CAN TEMPORARY ARTERY CATHETERIZATION EXTEND LIMITS OF ISCHEMIA TIME FOR MACROREPLANTATION?

IAMAGUCHI, RAQUEL BERNARDELLI; DIAS, GUILHERME MOREIRA; IWASE, FERNANDA DO CARMO; REZENDE, MARCELO ROSA DE; MATTAR JR, RAMES

doi:10.1590/1413-785220233105e267476

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Acta Ortopédica Brasileira

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ORIGINAL ARTICLE • Acta ortop. bras. 31 (6) • 2023 • https://doi.org/10.1590/1413-785220233105e267476 copy

CAN TEMPORARY ARTERY CATHETERIZATION EXTEND LIMITS OF ISCHEMIA TIME FOR MACROREPLANTATION?

CATETERIZAÇÃO TEMPORÁRIA ARTERIAL AMPLIA O LIMITE DE TEMPO DE ISQUEMIA NO MACRORREIMPLANTE?

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

We observe delayed referrals to appropriate Microsurgery Unit and definitive treatment of traumatic limb amputations. Cases with wrist proximal amputations have a deadline for surgical replantation as these configure life-threatening injuries.

Objective:

To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results.

Methods:

A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021.

Results:

In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours).

Conclusion:

Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

Keywords:
Amputation; Extremities; Forearm; Microsurgery; Catheterization; Wounds and Injury

Case	Age	Gender	Injury level	Mechanism	Ischemia (beginning of surgery)	Associated injuries
1	30	F	Proximal radius	Avulsion	8 hours	Extensive muscle injury of the amputated arm and forearm
2	37	M	Middle-third forearm	Avulsion	9 hours	Extensive muscle injury in the biceps and brachii muscles Irreparable damage of the ulnar nerve (over 30 cm)
3	24	F	Proximal radius	Avulsion	9 hours	Ipsilateral humerus fracture
4	23	M	Distal forearm	Avulsion	6 hours	Irreparable damage of the ulnar nerve (over 30 cm)
5	27	M	Arm diaphysis	Avulsion	6 hours	Extensive muscle injury of the arm
6	37	M	Distal forearm	Avulsion	7 hours	Amputation of the second finger + open fractures on the first and third fingers of the contralateral hand
7	23	F	Proximal radius	Avulsion with crushing	10 hours	Degloving up to the proximal third of the humerus
8	34	M	Proximal radius	Crushing followed by avulsion	9 hours	Vascular segmental lesion in the proximal third of the forearm and lesion of the palmar arch in the hand

Case	Tenorrhaphy or Myorrhaphy	Microneurorrhaphy	Arterial anastomosis	Venous anastomosis
1	Foream flexor and extensor muscle mass	Median and ulnar nerves	Brachial artery	A vena comitans of the brachial artery and a superficial vein
2	Deep flexor tendons of the fingers, long flexor tendon of the thumb, and finger and wrist extensor muscle mass	Median nerve with graft	Proximal ulnar artery and distal radial artery	A vena comitans of the ulnar artery and a superficial vein
3	Foream flexor and extensor muscle mass	Median nerve	Ulnar artery	A vena comitans of the ulnar artery and a superficial vein
4	Superficial and deep flexor tendons of the fingers and finger extensors	Median nerve	Ulnar artery	A vena comitans of the ulnar artery and a superficial vein
5	Myorrhaphy of anterior and posterior muscle bellies	Median nerve	Brachial artery	A vena comitans of the brachial artery and a superficial vein
6	Tenorrhaphy of flexors and extensors with solidarization	Median and ulnar nerves	Ulnar artery	Arteriovenous fistula of the radial artery with reflux in the cephalic vein with a saphenous vein graft
7	Tenorrhaphy of flexors and extensors with solidarity	Median Nerve	Ulnar artery	Arteriovenous fistula of the radial artery with reflux in the cephalic vein
8	No procedure	No procedure	Ulnar artery with saphenous vein graft	Amputation

Case	Ischemia (beginning of surgery)	Complications	Additional surgeries
1	8 hours	Muscle necrosis	Serial debridements (three) and amputation of the reimplantation
2	9 hours	Loosened Kirschner wire fixation	Revision two weeks after fixation for open reduction and internal fixation
3	9 hours	Skin necrosis on anastomoses	Anterolateral microsurgical flap of the thigh
4	6 hours	Failure of muscle area coverage.	Skin graft
5	6 hours	Failure of muscle area coverage.	Skin graft
6	7 hours	Pulmonary thromboembolism; Forearm pseudarthrosis	Skin graft and revision of the fixation with consolidation (4 months after surgery)
7	10 hours	Venous congestion and muscle necrosis	Amputation after 5 days
8	9 hours	Lack of intraoperative perfusion	Intraoperative amputation

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E-mail: actaortopedicabrasileira@uol.com.br

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[1] Correspondence: Raquel Bernardelli Iamaguchi. Rua Dr. Ovidio Pires de Campos, 333, Sao Paulo, SP, Brazil, 05403010. rbiamaguchi@gmail.com