WHAT TO DO IN CASE OF AMPUTATION:
– Elevate the amputated limb and make a compressive dressing (no tourniquet)
– Collect carefully the amputated fragment(s) and put it into a dry plastic bag
– Close the bag and put it into ice
– Reach ER immediately
Any continuity preserved between the fragment and the patient, even the thinnest skin bridge, can improve significantly the chances of success and should be preserved at all cost.
What is it? (definition)
It is the most severe possible lesion. Amputation means a complete separation of a fragment from the patient’s body.
Sometimes, the amputated fragment can be replanted. Results vary widely according to numerous parameters: mechanism of injury, damage on the fragment, medical background (age, smoker, diabetes, immunosuppression…).
What are the therapeutical options ? (treatment)
Decision to attempt replantation has to be made in emergency, but have to be thoroughly discussed with the patient. It depends on many parameters correlated to the chances of success, and to the patient’s need and will to commit to a long, fastidious, and uncertain therapeutical process.
In some cases, replantation is doomed to failed, or to provide a poor functional result even if the surgery is a success. In some others, replantation could work, but at the cost of several hours of surgery, several days of hospitalisation, and several months of intense and painful physiotherapy and sick leave that does not necessarily fit the patient’s will nor needs.
Thus, replantation should always been put in balance with its alternative, (debridement and closure of the stump), usually performed in a few minutes under local anesthesia in an ambulatory manner, allowing the return to daily life activity and even to work in no more than a few weeks.
If decision is made to attempt replantation, the surgery must be performed in emergency in order to limit the ischemia time (during which the fragment is deprived from blood supply).
Immediate, totale and definitive cessation of tobacco is mandatory for the surgery to succeed.
Replantation, Step by step:
1. Debridement of the wound & spotting of all structures that shall be repared :
Contaminated or damaged tissues are removed from the wound, and bones, tendons, nerves, arteries and veins are spotted and tagged on both the amputated fragment and the proximal stump.
2. Bone fixation :
The bone is cleaned, often shortened on both side to reach a healthy zone, and fixated with Kwires or screws.
3. Tendon repair :
Flexor and extensor tendons are then repaired if any joint can be saved. If not, a fusion of the joint is performed.
4. Arterial repair :
This step is performed under microscope, using sutures of the size of a tenth of a hair. Arterial repair provides blood supply to the fragment, which is the first step for viability. Sometimes, if the blood vessels are damaged, it is necessary to use one or several vein(s) from the forearm to perform a by-pass. Once the arterial repair is done, the fragment is filled by fresh blood, and ischemia time is over.
5. Nerve repair:
This step is also performed under microscope. Nerve repair aims to restore partial sensitivity in the amputated fragment, and to prevent the proximal stump of the nerve to form a painful scar called nevroma. Even in best cases, sensitivity takes several months to recover, and is never completely normal.
6. Veins repair:
This step is also performed under microscope, using the thinnest possible sutures. A by-pass using a vein from the foream can also be necessary. Veins are often the most challenging technical step, due to their small size, unpredicable anatomy, and extremely thin walls. It is also the most common reason for failure, as traumatised veins are likely to clot. That is why for each artery repaired, it is recommended to repair 2 veins when possible. Sometimes, a therapeutical bleeding is done in order to unclog the fragment if veinous drainage is insufficient. Nail bed scarification and/or leeches can be used.
7. Skin closure:
Repaired structures must be covered. In order to do so, plastic and reconstructive techniques can be used (skin graft of flaps) if the local skin is too damaged. Some areas can be left opened and close progressively thanks to appropriate dressing (secondary healing).
7. Dressing:
It is a crucial step, especially if the skin closure requests a skin graft or a flap. The dressing usually allows a visual access to the tip of the fragment in order to control its viability and to perform a therapeutical bleeding if needed. A cast/splint can be inserted into the dressing, or not, depending on the level of amputation.
What about the post-operative care ?
– If all goes well:
Several days of hospitalisation are necessary to allow a close monitoring of the viability of the replanted fragment. If the fragment shows signs of suffering, a quick and appropriate response is required to prevent the replantation from failure. It starts with simple bed-side measures (removal of a compressive dressing, elevation of the limb in case of congestion, warming up the limb in case of arterial insufficiency, therapeutical bleeding or leeches), but if the situation does not improve rapidly, revision surgery can be indicated to ensure the permeability of the vascular anastomosis.
After 6 days post operatively, skin healing and formation of neovessels facilitates veinous drainage. After 10 days, vascular balance of the amputated fragment is acquired, and the surveillance can be loosen. Physiotherapy and occupational therapy can then be started, in order to avoid stiffness and internal adhesions.
After 6 to 8 weeks, bone healing is usually stable enough to allow hardware removal if temporary devices have been used (Kwires).
Physiotherapy is pursued for several months, until reaching a plateau.
– In case of trouble :
If a vascular balance between blood supply and blood drainage fails to settle, survival of the replanted fragment is compromised, and the fragment dies and becomes necrotic. In that case, it must be removed to prevent from infections and to allow proper healing of the viable proximal stump. Once the stump is closed, physiotherapy and occupational therapy can be started and the patient is encouraged to get back to his/her life without restriction as soon as possible.
Later on, if the stump is unsightly or functionally inefficient, a revision surgery can be performed to improve its aspect and function. Sometimes, removal of the entire ray is the best solution (ray amputation, Chase or Leviet procedures), as a painful crooked finger is usually more disturbing than no finger at all. Adaptative capacities of the hand ensure usually a good result of those procedures.
Often, the tendons sticks into their sheath and lead to post operative stiffness. At first, physiotherapy and occupational therapy are very important tools, but if it is not enough after several months, revision surgery can be proposed (contracture release).
Some cases of persistant and unexplained postoperative pain have been described.
As in any operation, the theoretical risk of infection exists but this complication remains rare, thanks to rigorous prevention protocols.
Other complications may occur but appears to rare to be mentioned here.
Dr Franck Atlan