Proper preservation of amputated parts: A multi-level shortcoming.

BACKGROUND: Successful replantation relies on proper preservation of traumatically amputated parts. The established protocol for preservation, however, is inconsistently adhered to. The objective of this study is to examine the rate of proper preservation in multiple patient populations. METHODS: A retrospective review of patients from 2015 to 2019 at a single academic institution was conducted. Patients were included if they suffered a traumatic amputation, the amputated part was present for evaluation by the hand surgery team, and modality of preservation was documented. Additional data including method of patient transport, replantation attempt, and operative outcome were assessed. Patients were stratified based on whether proper preservation was employed and compared using chi-square tests. RESULTS: Ninety-one patients were included, thirty-one (34.1%) of whom had amputated parts which were properly preserved. Patients from referring facilities were more likely to present with properly preserved parts (45.0%) than those presenting from home (25.5%), though this did not meet significance (P = .051). In total, 74 patients arrived via EMS with 35.1% adherence to preservation protocol. Of the 31 patients who had properly preserved parts, 58.1% underwent attempted replant; of the 60 patients who had improperly preserved parts, 23.3% underwent attempted replantation (P = .001). CONCLUSIONS: The majority of patients who suffer traumatic amputations do not present with properly preserved amputated parts, limiting potential replantation. With a direct correlation to attempted replantation, proper preservation is a crucial aspect of care and should not be overlooked when seeking to optimize efforts and results. LEVEL OF EVIDENCE: Level IV.

Ex vivo limb perfusion for traumatic amputation in military medicine.

BACKGROUND: Limb loss has a drastic impact on a patient's life. Severe trauma to the extremities is common in current military conflicts. Among other aspects, "life before limb" damage control surgery hinders immediate replantation within the short post-traumatic timeframe, which is limited in part by the ischemic time for successful replantation. Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation. PRESENTATION OF THE HYPOTHESIS: The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device, as there are several opportunities present with the introduction of this technique on the horizon. We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time, provide surgical opportunities such as preparation of the stump and limb, allow for spare-part surgery, enable rigorous antibiotic treatment of the limb, reduce ischemia-reperfusion injuries, enable a tissue function assessment before replantation, and enable the development of large limb transplant programs. TESTING THE HYPOTHESIS: Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h. In the military setting, notably longer perfusion times need to be realized. Therefore, future animal studies must focus especially on long-term perfusion, since this represents the military setting, considering the time for stabilization of the patient until evacuation to a tertiary treatment center. IMPLICATIONS OF THE HYPOTHESIS: The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members. Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent, life-threatening situation to a highly methodical, well-prepared starting point for optimal treatment of the wounded service member. With its introduction, the principle of "life before limb" will change to "life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".

The robotic-assisted ureteral reimplantation: the evolution to a new standard.

The development of the robotic-assisted laparoscopic ureteral reimplantation has tracked a path searching for the optimal method of providing outcomes on par with the gold standard of open intravesical ureteral reimplantation combined with fewer complications and decreased discomfort for the patient. With this in mind, pioneers in pediatric urology minimally invasive surgery have put limits to the test with laparoscopic transvesicoscopic Cohen reimplants and laparoscopic extravesical Lich-Gregoir reimplants and then used the da Vinci platform to fine-tune and bring these skills into the 21st century.

Fingertip replantation without venous anastomosis.

BACKGROUND: Replantation of amputated fingertips is a technical challenge, as many salvage procedures fail because no suitable vein in the fingertip is available for anastomosis. In this study, we examined our experience in fingertip replantation in cases without venous anastomosis with our established fingertip replantation treatment protocol. METHODS: Between August 2002 and August 2010, a retrospective study examined all patients who had undergone fingertip replantation at Chang-Gung Memorial Hospital. All the patients (n = 24) suffered from complete digital amputations at or distal to the interphalangeal joint of the thumb, or distal to distal interphalangeal joint of the fingers. A total of 30 fingertips that were salvaged by microsurgical anastomosis of the digital arteries but not of digital veins were included in this study. On satisfactory arterial anastomosis, a 2-mm incision was made over the fingertip with a number 11 Scalpel blade, and 0.1 to 0.2 mL heparin (5000 IU/mL) was injected subcutaneously around the incision immediately and once per day thereafter to ensure continuous blood drainage from the replanted fingertip. None of the replanted nail plate was removed, and no medical leeches were used. The perfusion of the replanted digits and patient's hemoglobin level were closely monitored. The wound bleeding was maintained until physiologic venous outflow was restored. RESULTS: Of 30 fingertips, 27 (90%) replanted fingertips survived. The average length needed for maintaining external bleeding by chemical leech was 6.8 days (range, 5-10 days). Twelve patients (including a 2-year-old child) received blood transfusions. The average amount of blood transfusion in the 23 adults was 4.0 units (range, 0-16 units) for each patient or 3.29 units (range, 0-14 units) for each digit. A 2-year-old child received 100 mL blood transfusion or 50 mL for each digit. CONCLUSIONS: This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.

Replantation of scalp avulsion following a go-kart accident: a case report.

With the development of microsurgery, successfully replanted cases of scalp avulsions have been reported. In spite of previous publications of replantations based on a single artery and vein, it is now accepted that multiple anastomoses increase the success rate. We present herein the case of a successfully replanted avulsion in a child who caught her hair in a go-kart motor belt, and we discuss the mechanism of injury and number of anastomoses.

Remodeling or reimplantation for valve-sparing aortic root surgery?

BACKGROUND: Valve-sparing operations are gaining increasing acceptance; however, there is an ongoing discussion about the technique-specific indications. We present our experience with a follow-up of 123 months. METHODS: Between July 1993 and July 2005, 164 consecutive patients were operated on using the remodeling (group A, n = 96) or reimplantation technique (group B, n = 68). Fifty-seven patients presented with acute type A dissection. Aortic regurgitation was present in 84%. Follow-up was 54.7 +/- 28 in group A and 48.4 +/- 37.3 months in group B. RESULTS: After urgent operations, 4 patients died in each group, but none died after elective surgery. Late mortality was 8% in group A and 4% in group B. Seven patients of group A and 1 in group B required reoperation. Echocardiographic follow-up of reoperation-free survivors showed that 3 patients (all group A, 1.3%) had aortic regurgitation of more than grade II. Root diameter, valve pressure gradient, and valve orifice area were comparable. No gross thromboembolic or bleeding events occurred. CONCLUSIONS: Aortic valve-sparing operations can provide acceptable long-term results in both techniques. Particular care to the annulus in the remodeling technique and different prosthesis designs in the reimplantation technique may overcome the intrinsic problems of each procedure.

Management of complex tissue injuries and replantation across the world.

Management of complex tissue injuries and provision of replantation services calls for the availability of a dedicated team with high skill levels and good infrastructure. Centres of excellence which provide consistent good care exist in many parts of the world, but large populations are still left uncovered. In the developed world, the reduced exposure to such injuries, lesser training opportunities and poor reimbursement for the efforts put in are the problems. In the developing countries, lack of awareness of the possibilities, inadequate transport systems and infrastructure are the problems. In both systems the cornerstone for improvement will be the availability of well trained surgeons who will deliver consistent good results. Public education and developing a team around the surgeon will improve the results in developing countries. Collaboration with good units with high volume load in the developing countries will be beneficial for training and maintainance of the required skill levels in the developed world.

Cochlear implant candidacy and surgical considerations.

Numerous changes continue to occur in regard to cochlear implant candidacy. In general, these have been accompanied by concomitant and satisfactory changes in surgical techniques. Together, this has advanced the utility and safety of cochlear implantation. Most devices are now approved for use in patients with severe to profound rather the prior requirement of a bilateral profound loss. In addition, studies have begun utilizing short electrode arrays for shallow insertion in patients with considerable low frequency residual hearing. This technique will allow the recipient to continue to use acoustically amplified hearing for the low frequencies simultaneously with a cochlear implant for the high frequencies. New hardware, such as the behind-the-ear speech processors, require modification of existing implant surgery. Similarly, the new perimodiolar electrodes require special insertion techniques. Bilateral implantation clearly requires modification of the surgical techniques used for unilateral implantation. The surgery remains mostly the same, but takes almost twice as long, and requires some modification since at a certain point, when the first device is in contact with the body, the monopolar cautery may no longer be used. Research has already begun on the development of the totally implantable cochlear implant (TICI). This will clearly require a modification of the surgical technique currently used for the present semi-implantable devices. In addition to surgically burying the components of the present cochlear implant, we will also have to develop techniques for implanting a rechargeable power supply and a microphone for the TICI. The latter will be a challenge, since it must be placed where it is capable of great sensitivity, yet not exposed to interference or the risk of extrusion. The advances in design of, and indications for, cochlear implants have been matched by improvements in surgical techniques and decrease in complications. The resulting improvements in safety and efficacy have further encouraged the use of these devices. We anticipate further changes in the foreseeable future, for which there will likely be surgical problems to solve.

Infección de dispositivos intracardíacos: marcapasos y cardiodefibriladores / Infections of intracardiac devices: pasemakers and cardioverter-defibrillators

El uso de marcapasos definitivos y defibriladores automáticos implantables se encuentra en un creciente aumento a nivel mundial, incluyendo nuestro país, esperándose que la tasa de implantes siga experimentando un aumento sostenido en los próximos años. A pesar del progreso en las técnicas de implante y del diseño de estos dispositivos, las complicaciones infecciosas asociadas a su uso constituyen una preocupación permanente pues se relacionan con morbilidades potencialmente graves, especialmente el desarrollo de endocarditis infecciosa, incluyendo tasas variables de mortalidad, y un significativo incremento en los costos de salud. La aparición de complicaciones infecciosas asociadas al uso de estos dispositivos pueden ser precoces o tardías en relación al momento del implante, y pueden comprometer sólo el bolsillo del dispositivo o extenderse a tejidos más profundos y, a través de la colonización de el o los electrodos, afectar el endocardio mural y valvular. La mayor parte de las veces la infección del bolsillo se produce por la contaminación en el momento del implante o por la erosión, transcurrido un tiempo, de los tejidos que cubren el dispositivo. El diagnóstico de esta complicación exige al clínico un alto índice de sospecha pues la mayoría de los casos los síntomas y signos son sólo locales. En los casos de sospecha de endocarditis infecciosa, el ecocardiograma, especialmente la técnica transesofágica, constituye a la fecha el examen complementario de mayor rendimiento diagnóstico. Si bien la etiología puede ser variada, la mayor parte de las veces el agente aislado es el estafilococo aureus en las infecciones precoces y diversas cepas de estafilococo coagulasa negativo en el caso de las infecciones tardías, lo que debe considerarse en el momento de seleccionar la terapia antibiótica. Una ves diagnosticada la infección, el tratamiento más ampliamente aceptado consiste en una estrategia mixta, conformada por antibioterapia según cultivos y remoción de todo el sistema, dispositivo y electrodo(s), aun cuando no se haya demostrado infección de estos últimos. La extracción del sistema, la mayor parte de las veces mediante cirugía, conlleva sus propios riesgos, algunos potencialmente fatales. Sólo la implementación y cumplimiento de rigurosas normas de prevención podrá limitar la incidencia de esta temida complicación asociada al uso de marcapasos definitivos y defibriladores internos.

[Single digit replantations in ambulatory surgery. 85 cases]. / Les réimplantations unidigitales en ambulatoire. A propos de 85 cas cliniques.

The author performed 85 ambulatory digital replantations between 1994 and 1999. Ages varied from 15 to 33 (average 24), with a prevalence of the male sex. The main mechanism of injury was guillotine (60%), followed by avulsion (40%). Surgical procedure lasted approximately four hours. Patients remained in the hospital for eight hours maximum, period in which they were closely observed. Patients received printed instructions about the risks of arterial and venous thrombosis and how they could observe it themselves. A protocol was established to evaluate the results. Patients were instructed to call the surgeon as soon as any change--mainly in color--was noticed. Based on a phone call, twenty patients were evaluated in the immediate postoperative period (24 initial hours) to rule out circulatory problems. In fifteen patients, thrombosis was noted in the replanted segment. Twelve of these patients (14.11%) lost the replanted digit completely. The loss of the replanted segment was not observed in the group of patients that did not call the surgeon.

1457 years of microsurgical experience.

Microsurgery is a relatively new field of surgery involving various methods and practices that are currently evolving. Our goal was to register the current practices employed by the members of the American Society for Reconstructive Microsurgery. A survey was mailed to the 319 members of the society, resulting in a response rate of 33 percent (106 of 319). The data reflect the combined experience of 10,839 free-tissue transfers and 3487 digital and upper and lower extremity replants over a 4-year period between 1990 and 1994. Practices employed, such as pharmacologic adjuvant therapy, monitoring techniques, flap types, and success rates reported by the members of the American Society for Reconstructive Microsurgery, were analyzed.

A socioeconomic analysis of digital replantations resulting from home use of power tools.

Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was $7000 (surgeon's fee) plus $697 per hour (operating room fee), as per fiscal year 1987. Postoperative hospitalization averaged 15 days at a cost of $15,679. Hand rehabilitation averaged 8 months at a cost of $3348. Fifty-four percent of the patients had no insurance. Fourteen of 21 patients (67%) required at least one additional procedure. Two patients had to make a career change after the injury. The majority of patients with digital replantations were dissatisfied with the emotional costs and the number of subsequent operations. Lack of patient and family awareness of the length of the rehabilitative period was particularly evident.

Cirugía plástica: la mano / Plastic surgery: the hand

Nos muestra las posibilidades reconstructivas, por medio de la microcirugía, reimplantes, transplantes, cirugía de los nervios periféricos y otras tecnologías de avanzada, de las diversas patologías que afectan la mano

Cirugía plástica: la mano / Plastic surgery: the hand

Nos muestra las posibilidades reconstructivas, por medio de la microcirugía, reimplantes, transplantes, cirugía de los nervios periféricos y otras tecnologías de avanzada, de las diversas patologías que afectan la mano

Avulsed teeth. Management during anesthesia induction, surgery.

It is not known how often teeth are inadvertently knocked out in the operating room during intubation or surgery. When it occurs, it can be very disturbing to the operating room personnel and the patient when he or she recovers from the surgery. Research has shown that most avulsed teeth can be saved by replanting them within 15 to 30 minutes, aligning and splinting them into proper position, and instituting appropriate follow-up care. Because a dentist cannot easily be found in this time period, a system designed specifically to preserve the teeth can be used to provide optimum care in these situations. By using such a system, the physician can proceed with the surgery knowing that all the appropriate measures have been taken to save the knocked-out tooth.