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Sociedad Española de Cirugía Plástica, Estética y Reparadora



Asociación Americana de Cirujanos Plásticos



Asociación Americana de Cirujanos de la Mano

 


 

 

 

 

 

 

 

 

Delayed Ectopical Arm Replantation:

 

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31-January-2004
14,30 h.
X-Ray
31-January-2004
21 h.
Brazo Amputado
Muñón AmputaciónRadiografía Muñón
Reimplante primario

02-February-2004

03-February-2004
16,00 h.
03-February-2004
20,00 h.
Situación CríticaTransferencia a la ingle
Reimplante heterotópico transitorioReimplante heterotópico
12-February-2004
09,00 h.
12-February-2004
14,00 h.
05-March-2004
13,00 h.
Reimplante en brazo final
Finalizado reimplante
Resultado del reimplante
24 - April - 2004
24 - April - 2004
24 - April - 2004
PreOp
Nervio Radial, cabo distal
Nervio Radial, cabo proximal
Vision Macroscopica Nervio Radial
Injertos de Nervio
Injertos de nervio


Israel Sarrio arrived at the Center for Rehabilitation of Levante from Dr. Peset Hospital of Valencia on January 31st of 2004. This patient was referred for left arm replantation, which was clompletely amputated 5cms above the elbow.

At 2 pm, the microsurgical replantation started. The first maneuver was to wash the amputated part and then we undertook a vascular connection to the brachial artery with a silicone tube, to gain some hours of ischeamia by reperfusing the limb. After 15 minutes of reperfusing, we set the replantation to minute 1, as if it were just amputated..

Next we proceeded to fix bone and elbow, then we repaired the brachial artery and three veins. Afterwards all nerves were repaired with microsugical techniques. Finally skin and muscleas were repaired.

This lasted until 9 pm, and the replant was considered succesful. Patient was kept in the ICU for a night, but afterwards he was sent to his room.

During the next days, we proceeded to change dressings daily, and debride if necessary. On February 3rd, we found a wound infection, compromising de venous return, specially at the stump area. The situation was critical, and the arm was about to be lost. We explained this to his family, and they agreed we should attempt anything we could to save the arm, but avoid amputation.

Based on a similar case of ectopic replantation by Michael Wood (Mayo Clinic, Rochester, USA), we proceeded to use his technique in this delayed case that was about fail the replant because of infection and venous compromise. So we decided to amputate the arm and replant it on the femoral vessels, while we could solve the infection at the stump. This lasted four hours. We performed a by-pass over the femoral vessels, that were connected to the braquial artery and cephalic vein under loupe magnification.

The psychological issues with this patient wew significant. He was told that we were keeping his arm alive somewhere else. He was kept is this situation for nine days. After the first day, he understood what were we doing. We proceeded daily with wound cleaning, changing dressings and stump debridement. After some days we performed a test of stump-closing, so we could check that there was no remaining infection.

After nine days, we decided to replant the arm on the stump again, being sure that there was no infection left. This lasted six hours and we performed the same surgery as a conventional replantation. however, we decided finally to cover the replantation with a latissimus lorsi pedicled muscle flap.

At this moment, the patient is discharged from hospital. All wounds are healed well. He underwent some nerve grafting in April. Now he has recovered elbow movement, and has started moving his fingers. we are waiting for nerve growth, with a speed of 1mm per day. So we expect to have a full nerve lenght recovery in about six months.

We expect that this hand will function better than a prothesis, and willlet Israel be independent in hisr daily life.

In this surgery, all the team was present: Dr. Pedro Cavadas, Dr. Angel Navarro, Dr. Santiago Soler, and visitors: Dr. Luis Landin, and Dr. Orlando Gª Duque.

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For more information about this case, please contact us.

 


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