Monicccaabout 7 years ago

Reattachment of an Amputated Arm and Hand. Result 9 Years after Replantation.

The right arm of a 17-year-old patient was completely crush amputated at the above elbow level in a motor vehicle collision. The patient was admitted 4 hours after the accident. The avulsion crush injury involved skin, bone, tendon, nerve, and vascular defects. The reattachment procedure involved repair of all functional structures under general anesthesia. Following debridement and bone shortening metal plate osteosynthesis of the humerus shaft was performed. Vascular anastomoses of the brachial artery and two veins were performed under a microscope. Avulsed tendons of the biceps and triceps muscles were reimplanted into their muscle bellies. Median, ulnar, radial, and medial antebrachial cutaneous nerves were sutured. The ulnar nerve was transposed anteriorly to avoid tension at the repair site. Closed forearm fasciotomy was preformed to prevent compartment syndrome. The procedure lasted almost 5 hours. The total warm and cold ischemia time was appr. 7,5 hours. Postoperatively, the elbow was immobilized in up to 90º of flexion to reduce the tension on the nerve anastomoses. Surgeon-controlled active and passive motion of the elbow was started at 4 weeks postoperatively. To encourage nerve regeneration voluntary early exercises were advised for the still paralyzed muscles. To prevent stretch injury to the nerve anastomoses, full extension at the elbow was achieved gradually during the fist 3-4 postoperative months. Dynamic adhesive first web space splint to support recovery of the thumb extension and abduction was used. Static splints keeping PIP joints in extension were employed to facilitate intrinsic muscle function. The video also demonstrates useful functions of the replanted limb at 9-year follow-up. The replant remained cold sensitive. Reasonable sensory and motor function was achieved. The previous non-dominant right hand has spontaneously re-educated into the new dominant one. Conclusion: Tension free meticulous nerve repair and postoperative individual exercises are crucial for functional recovery after major limb replantation. Replantation was performed by Valdas Macionis, M.D., Plastic and Reconstructive Surgeon, at Vilnius University Hospital, Vilnius, Lithuania.