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Replantation surgery a great hope for amputees

By Dr Chandan Nag Choudhury
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Replantation refers to the surgical reattachment of a finger, hand or arm that has been completely cut from a person's body. The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged.

The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital and months or years of rehabilitation.

Anatomic features that are specific to the amputation and not related to the patients' health or history include the level and complexity of the injury. More distal injuries have better success in terms of function, but an exception is distal replants wherein establishing circulation may be more difficult. Sharp injuries tend to do better than crushing or avulsion injuries. Crush and avulsive injuries tend to involve a wide path of tissue that is irreversibly damaged.

The most important deciding factor for surgery is the ischemia time. Ischemia time refers to the total time the part doesn't have circulation and therefore, not receiving oxygen. The longer the ischemia time the worse the prognosis. This is particularly true for warm ischemia where oxygen consumption and free radical formation is increased. For this reason, parts are kept cool, but not frozen on ice. Warm ischemia ranges from 6 to 8 hours whereas cold ischemia ranges from 12 to 24 hours depending on the level of amputation.

Cooling the amputated part can substantially increase the time that can elapse between injury and surgery. When preparing patients for transfer to a replantation centre, emergency medical personnel will package the amputated limb or digits on ice in order to optimize the chance for successful replantation.

Transportation of the amputated part is very important in the success of the replantation. The amputated part should be cleaned preferably with normal saline or tap water and wrapped with a clean and moist towel and put in a plastic bag. This plastic bag, in turn, is kept in another plastic bag containing ice. The amputation stump should be given a compression bandage to stop bleeding.

The indications for replantation have broadened over the last decade as we have gained experience attempting to salvage more complex injuries. The following are indications for replantation: amputations in children, multiple fingers and hand amputations, thumb single finger injuries, ring avulsion injuries, et al.

Because the surgery can take many hours, the stresses of anaesthesia and vascular changes such as hardening of the arteries may substantially increase the risks of the procedure for the older patient and decrease the chances for replantation success.

There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are trimmed before they are rejoined. This makes putting together the soft tissue on either side of the wound easier. Arteries, veins, nerves, muscles and tendons are sewn back together. Areas without skin are covered with skin that has been taken from other areas of the body. Uncovered nerves, tendons and joints may be covered by a free-tissue transfer where a piece of tissue is removed from another part of the body, along with its artery and veins.

Patients are watched closely for the first 48 hours. The patient's room is kept very warm after surgery to keep blood vessels dilated and to prevent blood clot formation. Blood-thinning medication is required for up to a week after surgery.

Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, etc. Even after you have recovered fully, you may find that you cannot do everything you wish to do.

Some patients who have fully recovered from replantation surgery may need surgery later to reach full usage of the part. Some of the most common procedures are:

1. Tenolysis - It frees tendons from scar tissue.

2. Capsulotomy - It releases stiff, locked joints.

3. Tendon or muscle transfer - It moves tendons or muscles to another spot so that they can work in an area that needs the tendon or muscle more.

4. Nerve grafting - It replaces a scarred nerve or a gap in the nerves to improve how the nerve works.

You have many great gifts. Even with the best medical care, you need to be strong during the course of recovery. Remember that quality of life is directly related to your attitude and expectations not just regaining limb use.

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Replantation surgery a great hope for amputees

Replantation refers to the surgical reattachment of a finger, hand or arm that has been completely cut from a person's body. The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged.

The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital and months or years of rehabilitation.

Anatomic features that are specific to the amputation and not related to the patients' health or history include the level and complexity of the injury. More distal injuries have better success in terms of function, but an exception is distal replants wherein establishing circulation may be more difficult. Sharp injuries tend to do better than crushing or avulsion injuries. Crush and avulsive injuries tend to involve a wide path of tissue that is irreversibly damaged.

The most important deciding factor for surgery is the ischemia time. Ischemia time refers to the total time the part doesn't have circulation and therefore, not receiving oxygen. The longer the ischemia time the worse the prognosis. This is particularly true for warm ischemia where oxygen consumption and free radical formation is increased. For this reason, parts are kept cool, but not frozen on ice. Warm ischemia ranges from 6 to 8 hours whereas cold ischemia ranges from 12 to 24 hours depending on the level of amputation.

Cooling the amputated part can substantially increase the time that can elapse between injury and surgery. When preparing patients for transfer to a replantation centre, emergency medical personnel will package the amputated limb or digits on ice in order to optimize the chance for successful replantation.

Transportation of the amputated part is very important in the success of the replantation. The amputated part should be cleaned preferably with normal saline or tap water and wrapped with a clean and moist towel and put in a plastic bag. This plastic bag, in turn, is kept in another plastic bag containing ice. The amputation stump should be given a compression bandage to stop bleeding.

The indications for replantation have broadened over the last decade as we have gained experience attempting to salvage more complex injuries. The following are indications for replantation: amputations in children, multiple fingers and hand amputations, thumb single finger injuries, ring avulsion injuries, et al.

Because the surgery can take many hours, the stresses of anaesthesia and vascular changes such as hardening of the arteries may substantially increase the risks of the procedure for the older patient and decrease the chances for replantation success.

There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are trimmed before they are rejoined. This makes putting together the soft tissue on either side of the wound easier. Arteries, veins, nerves, muscles and tendons are sewn back together. Areas without skin are covered with skin that has been taken from other areas of the body. Uncovered nerves, tendons and joints may be covered by a free-tissue transfer where a piece of tissue is removed from another part of the body, along with its artery and veins.

Patients are watched closely for the first 48 hours. The patient's room is kept very warm after surgery to keep blood vessels dilated and to prevent blood clot formation. Blood-thinning medication is required for up to a week after surgery.

Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, etc. Even after you have recovered fully, you may find that you cannot do everything you wish to do.

Some patients who have fully recovered from replantation surgery may need surgery later to reach full usage of the part. Some of the most common procedures are:

1. Tenolysis - It frees tendons from scar tissue.

2. Capsulotomy - It releases stiff, locked joints.

3. Tendon or muscle transfer - It moves tendons or muscles to another spot so that they can work in an area that needs the tendon or muscle more.

4. Nerve grafting - It replaces a scarred nerve or a gap in the nerves to improve how the nerve works.

You have many great gifts. Even with the best medical care, you need to be strong during the course of recovery. Remember that quality of life is directly related to your attitude and expectations not just regaining limb use.