What are acquired limb defects and deformities ?

Acquired limb defects and deformities can be as a result of cancer, injuries or severe infections. Injuries are the leading cause of death and disability in children after infancy. Disabling injuries resulting from lawn mowers, traffic accidents, fireworks, power tools, farm equipment, gunshot wounds, or axes or hatchets that result in amputation.

Acquired limb defects require surgical procedures, rehabilitation and prosthetic fitting. One such surgery is replantation.

Replantation is the reattachment of a completely separated/cut body part. In hand surgery this is most commonly a finger or thumb, although replantations of the hand, forearm, arm and other body parts are possible.

Is replantation always possible?

Replantation is not always possible. Sometimes the separated body part is too badly damaged or crushed to reattach. If a patient is hemodynamically unstable/ very sick, or if it has been too long since the injury it might not be feasible to perform replantation. Sometimes surgeon believes that the reattached part will never gain proper movement or adequate sensation so advise against replantation.

What is the difference between a replantation and a transplantation?

In transplantation, the body part that is being attached comes from another person, so transplant recipients need to take medications to reduce the likelihood rejection of the reattached part – unless it comes from their identical twin. In replantation there is no danger that the body will reject the reattached part.

There is no major technical difference between a replantation and transplantation. Both need microsurgical techniques where one body part is reattached to another body part.

First aid treatment for amputation

First aid should be applied both to the affected person and to the amputated part. The primary goal is to ensure the survival of the person.

An amputated part needs to be treated carefully to maximise the chances of successful replantation surgery.

Do:

  • gently remove mud, grass or dirt by running under clean water for 5-10 seconds
  • wrap the part in moistened gauze (or a handkerchief, or a piece of cloth)
  • wrap the part in clean cling-wrap or plastic
  • transport the part with the patient to the nearest hospital

Don’t:

  • soak the part in water, or allow it to become waterlogged
  • allow the part to dry out
  • allow the part to lie directly on ice, as it will freeze (freezing is bad)
  • rub, crush or otherwise injure the part

The purpose of the ice is to keep the amputated part cool at 1-4 degrees celsius. This reduces the metabolism of the tissue, allowing it to remain viable for longer.

Ideally replantation surgery is commenced within 6 hours of the amputation, and the quicker the better.

What to expect during surgery

The damaged tissue is cleaned from the amputated part and from the injured body part. The bone ends are rejoined either using wires or plates. Tendons, muscles, arteries, veins and nerves are repaired insequence.

In successful replantation blood flows within the arteries and veins immediately. Sometimes skin grafts are required to cover where there is missing skin from the injury.

After Surgery

  • The reattached body part is monitored very closely for a number of days to ensure that adequate circulation (both arterial and venous) is maintained.
  • Sometimes a replanted part will get congested with blood because the venous blood flow is inadequate. In such instances leeching may be used temporarily to maintain adequate blood flow (either chemical leeching, or physical leeching – with real medical leeches).
  • Patient needs to be hospitalized for 4-7 days after successful replantation surgery, to monitor the surgery to reduce the likelihood of failure of the surgery due to clots in the blood vessels.
  • Often a blood thinner such as heparin, and aspirin are prescribed to help thin the blood and reduce the likelihood of clots. Antibiotics are also prescribed to reduce the risk of infection.
  • The recovery period varies widely depending on the type of amputation. Blood flow is restored immediately. Sensation in the affected part takes much longer to regain, as an injured nerve must grow (at a rate of 1 inch per month) from the injury site to the tip of the finger before sensation recurs.
  • The recovery of takes 6 weeks and take approximately 6-12 weeks. Return to work after replantation is usually slow (ie 3 months or more) .

Risks and Limitations

Sometimes, despite the rapid and best efforts of everyone involved, replantation surgery is unsuccessful.

Successful replantation surgery depends on delicate microsurgical techniques, where tiny blood vessels are stitched together by hand under a microscope.

Some factors make it more likely that microsurgery will fail (such as smoking, poor condition of the blood vessels, significant crush injury, long standing diabetes) so these factors sometimes may be considered contraindications to replantation.

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