Management of Proximal Third Arm Replantation — Suleyman Tas PubMed

Management of Proximal Third Arm Replantation Süleyman Taş Department of Plastic, Reconstructive and Aesthetic Surgery, İstanbul Kemerburgaz University School of Medicine, İstanbul, Turkey DOI: 10.5152/TurkJPlastSurg.2017.2142 Case Report 196 www.turkjplastsurg.org Correspondence Author: Süleyman Taş E-mail: drsuleymantas@live.com Received: 26.09.2017 Accepted: 03.10.2017 Cite this article as: Taş S. Management of Proximal Third Arm Replantation. Turk J Plast Surg 2017; 25(4): 196-200. Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Abstract Notwithstanding the recent success in major limb replantation achieved through the advancements in microsurgical techniques, the viability of the extremity is still relatively low at the transhumeral level following a replantation. There are no exact guidelines for deciding whether to undertake a stump repair or a replantation in such amputations at the proximal level. However, a highly motivated patient with realistic expectations and protected shoulder function can be a candidate to undergo replan- tation. The replanted arm may help the uninjured arm in daily activities. In this report we present the case of a 47-year-old man whose arm was amputated at proximal third level by an asphalt machine and suc- cessfully replanted together with the encountered problems and their solutions. The roadmap followed in this rare case may be a guide for hand surgeons. Keywords: Proximal, arm, replantation INTRODUCTION Replantations of the hand and the digits have become common surgical procedures through well-defined indications and contraindica- tions. Yet, cases above the wrist level are still rare, with no definitive indications. The incidence of transhumeral amputations, on the other hand, constitute only 3% of the amputation-type injuries to the upper limbs. 1,2 Despite the advancements in microsurgical techniques, the viability prognosis of the limb is still a low 50 to 70% following a replantation at transhumeral level.2,3 Using a precise algorithm is critical in achieving successfully viable outcomes in major replantation procedures, and allow for potential secondary functional reconstructions. 4 Traumatic major amputations of the upper limb are reported to be devastating injuries with extensive impacts on the life quality, so - cio-economic and psychological states of patients.5,6 Since the first replantation of the upper limb performed by Malt and McKhann7 in 1962, the number of replantation cases have gradually increased and ever more patients, regardless of the type and severity of the injury, apply to hospitals in hope of recovering a severed body part. 8-10 In major replantations the decision should be based on the overall condition of the patient, ischemic time, the level, type and extensity of the injury. 10-13 Replantation procedures also require long operating times, repeated procedures, long rehabilitation periods, as well

as patient motivation for optimal outcomes. Therefore, to en- sure the safety of the patient, the decision should be made by an experienced surgeon that has the technical means as well as access to resources including ER, ICU, anesthesia and physiotherapy teams.4,14 Replantations at the level of radiocarpal joints or at higher levels, such as the wrist, forearm, transhumeral or shoul- der, are defined as major replantations. 15 While substantial clinical experience can be found in the literature in digital and mid-hand replantations, less is known about major replantations due to the scarcity of clinical series. 6, 16-18 To contribute to the availability of reports in this area and to offer a possible guide for hand surgeons, in this case report we present our experience, and our treatment and man- agement approach in the replantation of a proximal-third avulsed arm. CASE REPORT A 47-year old male patient applied to the ER after his left arm got caught in the belt of an asphalt machine and was am- putated at the proximal one-third portion. The patient pre - sented with high-level humeral amputation at the immediate distal portion of deltoid attachment together with a crush- type injury running to the mid-upper arm. Physical examina- tion of the patient revealed no bolus-type bleeding, but an avulsion-type injury was observed together with compressed blood vessels and nerves and thrombosed vessel ends. Bra- chial plexus was evaluated and found intact. Cold ischemic time was one hour. The patient reported his dominant hand to be the right one, and having no disease history, use of medication or previous surgery. The amputated piece of the arm was seen to be brought in optimal condition, however had been subjected to a crush injury when caught between the belts of the machine (Figure 1). Direct radiography showed that the left shoulder joint had been totally amputated with a transverse fracture approx - imately 5 cm to the distal. Direct radiography of the ampu- tated piece showed no additional fractures. In the absence of any other traumas and after the patient and his family were informed, the patient was prepared for an emergency replan- tation. Since the patient’s preoperative hemoglobin level was 6.0, blood was procured before the patient was transferred to the operating room. Before the patient was moved to the operating table and rou- tine preparations were performed, the amputated piece was placed on a separate operating table for debridement and ir - rigation followed by microscopic identification of the vascular and neural structures. After the patient was sedated, debri- dement, irrigation and neurovascular examination were also performed on the stump and decision was made to excise a 5-cm vascular segment associated with an avulsion-type injury pattern. After a 2.5-cm osteotomy was performed on both the stump and the amputated piece, the bone was fixed using one dynamic compression plate and six screws. Brachial artery was repaired microscopically with 8-0 prolene. After reperfusion the patient was alkalized using 2 vials of so- dium bicarbonate. 50 mL mannitol was administered as os- motic diuresis and fluid therapy was started with urine output at 100 mL/hr. The time from the injury to arterial revasculari- zation was 3 hours. To prevent release of lactate and myoglo- bin content from the amputated piece to systemic circulation, the arm was allowed to reperfuse for 30 minutes before pro - ceeding to venous anastomosis. In the meantime, epineural repair was performed on the median nerve at intact fascicular level using 8-0 prolene. Three veins, brachial, cephalic and ba- silar, were repaired. Epineural repair was performed on ulnar and radial nerves also at fascicular level. Vein and nerve graft- ing were not deemed necessary since osteotomy allowed for a primary reconstruction of the neurovascular structures. Af- ter muscle and skin reconstruction, it was seen that the total operation time was 10 hours. Cold ischemic time was 3 hours and hot ischemic time was one hour. Dermo-fasciotomy was planned as part of the follow-up since perfusion of the limb was good and edema was minimal. After a penrose drain was placed, wound dressing, and plaster cast splinting were ap - plied, and the patient was transferred to the ICU (Figure 2). When increased pressure in the arm and forearm compart - ments was identified by skin turgor and palpation 32 hours after the surgery, decision was made for emergency dermo- fasciotomy—notwithstanding that capillary refill rate at the finger tips and oxygen saturation measured by oximeter was 96—and the procedure was performed while the patient was Turk J Plast Surg 2017; 25(4): 196-200 Taş S / Proximal Third Arm Replantation 197 Figure 1. View of the left arm amputated at the proximal one-third portion as a result of an avulsion injury

in the ICU. Instead of a typical line, the fasciotomy incision line of the arm was placed on the lateral arm, at a distance of 15 cm to the sulcus between the biceps and triceps muscles. Fasciotomy was performed over this incision on the anterior, lateral and posterior compartments of the arm. The incision line of the forearm was placed on the anterior mid-line, also at a distance of 15 cm. Anterior compartment fasciotomy was performed over this incision. Additional fasciotomy of 3 cm each was performed in the 2 nd and 4th web spaces on the hand dorsal. Open wounds were closed using wet dressing over gauze soaked in antibiotic skin ointment. Following 2-3 hours of natural hemostasis on wound borders, negative pressure wound therapy (V.A.C. Negative Pressure Wound Therapy System, KCI, Inc., San Antonio, Texas, USA) was started for the open wounds that formed on the arm and forearm due to fasciotomy. Measurement after the first vacuum application showed that the patient’s arm diameter was 53 cm, and fore- arm diameter was 42 cm (Figure 3). After four sessions of vacuum therapy applied at 2-day inter - vals, the diameters of the arm and the forearm had decreased to 39 cm and 35 cm, respectively (Figure 4). Since the patient’s overall condition was good, a reconstruction procedure was performed on the granulated tissue using partial-thickness skin graft. No graft loss was seen on the 3 rd postoperative day. Physiotherapy was started at the 1 st postoperative month. At the 3rd postoperative month Tinel’s positivity was compatible with the course of all three nerves, and at postoperative 6 th, 9th, and 12th months Tinel’s positivity was seen to advance at the elbow level. At the 12 th postoperative month the patient was observed to have shoulder mobility and limited elbow flexion, but had not regained any other motor functions. All joints were within normal passive mobility limits. All fingers showed reaction to hot and cold, and protective sensation was present. The patient’s functions were classified as Grade 3 according to Chen’s 19 criteria (Figures 5, 6). DISCUSSION Since major amputations of the upper limbs can give rise to devastating psychological and socio-economic scenarios, replantation should be considered if the patient is in good health and has no contraindications. 4 There are no clear guidelines for deciding whether to treat the limb with replantation or with stump reconstruction. 2 Replan- Turk J Plast Surg 2017; 25(4): 196-200Taş S / Proximal Third Arm Replantation 198 Figure 2. Circulation in the replanted limb was seen to be good in the patient who was transferred to the ICU immediately after the pro- cedure Figure 4. After four VAC applications and before grafting, the diame- ter of the arm (left) and the forearm (right) decreased to 39 cm and 35 cm, respectively Figure 3. View of the replanted arm (left; diameter: 53 cm) and forearm (right; diameter 42 cm) after fasciotomy and first VAC app - lication

tation of the arm can be tried in a highly-motivated patient fostering realistic expectations if the shoulder functions are intact. 20 Nevertheless, the patient should be prepared for a long rehabilitation period and a number of surgeries. In these types of replantations, rather than a full recovery, the primary aim is to ensure the viability of the replanted limb and the secondary aim is to provide a ‘helper arm’ . The con- cept of a helper arm comes from the literature on brachial plexus, and is defined as having a stable shoulder, active el- bow flexion and some sensation in the hand. In the presence of these, the replanted limb can assist the other arm in tasks such as carrying and holding. It is known that if shoulder func- tions and brachial plexus remain unharmed, a helper arm can be achieved even if the muscles and the nerves are avulsed. 2 Sensation can be achieved with nerve grafting. In the case we present, a helper arm concept could be achieved since shoul- der mobility, elbow flexion and protective sensation of the hand were not lost. Fasciotomy is recommended as a routine procedure when the injury is of a crush type and total ischemic time (hot/cold) is six hours or longer. 21 A typical fasciotomy line on the volar side will begin at the mid-line of the wrist and follow an in- cision line decompressing the median nerve, radial artery, ulnar artery, ulnar nerve, and brachial artery-vein packages. On the extensor side, the 2 nd and 4th web spaces are the inci- sion lines frequently chosen for decompression. 22 While fas- ciotomy aims at relieving the nerve-artery/vein packages, it also causes these packages to be exposed, thereby leading to problems at dressing and reconstruction stages and neces- sitating challenging flap surgeries rather than easier wound closure methods such as grafting. Therefore, artery-vein pack- ages that are exposed in the replanted limb as a result of a fasciotomy are usually covered by transpositioning the sur - rounding muscle tissues. Since in crush-injuries circulation in the muscular tissue is also damaged, transposition can also increase the amount of ne - crosis that can develop on the wound line. Vacuum application is a frequently used, almost routine, method in both plastic and reconstructive surgery. In our review of the literature we found no reports about it use in limb edema and compartment syndrome. In the case we present, we decided for an immediate fasciotomy after the total ischemic time was seen to be 4 hours, and aimed at le - veraging the controlling effect that the skin has on edema. In the fasciotomy performed 32 hours after the surgery, instead of a typical fasciotomy incision line, we chose the lateral arm in the absence of a risk of exposing the brachial artery-vein package, and simultaneously started a vacuum therapy for the fasciotomy wounds on the arm and forearm. This, while quickly taking under control the edema in the limb, also en- abled granulation of the surface for holding the graft over the fasciotomy lines, since primary closure would not be possible and graft surgery was required. CONCLUSION Despite the technological advancements, major limb re - plantations still continue to be a challenging process from the decision for surgery to its long-term outcomes. Never - theless, we believe that better outcomes will be achieved with the help of scientific and technological advance - ments. Informed Consent: Written informed consent has been obtained from the patient. Peer-review: Externally peer-reviewed. Conflict of Interest: No conflict of interest was declared by the author. Financial Disclosure: The author declared that this study has recei- ved no financial support. Turk J Plast Surg 2017; 25(4): 196-200 Taş S / Proximal Third Arm Replantation 199 Figure 6. One year after the surgery, two-way direct radiography showed that the bones were united and stable Figure 5. (Left) One year after the surgery, the replanted limb was seen to have formed a regular-shaped shoulder with no abnormality in posture. (Right) The patient was also observed to have shoulder mobility and limited elbow flexion

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