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Case Report True proximal third arm replantation: A rare case

Authors:

Abstract

Proximal arm replants are devastating injuries which leave significant disability for the patient. Replantation of proximal limb injuries is widely considered to have poor results, especially so of the proximal third of the arm due to the difficulty in anastomosis of the vessels in the axilla. Furthermore, crush avulsion injuries have a much worse prognosis than clean-cut injuries. Here, we present the successful replantation of a true proximal crush amputation of the upper limb at the level of proximal third arm with satisfactory results in a 19-year-old male. KEYWORDS: Amputation, Microsurgery, Replantation, True proximal third amputation, Upper limb crush injury
Vol 4 | Issue 6 | Nov - Dec 2018 Indian J Case Reports 492
Case Report
True proximal third arm replantation: A rare case
Abhishek Ghosh
From Consultant, Microvascular and Plastic surgery, Noble Hospital, Magarpatta Road, Hadapsar, Pune, Maharashtra, India
Correspondence to: Dr Abhishek Ghosh, Noble Hospital, Magarpatta road, Hadapsar, Pune, Maharashtra, India.
E-mail: drabhishekghosh@gmail.com
Received - 23 October 2018 Initial Review - 08 November 2018 Accepted - 07 December 2018
The functional outcome of a replantation surgery varies
greatly with the level of injury. The general dictum is that the
more distal the injury, the better the outcome. Conversely,
proximal injuries have been handled with the trepidation of
impending failure. Proximal injuries in the arm have been used
loosely to define any upper half injuries of the arm. However, a
true proximal arm amputation is defined as an amputation from
the proximal upper-third of the humerus. True proximal injuries
of the upper limb have suffered from this dismal outlook, with
surgeons more inclined toward amputation than attempt a surgery
that is not only labor intensive but also seems unlikely to succeed.
Although modern prosthetic devices have improved over recent
years, high rejection rates are still observed in patients supplied
with prostheses; thus, replantation of the lost extremity is still
believed to yield better overall subjective results.[1]
Here, we report the case of a successful replantation of a true
proximal arm injury. We hope to challenge the negative outlook
associated with proximal limb injuries and encourage more
surgeons to attempt to salvage the limb whenever possible.
CASE REPORT
A 19-year-old male patient sustained a total amputation at
the level of the right upper third arm after his upper limb got
entangled in a crusher machine in an occupational injury on
November 3, 2015. The patient had complete avulsion of his
upper limb with disruption of the skin, soft tissues, muscles,
vessels, nerves, as well as a fracture of the humerus in the
proximal third (Figs 1 and 2). The patient had no other injuries
and was otherwise fit and healthy. The patient had lost a lot of
blood when he reached the hospital and immediate resuscitative
measures were instituted. The avulsed stump was later brought
in by a bystander. A discussion about replantation attempt was
done with the patient’s relatives, and a decision was made for
emergency replantation.
The patient was in hypovolemic shock with a very feeble
pulse rate of 140/min and blood pressure of 60/40 mmHg. The
patient was resuscitated with intravenous fluids and colloids,
and then, the systolic blood pressure came to 80–90 mmHg.
The patient was shifted to the operation theater and immediate
preparation of the amputated arm was performed while the patient
was being stabilized. The amputated arm was washed copiously
with normal saline and all foreign material was removed. The
vessels and nerves were identified and tagged. The bone was
cleared for about 5 cm to facilitate quick fixation. After general
anesthesia, the stump was debrided and neurovascular structures
were identified and tagged.
The humerus was shortened by about 2.5 cms, and a
stable osteosynthesis with a 4.5-mm plate was performed.
Subsequently, an anastomosis of one deep vein was performed
under magnification with 8-0 polypropylene sutures. The venous
anastomosis was done before the arterial anastomosis to reduce
blood loss after arterial revascularization. The axillary artery
was then anastomosed under magnification and the clamps were
released. Successful revascularization was achieved within 4 h of
the trauma. There was good flow in the vein and distal vessels post-
anastomosis. Two more veins were anastomosed and hemostasis
was achieved. Then, an epineural repair of the radial, ulnar, and
median nerves was performed using microneural techniques.
The muscles were repaired. A fasciotomy of the lower arm and
carpal tunnel release were also performed. The proximal wound
was covered with skin graft after covering the neurovascular
structures with muscle. The distal wounds were repaired, and the
procedure was completed in about 6 h (Fig. 3).
ABSTRACT
Proximal arm replants are devastating injuries which leave significant disability for the patient. Replantation of proximal limb
injuries is widely considered to have poor results, especially so of the proximal third of the arm due to the difficulty in anastomosis
of the vessels in the axilla. Furthermore, crush avulsion injuries have a much worse prognosis than clean-cut injuries. Here, we
present the successful replantation of a true proximal crush amputation of the upper limb at the level of proximal third arm with
satisfactory results in a 19-year-old male.
Key words: Amputation, Microsurgery, Replantation, True proximal third amputation, Upper limb crush injury
Ghosh Proximal arm replant
Vol 4 | Issue 6 | Nov - Dec 2018 Indian J Case Reports 493
Postoperatively, the patient showed good capillary filling of
the fingers and bright red blood on pinprick. Heparin therapy
was instituted postoperatively. Continuous monitoring of the
patient was done in the immediate post-operative period. There
was some proximal skin loss at the site of amputation where
there was severe pre-operative crushing. This was treated
with skin grafting and the wound settled well. Once all the
wounds had healed, the patient was referred for rehabilitation.
The patient showed good progress in the shoulder and elbow
movement and slight movements of the thumb and fingers
(Fig. 4).
Two years after the trauma, the sensitivity of the fingers was
regained. He displayed a good capacity for shoulder and elbow
motion. Wrist movement was possible, but finger movements
were significantly reduced (Fig. 5). Although the patient was
unable to return to his previous work after the injury, he was
satisfied with the procedure and confirmed that he would opt for
replantation again if needed. He is able to independently perform
daily activities and has joined work as a supervisor.
DISCUSSION
Reimplantation is the reattachment of a completely severed body
part and involves reconstruction of all the separated components
of an extremity, including arteries, nerves, and veins [2,3]. The
success of a replantation is not only merely anatomic survival
of the body part but also the functional capability of the rescued
limb. Functional outcomes are known to vary greatly with the
level of amputation [4]. Hand and digit reimplantation are fairly
common procedures now, with well-defined indications and
Figure 1: Complete amputation of the arm at the proximal third
level with avulsed neuro vascular bundles
Figure 2: Avulsion amputation at proximal third arm level
Figure 3: Immediate post-operative picture showing good vascularity
Figure 4: 6 weeks post-operative picture showing well settled
replanted upper limb
Figure 5: Post-operative picture showing (a) good shoulder
movements and (b) satisfactory elbow and wrist movements
a b
Ghosh Proximal arm replant
Vol 4 | Issue 6 | Nov - Dec 2018 Indian J Case Reports 494
contraindications, and a high percentage of success [5]. However,
above-elbow amputations are less common, and indications for
replantation less clear [5,6]. The general dictum is that the more
distal the injury, the better the outcome of replantation [7]. This
is because the more proximal the injury, the greater the muscle
mass, and muscle does not tolerate ischemia well [6-8]. Another
major reason for poor outcome in proximal reimplantation is
difficulty in restoring nerve function, resulting in joint stiffness,
joint instability, infections, and skin and muscle necrosis [3,8,9].
Proximal reimplantation of the upper limb is a complex
surgery and demands a high degree of surgical skill. The
difficulties in anastomosing the vessels inside the axilla in
very high amputations of the arm make these cases particularly
challenging. This is, especially, true for crush injuries, where the
technical demand is high, the surgical duration is long, and the
tissue condition is suboptimal [6,8,9]. These conditions combined
with the cost involved and the poor prognosis associated often
lead to the surgeon considering amputation to be a better option.
However, the loss of an upper limb not only has a very significant
negative effect physically but also severely impacts the patient
psychologically. The stigma of physical impairment and the
negative outlook regarding gainful employment, lifestyle, and
self-care brings on a tremendous psychological stress on the
patient [10]. Furthermore, unlike lower limb prosthesis, even the
latest upper limb prosthesis offers only suboptimal function by
any measure. Despite the increased cost, longer post-operative
care, and higher potential for secondary infection or secondary
operations, reimplantation if successful provides a limb that
affords the patient a level of function and independence far
superior to any prosthesis [10,11].
Patients suffering an amputation usually demand reattachment
without any appreciation of the implications. The patient must be
aware of the possibility of failure, prepared for the lengthy hospital
stay and rehabilitation, financial implications, family hardships,
and psychological stress [5]. Like any surgical procedure,
patient selection is important, and reimplantation criteria include
the essential structures of the amputated part which are well
preserved, the cold ischemia time of the severed limb at normal
temperature which should not exceed 4 h, and the warm ischemia
time which should be ideally less than an hour. The patient should
be in good general health without any serious associated injuries
or systemic disorders.
The experience and skill of the surgeon and the availability
of required instruments and an operating microscope are other
important considerations. If these criteria are fulfilled, then all
attempts should be made to provide the patient with a functional
limb [12]. Ultimately, it is functionality and not anatomic survival
that is important, and hence, meticulous anastomosis of the vessels
and repair of nerves and musculotendinous units primarily are
of utmost importance. In general, the order of tissue repair is as
follows: Bone, tendons, artery, nerve, vein, and skin. However,
in proximal replants, we prefer to anastomose the vein before the
artery so as to reduce the blood loss after revascularization.
Post-operative care is also very important and there is a risk of
reperfusion injury which one should be careful about. Adequate
hydration, probable need for diuresis, wide antibiotic cover, and
maintenance of hemodynamic parameters are the mainstay of
post-operative management. Structured physiotherapy also plays
a very important role to restore the function of the arm.
CONCLUSION
Meticulous surgery followed by stringent post-operative care can
give very rewarding results even in cases of crushed avulsion major
limb amputations dramatically improving the quality of life of
the patient. Here, our patient made a remarkable recovery despite
battling the odds of two negative prognostic factors of being a
true proximal injury, as well as the mechanism of amputation
being a crush avulsion injury. Although this is only a case report
and further studies are undoubtedly required, it is worthwhile to
note that we should not allow the negative prognosis to intimidate
us from doing our best to salvage the limb.
REFERENCES
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2. Whitaker I, Josty IC, van-Aalst VC Jr., Banis JC, Barker JH. Microvascular
reconstruction of the upper extremity. Eur J Trauma Emerg Surg
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3. Webb JB. Replantation in trauma. Trauma 2005;7:1-9.
4. Wood MB, Cooney WP 3rd. Above elbow limb replantation: Functional
results. J Hand Surg Am 1986;11:682-7.
5. Dagum AB, Slesarenko Y, Winston L, Tottenham V. Long-term outcome of
replantation of proximal-third amputated arm: A worthwhile endeavor. Tech
Hand Up Extrem Surg 2007;11:231-5.
6. Medling BD, Bueno RA Jr., Russell RC, Neumeister MW. Replantation
outcomes. Clin Plast Surg 2007;34:177-85, vii-viii.
7. Neumeister MW, Brown RE. Mutilating hand injuries: Principles and
management. Hand Clin 2003;19:1-15.
8. Chew WY, Tsai TM. Major upper limb replantation. Hand Clin
2001;17:395-410.
9. Kleinert JM, Graham B. Macroreplantation: An overview. Microsurgery
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10. Laing TA, Cassell O, O’Donovan D, Eadie P. Long term functional results
from major limb replantations. J Plast Reconstr Aesthet Surg 2012;65:931-4.
11. Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper
extremity amputations. J Hand Surg Am 1995;20:619-22.
12. Ng WK, Kaur MN, Thoma A. Long-term outcomes of major upper extremity
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Ghosh A. True proximal third arm replantation: A rare
case. Indian J Case Reports. 2018;4(6):492-494.
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