Complications of major limb replantation can be life threatening and should be appreciated by the surgeon and the patient. In some cases, major limb replantation allows for better function than a prosthesis. The best of these results occur at the level of the midforearm to distal forearm. For more proximal injuries, the goal is to provide a functioning wrist and hand for simple hook-grasp and prehension with
protective sensibility60 (Fig. 4.10). Fasciotomy of the amputated part is routinely performed after debridement. Muscle tissue is sensitive to ischemia, thus, extensive debridement of both the detached part and the amputation stump is essential to prevent the absorption of toxic metabolites from necrotic muscle and infection.61 In
major limb replantation, the surgical sequence is altered to restore the arterial supply quickly and limit myonecrosis. In replantation proximal to the metacarpal level, a vascular shunt is used initially to restore the arterial supply (Fig. 4.11). After that point, bone stability can be achieved while the limb perfuses. The limb is allowed to perfuse before reestablishing venous repair to purge accumulated toxic metabolites from necrotic muscle. Care must be taken to avoid excessive exsanguination because bleeding can be significant and life threatening. After re-establishing the circulation, tendon and nerves can be repaired. The patient is given a bolus of sodium bicarbonate before establishing venous return and is monitored closely for signs of systemic acidosis. After major limb replantation, the patient is returned to the operating room for evaluation of the muscle tissue and redebridement within 48-72 hours.
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