Case Of Multiple-Level Replantation In 62-Year-Old

Before replantation with intermediate segment

62-year-old woman required multiple-level replantation after amputation across her left distal forearm and limb because of a tree-shredder accident.

This case is of a 62-year-old woman who required multiple-level replantation after she suffered a complete double-level amputation across her left distal forearm and wrist. The patient’s midhand got caught in a tree-shredder resulting in a severe crush injury. The cold ischemic time of the limb was less than 2 hours.

Examination showed that the amputation occurred 3 cm proximal to the radiocarpal joint, at the forearm. Treatment included revascularization of the limb proximally after bony fixation. Moreover, the crushed arterial parts were excised and repaired primarily at the midhand level. Similarly, all flexor tendons were repaired primarily. In addition, the repaired parts were flushed out with 500 cc of blood to reduce reperfusion toxicity after completion of arterial anastomoses.

The median and ulnar nerve were further repaired after completely reestablishing proximal and distal venous outflow. However, the fracture at the metacarpal level was deemed stable, therefore, not fixed.

After the procedure the patient developed disseminated intravascular coagulopathy (DIC) and was transferred to the intensive care unit. The patient required substitution of clotting factors and revision surgery after 3 hours of continuous bleeding. The bleeding was controlled with meticulous hemostasis and Arista (C.R. Bard Davol, Warwick, R.I.).

Postoperative care

The patient was prescribed high doses of vasopressors, 46 units of fresh frozen plasma, 22 and 4 units of packed red blood cells and platelet concentration including prothrombin complex replacement, fibrinogen and antithrombin III. The postoperative period was uneventful with a minor wound dehiscence at the intermediate segment. The skin was grafted after 10 days.

The 62-year-old was discharged after 20 days. Although the Kirschner wires were partially removed after 3 months, the bony union at the distal ulna was delayed after 14 months. The patient returned to work 6 months after the procedure. She was not in favour of any further corrective surgeries.

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Three months postoperatively

Follow-up after two years of the accident showed fair recovery of sensation with protective sensibility in the ulnar nerve distribution. There was no sensory loss in the median nerve distribution with 30 degrees of flexion and 5 degrees of extension at the wrist. However, there was no active flexion at the metacarpal-phalangeal, proximal interphalangeal, distal interphalangeal joints. She did not require pain medication on a regular basis.


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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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