Abstract
Surgery for limb replantations dates back to the 1960s when two American surgeons, R. Malt and CF McKhann, performed the very first limb replantation on a 12-yearold boy. The firm criteria for limb replantations have been established over time, However, contraindications are still debatable. Management of limb amputations at Tartu University Hospital follows International indication criteria.
We treated a 22-year-old man, referred from the North Estonia Medical Centre, who suffered a total right dominant arm amputation as an occupational accident at a waste-processing plant. The patient was stable on arrival to the hospital and due to the limited time of ischaemia (3.5 h) we proceeded with urgent replantation. We performed an arm replantation at the level of the humeral diaphysis or mid parts of the biceps/triceps muscles. The total ischaemia time was 5 hours and cefazolin was used as the perioperative antibiotic. The mechanism of trauma was elucidated on the following next day, which was household waste destruction rollers.
On the 3rd postoperative day, a major bleeding occurred from the brachial artery anastomosis. Revision of the anastomosis and interposition grafting was performed using the great saphenous vein, in addition to trombectomy of the deep upper arm veins. The major soft tissue infections with tissue necrosis and three major anastomotic bleedings were attributed to the septic conditions of limb amputation and extensive soft tissue injury. Pseudomonas aeruginosa, Escherichia coli (ESBL positive), Pseudomonas aeruginosa (ESBL positive), Citrobacter coseri, Klebsiella pneumonia, Enterococcus faecium. were grown from the wound cultures. Proceeding from the evolving culture results, multiple antibiotics were administered including cefuroxime, metronidazol, piperacillin-tazobactam, meropenem, imipenem, and vancomycin. Because of the recurring infections, the biceps brachii and brachialis muscles were entirely debrided and a vascularized latissimus dorsi and serratus anterior muscle transposition was performed. Recurrent bleedings from the vascular recosnstructions and soft tissue infections were controlled after the muscle transposition. The patient required altogether 10 operations and the hospital length of stay was 4 weeks.
The final evaluation by the hand surgery service was made in October 2016. Fourteen months after the amputation the patient wasable to use the limb for easier manipulations: shoulder abduction 100° and flexion 80°, outer rotation 45°, inner rotation Th10. Wrist extension and flexion were weak, supinationpronation were at 45°. Considering the level of replantation, our service will re-evaluate the subsequent functionality of the limb two years after the treatment.