Amputation is the complete separation of a body part from the body. Replantation is the suturing of this broken piece using microsurgical methods. The term revascularization refers to the re-vascularization and continuation of nutrition of this part whose nutrition is impaired, in cases where there is no complete rupture and the limb is still connected to the body in some way. The aim of both replantation and revascularization is to achieve as close to full function as possible. At the same time, it is aimed to have the sensation of this piece stitched into place as close to complete as possible.
Replantations are divided into two according to the level of rupture: major (for ruptures in the upper part of the wrist) and minor (for ruptures below the wrist level). .
Any broken piece can technically be vascularized, but there are medical indications (requirements) and contraindications (situations that should not be done) for stitching the severed piece.
Replantation Indications:
Age: Replantation can be performed at any age, but the results are worse in the elderly, those with vascular disease, diabetics and smokers. Since the duration of the surgery is long, the general conditions of older patients should be taken into consideration. Replantation should be tried in all amputations in children.
Systemic condition of the patient: Since the main thing is the patient's survival, if the patient cannot tolerate this surgery for any reason (severe trauma, heart disease, etc.), replantation should not be tried. . Those with psychiatric illnesses are not suitable candidates for replantation. Replantation should be tried in those who have a profession where all fingers need to be protected.
Incision, severing method: The results of incisions made with a sharp object, described as guillotine style without crushing, are better. The chance of success is lower in crushing and separation-type ruptures, cuts with more than one level of injury, and dirty wounds. Very dirty wounds are not suitable for replantation. The risk of infection is very high in such injuries.
Level: In ruptures that usually occur around the shoulder, the results are poor and replantation is not recommended. It should not be performed, especially in the elderly and in cases where ischemia time is long. At levels below the shoulder, the patient's The decision should be made according to the condition of the case. In case of thumb amputations and multiple finger amputations, replantation should be tried.
Time: Warm ischemia time (bloodlessness at normal temperature) is important. The greater the amount of muscle in the severed piece, the more important it is. If the muscles remain without blood for about 6 hours at normal temperature, they begin to die (necrosis). If the limb can be protected at +4 degrees, this necrosis period can be extended. But still, over 8 hours is very risky. If blood cannot be supplied to the severed part after this time, that is, in less than 8 hours, replantation should not be performed. The patient's life is put at risk due to some systemic problems. There is an exception for fingers. Since there is very little muscle mass, replantation can be attempted even after 24 hours if proper storage is done.
Replantation contraindications:
If there is a life-threatening injury,
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Those who have a systemic disease that will prevent replantation,
Very dirty and severe injuries involving crushing or creep separation,
Prolonged hot and cold ischemia time.
It is important to transport the severed part in accordance with the procedure and keep the patient's wound as clean as possible. Since the priority is the patient's life, it is essential to control bleeding. Bleeding should be controlled with a blood pressure monitor or similar pressurized system, or at least with pressure dressings. A tourniquet can be used if available. In order not to compromise the chances of stitching, exposed vessels should be clamped, etc. It should not be tightened or tied.
If the broken part is dirty, it should be cleaned gently without applying pressure. It should not be wiped with iodine or alcohol. For proper transfer of the cleaned part, it is wrapped in cloths moistened with saline or a sugar-free serum and placed in a nylon bag, tightly tied to prevent water from leaking into it. The part should never come into contact with water or alcohol. In order to prolong the ischemia time, it is necessary to keep the severed part at a temperature close to +4 degrees. Therefore, this broken piece, wrapped in a damp cloth and placed in a bag, is placed in a container with ice water and transferred. Ideally, 2/3 of this ice water should be ice. The broken piece should not come into contact with ice. What's this Therefore, when preparing ice water, ice should be placed in the bag in small pieces, not in blocks, and all parts of the ice water bag should be at the same coldness.
Although replantation results are better day by day, the desired success may not always be achieved. It should not be forgotten that there are many factors that affect the outcome, and even in similar injuries, the results of the same surgeon may not be the same.
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