Major Limb Replantation and Postischemia Syndrome: Investigation of Acute Ischemia-Induced Myopathy and Reperfusion Injury

137 Pages·1988·2.59 MB·English

by  Priv. Doz. Dr. med. Hans-Ulrich Steinau (auth.)

Hans-Ulrich Steinau
Major Limb Replantation
and Postischemia Syndrome
Investigation of Acute
Ischemia-Induced Myopathy
and Reperfusion Injury
With 42 Figures and 5 Tables
Springer-Verlag Berlin Heidelberg GmbH
Priv. Doz. Dr. med. Hans-Ulrich Steinau
Abteilung fur Plastische und Wiederherstellungschirurgie,
Klinikum rechts der Isar, Ismaninger Str., 0-8000 Munchen
Translation: Susan Moore-Heidecke, Munchen
ISBN 978-3-662-02482-9 ISBN 978-3-662-02480-5 (eBook)
DOI 10.1007/978-3-662-02480-5
Library of Congress Cataloging in Publication Data.
Steinau, Hans-Ulrich. Major limb replantation and postischemia syndrome.
Bibliography: p.
1. Extremities (Anatomy)-Reimplantation-Complications and sequelae. 2. Ischemia. 3. Muscles-Blood
Vessels. 4. Surgery, Experimental. 1. Title. [DNLM: 1. Extremities-surgery. 2. Ischemia-pathology.
3. Muscles-blood supply. 4. Muscles-pathology. 5. Perfusion. 6. Reimplantation. WE 800 S819m)
RD551.S69 1987 617'.58 87-26307
ISBN 0-387-15805-7 (U .S.)
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2124/3020-543210
For Rita
who shared all the joy as well as the frustration,
and
for those patients who have endured the
agony of repeated limb loss
Preface
Posttraumatic stump formation and replantation of the severed limb are both
reconstructive plastic operations which may lead to improvement or destruction
of a patient's lifestyle.
For the primary attending surgeon, the difficult decision whether to undertake
such an operation depends on the patient's clinical condition, the operational
circumstances, the psychological and social aspects and, last but not least, on the
surgeon's own abilities.
This monograph is designed as a synopsis of the great number of patho
physiological parameters and surgical and rehabilitational aspects which must be
considered in the analysis of complications in major limb replantation. In
addition, basic information about the key role of ischemic myopathy and micro
angiopathy is supplied, to encourage further experimental investigations.
As no new book is truly original, I wish to acknowledge the help of those listed
below, with thanks for their friendly support, critical discussion, technical advice,
and helpful cooperation:
Dr. A. Encke, Professor and Head of Department of General Surgery,
University Hospital, Frankfurt, FRG;
Dr. O. Elert, Professor and Head of Department of Cardiothoracic Surgery,
University Hospital, Wiirzburg, FRG;
Dr. E. Eriksson, Professor, Harvard Medical School, and Head of Department
of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA;
Dr. H. P. Fortmeyer, Ph. D., Director, Experimental Laboratory,
University Hospital, Frankfurt, FRG;
Dr. M. Schneider, Ph. D., Department of Pathology - III, University Hospital,
Frankfurt, FRG;
Dr. H. Forster, Professor of Biochemistry, and Dr. Askali, Department of
Experimental Anesthesia, University Hospital, Frankfurt, FRG.
Ms. V. Beinrucker, HLM Laboratory, Department of Thoracic, Heart and
Vascular Surgery, University Hospital, Frankfurt, FRG;
Ms; G. Schroder, Department of Surgery, Histological Laboratory,
University Hospital, Frankfurt, FRG;
Dr. W. Haase, Institute for Numerical Statistics, Koln, FRG;
Dr. Bonhard, Dr. Uthemann, and Mr. Boysen, Biotest Inc., Frankfurt, FRG;
Miinchen, September 1987 Hans-U. Steinau
Foreword
The postischemia syndrome is of increasing importance in reconstructive
procedures of the extremities. It is very likely that traumatologists and plastic
surgeons will be confronted with local and systemic pathological reactions of cell
necrosis and ischemia-induced micro angiopathy in major limb replantation as
well as with perfusion problems in pedicled or microsurgically transferred free
flaps. The author therefore, analyzed the pathophysiological causes and the
interactions of the developing "no reflow phenomenon" by reviewing an
enormous number of references from the different SUbspecialities concerned. In
addition, he presents experimental investigations on the value of oxygenation,
substrate, and waste product transport during hypoxic conditions. The results
show that perfusion with an oxygen-containing medium provides better preven
tion of the postischemia syndrome than the dry cooling preservation currently
in use.
The author also describes the fact that in major limb reattachment, com
plications can become life threatening if there is no early intervention. Even in
primarily successful cases ischemia-induced myopathy and microangiopathy
impede the functional rehabilitation of the limbs. In the group of patients with
large soft tissue defects, loss of flap requires complicated secondary surgical
procedures.
This monograph fills a gap in its field, as the complex theoretical knowl
edge and the clinical and therapeutical consequences of postischemia syndrome
have not previously been made a focus of attention.
I am proud that such an essential work has been prepared by a plastic
and reconstructive surgeon, who has gained extensive experience in the prevention
of possible early and late complications in replantations and flap transfers.
Munich, September 1987 E. Biemer
Foreword
Following animal experiments conducted since the beginning of this century, the
first successful clinical replantation of a completely severed arm was performed
by Malt and McKhann in 1962 on a 12-year-old boy. Since then further
experimental work and the development of microsurgical techniques have moved
replantation of large and small extremities into clinical practice. Yet technically
successful replantations are still often endangered by infection, acute renal and
pulmonary insufficiency, hypovolemia, and clotting defects. The most common
causes of these complications are thought to be muscular ischemia and micro
angiopathy.
Hans-Ulrich Steinau, the author of this monograph, has contributed to our
knowledge of the underlying pathophysiology by performing extensive animal
experiments, which led to his "Habilitation" at the Johann Wolfgang Goethe
University in Frankfurt/Main, and to his being honored by the German Surgical
Society with the von Langenbeck Prize in 1985.
Steinau demonstrated that the perfusion of ischemic extremities, especially
perfusion with an oxygenated hemoglobin solution, was significantly better at
preventing the sequelae of ischemia than dry cooling.
Based upon the author's experimental work, extensive knowledge of the past
and present world literature, clinical experience, and operative expertise gained
in Frankfurt and Munich, this monograph gives an excellent synopsis of the
pathophysiology of ischemic damage during and following the replantation of
extremities. In addition to this critical survey, Steinau has added a chapter on the
clinical importance of traumatic amputations of large extremities.
I am convinced that this monograph will be a valuable guide to all
experimental and clinical surgeons who are interested in this field.
November 1987 Albrecht Encke, M.D.
Professor of Surgery
Johann W. Goethe University
Frankfurt/Main
Quotations to Note
Sir J. Hunter - 1784 "Loss of a limb a man can hardly bear."
J. S. Haldane - 1931 "Anoxia not only stops the machine, but also wrecks the
machinery. "
F. Griffith - 1948 "Little good can come from attempts to relieve total
ischemia of 12 hours' standing."
L. Koslowski - 1959 "Durch isolierte Durchstromung geschadigter Glieder
mit Hilfe kiinstlicher Herz-und Lungensysteme die Gift
resorption aufzuhalten und auszuschalten."
R. Judet - 1962 "Au niveau des membres, la vie c'est Ie mouvement."
J. M. Cormier- 1962 "La mort est l'evolution frequente en I'absence de
l'amputation."
F. Linder - 1965 "Darum kann gerade bei multiplen Traumen mit GefaB-,
Knochen-und N ervenbeteiligung auch heute noch immer
der EntschluB zu einer Amputation weiser sein."
B. Mc O'Brien - 1976 "Mild ranges of digital movement, combined with pro
tection sensation, offer a better result than it is possible
to achieve by a prosthesis."
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . 1
1.1 Historical Review. . . . . . . . . . . . . . . 1
1.2 Statistical Frequency of Major Limb Replantation 2
t.3 Problematical Aspects of Major Limb Replantation and Prosthetic
Supplementation . . . . . . . . . . . . . . . . . . . .. 3
2 Pathophysiological Analysis of Ischemia-Induced Injury in Major Limb
Replantation. . . . . . . . . . . . . . 9
2.1 Dermis and Subcutaneous Tissue . . . 9
2.2 Connective Tissue, Bone, and Cartilage 10
2.3 Lymphatic System . . . . . . . . . 11
2.4 Peripheral Nerves. . . . . . . . . . 12
2.5 Ischemia-Induced Myopathy and Microangiopathy 14
2.5.1 Anatomical and Physiological Basis of Striated Muscle
Perfusion. . . . . . . . . . . . . . . . . . . . 14
2.5.2 Regulatory Mechanisms of Fiber-type Distribution and
Muscle Cell Morphology. . . . . . . . . . . 16
2.5.3 Muscle Cell Metabolism and Ischemia Tolerance. 18
2.5.4 The "No-Reflow Phenomenon" . . . . . 22
2.5.5 Regeneration Potential of Striated Muscle 27
2.6 Compartment and Postischemia Syndromes 30
2.6.1 Compartment Syndrome . . . . . . . . 30
2.6.2 Postischemia Syndrome . . . . . . . . 32
2.6.2.1 Circulatory System and Metabolic Disorders 34
2.6.2.2 Kidney Function . . . 35
2.6.2.3 Coagulation Disorders. 37
2.6.2.4 Toxemia and Infection 39
3 Materials and Methods . 41
3.1 Product Description. . . . . . . . 41
3.2 Analytic Methods. . . . . . . . . 42
3.2.1 Storage and Perfusion in Isolated Rat Hind Limbs . 42
3.2.2 Analysis of Perfusate. . . . . . . . . . . 44
3.2.3 Storage and Perfusion in Canine Hind Limbs 44
3.2.4 Determination of Reperfusion Effect. . . . 47
3.2.5 Histological and Electron-Optical Analyses . 48
3.2.6 Washout Effect and Quantitative Determination of Residua. 49
3.2.7 Method of Perfusion. 49
3.3 Statistical Methods . . . . . . . . . . . . . . . . . . . . . 50