days more. There were 11 patients included of which nine amputations were complete and two were nearly total amputations of forearm. Granulation tissue was observed following 6 days of NPWT application in all patients. Graft survival was observed to be almost complete. Wound infection did not occur and tissue cultures obtained in the course of debridement were all negative. Partial oxygen saturations were between 96-99% during the NPWT. NPWT (75 mmHg) can be used in the intermittent mode in order to improve wound healing and shorten the period to start physical therapy in the early period after replantation and revascularisation.

Limb salvage procedures for mutilated forearm injuries

Objective To report the limb salvage experience in patients with mutilated forearm severance. Methods From September 2012 to October 2014, 8 severed forearms with mutilated injuries were salvaged by shortening and replantation of the forearm after emergency debridement. Results The replants survived in all 8 cases. Postoperative follow-up ranged from 6 to 24 months. Based on the evaluation criteria for the upper extremity issued by the Hand Surgery Society of the Chinese Medical Association, functions of the salvaged forearms were rated as excellent in 1 case, good in 5 cases, and poor in 2 cases. Postoperative complications included arterial crisis in 1 case that was rescued by surgical exploration and vascular re-anastomosis; severe infection in 1 case that was successfully managed with antibiotics treatment; forearm fracture nonunion in 1 case that was healed with secondary fixation and bone graft; and tendon adhesion in 1 case that was treated with secondary tenolysis. Conclusion Limb-salvage procedures should be considered in mutilated forearm severance cases when conditions allow. Reasonable functional outcomes can be expected. Key words: Forearm; Treatment outcome; Mutilated injuries; Limb salvage

Evolution and clinical application of microsurgery

Evolution and clinical application of microsurgery

Proximal Forearm Transplantation for Below Elbow Amputations: Rationale and Surgical Technique

Proximal forearm replantation presents with multiple challenges. In this paper, we present the unique advantages of transplantation at the level of proximal forearm and contrast this to replantation. We describe the rationale for transplantation following below elbow amputation: the bone level allows fixation and preservation of the functioning elbow joint, and the muscle can be reconstructed above the elbow. The surgical procedure including anatomic dissections is also illustrated.

Combination Therapy Comprising Intra-wound Continuous Negative Pressure, Irrigation Treatment and Artificial Dermis was Useful for Successfully Salvaging an Exposed Artery after Crushed Forearm Replantation

Combination Therapy Comprising Intra-wound Continuous Negative Pressure, Irrigation Treatment and Artificial Dermis was Useful for Successfully Salvaging an Exposed Artery after Crushed Forearm Replantation

An economic analysis of hand transplantation in the United States.

Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations. One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results. For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY. Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

Continuous Infraclavicular Block for Forearm Amputation After Being Bitten by a Saltwater Crocodile ( Crocodylus Porosus): A Case Report

Two important issues after a complete right forearm amputation are replantation and ongoing pain management. There are no reports of successful forearm replantation as a consequence of a crocodile bite. Here, we discuss our pain management in a case of complete forearm amputation after a bite from a saltwater crocodile (Crocodylus porosus), which necessitated six further operations to achieve successful replantation. Continuous infraclavicular brachial plexus block was effective for acute pain control in this case. We strongly recommend performing the block with an indwelling catheter under ultrasound guidance for higher accuracy and safety.

A Detailed Comparison of the Functional Outcome After Midforearm Replantations Versus Midforearm Transplantation

Objectives The functional outcome after midforearm transplantation (HT) is believed to be similar to the outcome after replantation. However, the few existing reports comparing functional outcomes are based on amputations at the level of the distal forearm. This report provides a comparative analysis of the functional results after midforearm replantation (HR) versus HT. Materials and Methods Transplantation of a dominant right forearm performed in a 32-year-old man was compared to the outcomes after five dominant (right) forearm replantations (four men and one woman) in patients ranging from 22 to 38 years of age. Cold ischemia time ranged from 6 to 12.5 hours in all cases. We used similar operative technique and rehabilitation protocol. At 26 (±2) months after replantation/transplantation, we recorded, bony union (x-ray), arterial flow (ultrasonography), range of motion, grip strength, sensation (2 PD Weisensten's filaments), quality of life (DASH, 30–150 points), general evaluation of function according to Chen's or the IRHCTT scoring system. Results A complication of wound infection was observed in one HR patient; Marginal skin necrosis accompanied by prolonged wound healing, in one HT patient. Unification of bones was achieved faster after forearm replantation when compared with transplantation. Grip strength was 17% greater after replantation, but ranges of motion were comparable in both groups. Sensitivity was superior after forearm transplantation (2 PD 15 mm) and overall patient satisfaction was comparable (90 points of DASH questionnaire for HR versus 108 points for HT patients). None of the patients returned to their previous occupations. Conclusion The functional outcome after HT was comparable, and in some respects superior, to the outcome after replantation performed at the midforearm level.

Osteomyoperiosteal Decortication Supplemented by Bony Transplants in the Treatment of Primarily Created Bony Defects of the Forearm Bones in Patients After Forearm Replantation

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Low-Molecular-Weight Heparin for Prevention of Thrombosis: Inverted Role

Heparin induced thrombosis (HIT) after low-molecular-weight (LMWH) administration for thrombosis prevention is a limb and life threatening condition. Two previously healthy individuals, with nonviable forearm amputation and knee osteoarthritis, suffered from multiple arterial thromboses (>2 sites each) after postoperative administration of LMWH. Both patients suffered from thrombocytopenia on the first postoperative days (4-7) and had signs of arterial occlusions on the 9th and 10th postoperative days. The patient with the initially successful forearm replantation was finally amputated below the elbow, whereas the lower extremity of the patient with total knee arthroplasty and contralateral femoral artery occlusion was salvaged with foot fingers amputation only. Early recognition of the syndrome by monitoring daily platelet counts during heparin therapy is essential. In case of postheparin (LMWH or unfractionated) platelet decrease, heparin administration should be ceased after emergency testing for heparin induced antibodies. When HIT syndrome is confirmed to have occurred, heparin/LMWH must be replaced with thrombin-specific inhibitors.

Treatment of Infected Wounds with Maggot Therapy after Replantation

Postoperative wound infection is a rare, but major, complication of replantation. Failure to control infection can lead directly to vascular thrombosis and, in turn, to loss of the replanted extremity. The use of maggots for wound debridement has a long history and has been lately re-introduced for treatment of intractable wounds. In this report, the authors present the experience of successful debridement of a severely infected wound after forearm replantation, using maggot therapy. The results and mechanism of maggot therapy are discussed.

Replantacja kończyny górnej u 55-letniego chorego - opis przypadku

Replantacja kończyny górnej u 55-letniego chorego - opis przypadku