The Effectiveness of Microsurgical Procedures inPatients with Upper Extremities Trauma

Abstract

Background: The microsurgical techniques have evolved along the last decades, allowing excellent functional results in cases of reimplantation after amputations. The objective of this study is to evaluate the effectivity of those techniques in a trauma reference center in México. Material and Methods: Patients with microsurgical procedures in the context of upper extremities trauma performed between March 01 of 2010 and August 01 of 2013 were included. The demographic and medical data were recorded and analyzed, identifying interest factors like type of lesion, level of lesion, ischemia time, lesion mechanism, type of magnification for repair and clinical evolution. Statistical analysis was performed with parametric statistics, central tendency and dispersion measures. Results: From a total of 10 patients included, 9 were men (90%) and 1 woman (10%). About age, there were no patients from the first decade of life, 3 patients of the second, 3 patients of the third, 1 patient of the fourth and 3 patients of the fifth decade of life. The mechanisms of trauma reported include 1 patient with a sharp cut, avulsion in three patients, avulsion / tearing in 6 patients. The level if amputation according to the classification of Daniel and Terzis was 2 in two patients, 3 in six patients, 4 in one patient, and 6 in one patient. Other associated lesions were registered only in one patient. Ischemic processes were found in 7 patients with cold ischemia and 3 with warm ischemia. The time of ischemia vary from 2 to 9 hours, with a range between 0-2h in 1 patient; 3 to 4 h in 2 patients; 5 to 6 h in 5 patients; 9 to 10 h in 2 patients. Only 1 patient referred smoking. In five cases the patients were treated with magnifiers only and 5 with microscope assistance. Five patients presented a good evolution and five an unfavorable one. Conclusions: There were lower cases than expected for a third level trauma center in the period of study, with favorable evolution under the worldwide levels reported. The patients with good evolution were younger and with a proximal amputation, the other factors were not significant for the evolution. More studies and a bigger simple are needed to elucidate the significance of other variables in the evolution. The Effectiveness of Microsurgical Procedures in Patients with Upper Extremities Trauma ARC Journal of Surgery Page |2 exist four stages in the development of microsurgery: 1) early morning period (19501970),2) development period (1981-1997) 3)full maturity period (1981-1997) and 4)transition period from autogenous transplantation to allogeneic transplantation and regenerative medicine (1998-2007) [1-17]. The history of digital reimplants started more than 200 years ago when in 1814 William Balfour completes a finger autograft in a carpenter. After this description, many surgeons for more than 100 years treat the amputations with the use of a tubulized pedicled graft. In 1940 Harold Gillies suggest to remove the skin Surface of the finger before the autograft and add the tubulized graft, and in 1944 Stuart Gordon completes this technique with insensitive and non-functional results [13]. With the development of microsurgery the surgical techniques progress, so in the last 20 years, the microsurgical centers publish series of reimplantation with success in 80% of the patients. The success in those cases is secondary to the development of higher magnification surgical microscope, focus, and light; ultrafine sutures; small needles of high precision and other microsurgical isntruments [2], [4], [5], [13], [14]. Reimplantation is referred to reattach a segment of the body that was completely amputated, there is no conexión between the amputated segment and the body, and is the procedure of higher difficulty in reconstructive surgery [2], [3], [13], [14], [17]. The reimplantation is an expensive and complex procedure, that require prolonged surgical time, multiple surgeries and motivation for the rehabilitation by the patient for optimal results [3]. The incidence of hand trauma is variable between countries because is related to safety industrial standards. Constantly the amputations are more frequent in males compared to females about 5:1 to 6:1 and near 30 years of age, personal of industry, and in home in second place; the proximal phalanx is the most frequent amputation site and above the elbow the less frequent; with the non-dominant hand as the less frequent affected [13]. In an epidemiological review in the USA in 2011, they observe 9407 patients with amputations in upper extremities, 1361 treated with reimplantation, where success in younger patients was higher significantly, ages between 36 and 44 years old, and longer hospital stay in the reimplantation patients as well as higher cost [4], [7], [19]. The patients that assist urban hospitals and higher volume have a higher probability of reimplantation for the resources of these hospitals in equipment and qualified surgeons. This reference centers develop complex reimplantation of multiple fingers, hand, thoracic member and others [4], [7], [8]. The success is related with the family support, by the long periods of treatment and rehabilitation; the study and management must be given by a multidisciplinary team including hand surgery, psychiatry, physical medicine, occupational medicine, nursing, etc. [6], [7]. The initial management of the patients is in the emergency service according to the clinical state because in many cases the amputations are accompanied with other multisystemic lesions and must be treated according to ATLS guides, and only if the patients are stable and do not have associated injuries the reimplantation must be considered [6]. Factors that must be considered for reimplantation are the associated morbidity, possibility of survival, functionality of the reimplanted segment that must be equal or better than the previous, the total cost for patient or health service. The patients with a clean amputation are the ideal candidates, but these lesions are infrequent; the most frequent etiology is the crush and avulsion, diminishing the viability rate [2], [5], [6], [7], [9], [13]. Across the time the indications for reimplantation have not changed, including thumb amputation at any level, multiple fingers, through the palm, any segment in the child, amputation of the wrist, forearm, elbow and above this level, amputation distal to the insertion of the digitorum sublimis flexor; those are not necessary absolutely indications, but if there are other favorable factors the reimplantation must be considered, inclusive in avulsion lesions that require thumb shortening, fusión of metacarpophalangeal joint, with vein or nerve graft, and the results are frequently superior compared with other methods of reconstruction; in the zone II of Verdan area of flexors, zone III of Daniel and Terzis the digital reimplantation could have a comparable morbidity with the flexor tendons lesions [2], [5], [7], [13], [14], [15], [16], [18], [20]. The contraindications for reimplantation are relative, including severe injuries, severely crushed or shattered, amputation in multiple levels, amputation in a patient with severe The Effectiveness of Microsurgical Procedures in Patients with Upper Extremities Trauma ARC Journal of Surgery Page |3 previous diseases, with atherosclerotic vessels, amputation with prolonged hot ischemia (> 6h in a major segment or > 12h in a finger), amputation in mentally ill patients [2], [3], [5], [7], [9], [13], [14], [20]. The fingers amputated could be regarded at 4oC for 24 hours before reimplantation or 6h with hot ischemia. According to the level of amputation, specialized material must be used for the reimplantation. The success of reimplantation is related to the age of patients, comorbidities, trauma mechanism, surgeon skills, postoperative management [2], [5], [18]. The Ishiwaka classification localize the level of amputation of the distal phalanx as follows: zone 1, distal to the distal phalanx; zone 2, across the ungueal plate, retaining 50% of this plate; zone 3, across the ungueal plate with less than 50% of the plate; zone 4 is proximal to the distal phalanx [16]. Initial surgical treatment must have a multidisciplinary team with experience and the required equipment for maximum quality. It begins with the administration of antibiotics, antitetanic vaccination, x rays for the amputated segments; while a team is preparing the amputated segment for reimplantation with amplification equipment, with debridement, location of nerves and vessels; molding and shortening the bone, the Kirschner spike or plates are placed; the second team prepare the patient for surgical intervention, ideally with microscopes of high power [2], [5], [7], [15]. The regional anesthesia is preferred by the vasodilator effect. The sequence of reimplantation is influenced by the amount of muscle in the amputated segment and the time of ischemia, kind of lesion and the surgeon preference [2], [7], [13]. Post-surgical treatment includes anticoagulation and there no exist a determined protocol for all cases and centers by the lack of superiority of one protocol among the others. The first 2 days the risk of thrombosis is very high (80%) and decrease to 10% after the third day. Conrad and Adams recommend the trans surgical use of a heparinized solution, a dose of heparin of 50-100 U/Kg after the release of the clamps, and Dextran 40 at 0.4 mL/kg/hr to the 5th day. Pederson recommends the application of Bupivacaine form an axillary catheter for 5 days to produce a chemical sympathectomy, the use of Chlorpromazine 25mg orally every 8 hours as a peripheral vasodilator for 3-5 days, and the use of acetylsalicylic acid 325 mg orally each 24h for the platelet antiaggregant effect for 3 weeks. Sabanpathy reports the use of a solution for irrigation during surgery prepared with 2000 heparin units, 20cc of lidocaine in 200cc of saline solution; 50U/Kg of