International
International Orthopaedics (SICOT) ( 199 l) 15 : 289 - 291
Orthopaedics © Springer Verlag 1991
Preservation of the amputated canine hind limb by extracorporeal perfusion J. Domingo-Pech, J. M. Garriga, N. Toran, M. Rusinol, F. Girvent, D. Rosines, E. Rodriguez and M. Tegiacchi Centre de Cirurgia Experimental de la Mutua Sabadellenca, Sabadell, E-08037 Barcelona, Spain
Abstract. The hind limbs of six dogs were reimplanted immediately after amputation. Another nine were conserved by extracorporeal circulation for 24 h, and then examined histologically. A further six were conserved by the same method and then reimplanted after 24 h. Conservation by extracorporeal circulation maintained the limbs in good condition. Less than 5% o f the muscle fibres showed abnormality when examined, and the lesions were reversible.
R/~sum~. Six pattes postdrieures de chien ont ktb
r~implantOes immOdiatement aprOs l'amputation, neuf ont OtO conservOes en circulation extra-corporelle pendant 24 heures et six autres, Ogalement conservOes en circulation extra-corporelle pendant 24 heures, ont ~tO ensuite rOimplantOes. La conservation en circulation extra-corporelle donne des rdsultats favorables car 0 gt 5% seulement des fibres musculaires montrent l'existence de l~sions.
Introduction Successful conservation of an amputated limb p r i o r to r e i m p l a n t a t i o n r e q u i r e s a m i n i m u m p e r i o d o f i s c h a e m i a a n d a d e q u a t e p e r f u s i o n at l o w temperature. Several methods of perfusion have b e e n u s e d [1, 2, 3, 4, 5]. W e h a v e a t t e m p t e d to f i n d a m e t h o d w h i c h w o u l d c o n s e r v e the l i m b i n
Reprint requests to: J. Domingo-Pech
p r o p e r p h y s i o l o g i c a l c o n d i t i o n s , a n d e x t e n d the t i m e f o r w h i c h t h e l i m b m a y b e safely s e p a r a t e d from the body.
Material and methods We divided 21 mongrel dogs into three groups:
Group l (6 dogs). The left leg was amputated through the proximal part of the thigh under general anaesthesia and immediately reimplanted. The average time of anaesthesia was 2h. Group 2 (9 dogs). The leg was amputated with careful haemostasis, heparinised and the iliac artery and vein divided. It was then connected to an extracorporeal circulation with a paediatric oxygenator (Shilley S-70) and a Sarns low velocity pump. The arterial line was inserted into the iliac artery and a venous outlet established by cannulation of the iliac vein. The arterial and venous pressures were monitored. The circuit was primed with the solution described in Table 1, and the perfusion flow calculated according to the relationship between the superficial corporeal area (SCA) and the weight of the limb. Oxygenation was maintained at 0.5 L/min with an arterial pressure greater than 100 mm Hg. Hypothermia was maintained by running cold perfusate through the oxygenator. The initial dose of heparin was 3 mg/kg and this was sustained by fresh doses of heparin, 2 mg/kg, every two hours. The priming solution was changed every four hours and Sodium heparin 5%, 3 mg/kg, Prednisolone 20 mg, Piperalicine Na 1 g and Nitroglycerin 5 mg were added to the solution. The limb was perfused for 24 h.
Table 1. Composition of Perfusate Ringer's lactate solution Rheomacrodex Preserved blood Mannitol Sodium Bicarbonate Total
27.5% 20.6% 27.5% 13.7% 10.3% 725 cc
290
Fig. 1. Ultrastructural appearance 6.000 x . Normal Z bands
J. Domingo-Pech et. al.: Extracorporeal circulation in canine hind limb
of the muscle
fibres.
Fig. 4. Small artery and nerve fibre without anomalies. HE 100 x
Fig. 2. Cross section of skeletal muscle. Minimal degenerative changes of fibres. Interstitial oedema. HE 100 x
Fig. 5. Cellular necrosis. Sarcolemmal destruction. Interstitial connective tissue oedema. HE 400 x
Fig. 3. Sarcoplasmic vacuoles. Loss of striations. HE 400 x
Fig. 6. Degenerative changes of sarcoplasma. Rycnosis of the nuclei and loss of the cellular edge. Masson 250 x
J. Domingo-Pech et. al.: Extracorporeal circulation in canine hind limb
291
seen (Fig. 2). At cellular level cytoplasmic vacuolation was present, with loss of striation and sporadic destruction of the sarcolemma (Fig. 3). There was no evidence of vascular thrombosis, fibrinous plaquette aggregation in the interstitial arteries or infarction (Fig. 4). The appearances of reimplanted muscle were similar, although more marked. However less than 5% of fibres were affected. Interstitial oedema was more obvious (Fig. 5). The appearance of the fibres was similar to that seen in the specimens which had not been reimplanted. There was minimal evidence of microfibrillar infarction, and no cicatricial fibrosis (Fig. 6). Fig. 7. Normal arterial vessel. HE 100 x Group 3 (6 dogs). The limbs were treated with the same regime as those in Group 2. They were then reimplanted and 6 h later the dogs were killed. In all groups biochemical studies on the blood were undertaken every two hours, and biopsies were obtained for histological study at the end of the experiment.
Results
In Group 1 the pH was maintained at a normal level, but there was a considerable rise in the muscle enzymes SGOT and CPK. In Groups 2 and 3 there was a metabolic acidosis in the extracorporeal phase which was corrected by infusion of sodium bicarbonate. Oedema was treated with a peripheral vasodilator (Nitroglycerin), Prednisolone and by lowering the temperature in the infusion circuit. By the end of the experiment in the third group the macroscopic appearance of the limb appeared healthy, there was an increase in weight of between 20 and 50% due to oedema, and the peripheral vessels were well perfused. Histological study of the biopsy specimens showed that extracorporeal circulation produced only minor changes in muscle fibres which were easily reversible and affected up to 5% of fibres only (Fig. 1). There was little evidence of fibre destruction, but progressive interstitial oedema was
Discussion
Immediate reimplantation of a severed limb is only possible as an experiment. In practice extracorporeal perfusion should aim to keep the limb in prime condition for reimplantation, which may be delayed. In order to preserve a limb for 24 h by this method we have found that it is necessary to treat the oedema with peripheral vasodilators, steroids and by cooling the perfusate. Acidosis is controlled by infusion of bicarbonate. These measures have produced minimal damage to muscle fibres and preserved vascular permeability (Fig. 7), enabling maintenance of the limb in good condition. References 1.
2.
3. 4.
5.
Ch'En Chung-Wei, Ch'Ien Yun-Ch'Ing, Pao Yfieh-Se (1963) Salvage of the forearm following complete traumatic amputation. Chinese Med J 82:632-638 Inoue T, Toyoshima Y, Fukusumi H, Uemichi A, Inui K, Harada S, Hirohashi K, Kotani T, Shiraha Y (1967) Replantation of severed limbs. J Cardiovasc Surg 8 : 3 1 - 3 9 Malt RA, Remensnyder JP, Harris WH (1972) Long-term utility of replanted arms. Ann Surg 176:334-342 Smith AR, Van Alphem B, Faithfull MS, Fennema M (1985) Limb preservation in replantation surgery. Plastic and reconstructive surgery. 75 (2): 227-237 Usui M, Sakata H, Ishii S (1985) Effect of fluorocarbon perfusion upon the preservation of amputed limbs. J Bone Joint Surg 67-B: 473-477
International Orthopaedics (SICOT) ( 199 l) 15 : 289 - 291
Orthopaedics © Springer Verlag 1991
Preservation of the amputated canine hind limb by extracorporeal perfusion J. Domingo-Pech, J. M. Garriga, N. Toran, M. Rusinol, F. Girvent, D. Rosines, E. Rodriguez and M. Tegiacchi Centre de Cirurgia Experimental de la Mutua Sabadellenca, Sabadell, E-08037 Barcelona, Spain
Abstract. The hind limbs of six dogs were reimplanted immediately after amputation. Another nine were conserved by extracorporeal circulation for 24 h, and then examined histologically. A further six were conserved by the same method and then reimplanted after 24 h. Conservation by extracorporeal circulation maintained the limbs in good condition. Less than 5% o f the muscle fibres showed abnormality when examined, and the lesions were reversible.
R/~sum~. Six pattes postdrieures de chien ont ktb
r~implantOes immOdiatement aprOs l'amputation, neuf ont OtO conservOes en circulation extra-corporelle pendant 24 heures et six autres, Ogalement conservOes en circulation extra-corporelle pendant 24 heures, ont ~tO ensuite rOimplantOes. La conservation en circulation extra-corporelle donne des rdsultats favorables car 0 gt 5% seulement des fibres musculaires montrent l'existence de l~sions.
Introduction Successful conservation of an amputated limb p r i o r to r e i m p l a n t a t i o n r e q u i r e s a m i n i m u m p e r i o d o f i s c h a e m i a a n d a d e q u a t e p e r f u s i o n at l o w temperature. Several methods of perfusion have b e e n u s e d [1, 2, 3, 4, 5]. W e h a v e a t t e m p t e d to f i n d a m e t h o d w h i c h w o u l d c o n s e r v e the l i m b i n
Reprint requests to: J. Domingo-Pech
p r o p e r p h y s i o l o g i c a l c o n d i t i o n s , a n d e x t e n d the t i m e f o r w h i c h t h e l i m b m a y b e safely s e p a r a t e d from the body.
Material and methods We divided 21 mongrel dogs into three groups:
Group l (6 dogs). The left leg was amputated through the proximal part of the thigh under general anaesthesia and immediately reimplanted. The average time of anaesthesia was 2h. Group 2 (9 dogs). The leg was amputated with careful haemostasis, heparinised and the iliac artery and vein divided. It was then connected to an extracorporeal circulation with a paediatric oxygenator (Shilley S-70) and a Sarns low velocity pump. The arterial line was inserted into the iliac artery and a venous outlet established by cannulation of the iliac vein. The arterial and venous pressures were monitored. The circuit was primed with the solution described in Table 1, and the perfusion flow calculated according to the relationship between the superficial corporeal area (SCA) and the weight of the limb. Oxygenation was maintained at 0.5 L/min with an arterial pressure greater than 100 mm Hg. Hypothermia was maintained by running cold perfusate through the oxygenator. The initial dose of heparin was 3 mg/kg and this was sustained by fresh doses of heparin, 2 mg/kg, every two hours. The priming solution was changed every four hours and Sodium heparin 5%, 3 mg/kg, Prednisolone 20 mg, Piperalicine Na 1 g and Nitroglycerin 5 mg were added to the solution. The limb was perfused for 24 h.
Table 1. Composition of Perfusate Ringer's lactate solution Rheomacrodex Preserved blood Mannitol Sodium Bicarbonate Total
27.5% 20.6% 27.5% 13.7% 10.3% 725 cc
290
Fig. 1. Ultrastructural appearance 6.000 x . Normal Z bands
J. Domingo-Pech et. al.: Extracorporeal circulation in canine hind limb
of the muscle
fibres.
Fig. 4. Small artery and nerve fibre without anomalies. HE 100 x
Fig. 2. Cross section of skeletal muscle. Minimal degenerative changes of fibres. Interstitial oedema. HE 100 x
Fig. 5. Cellular necrosis. Sarcolemmal destruction. Interstitial connective tissue oedema. HE 400 x
Fig. 3. Sarcoplasmic vacuoles. Loss of striations. HE 400 x
Fig. 6. Degenerative changes of sarcoplasma. Rycnosis of the nuclei and loss of the cellular edge. Masson 250 x
J. Domingo-Pech et. al.: Extracorporeal circulation in canine hind limb
291
seen (Fig. 2). At cellular level cytoplasmic vacuolation was present, with loss of striation and sporadic destruction of the sarcolemma (Fig. 3). There was no evidence of vascular thrombosis, fibrinous plaquette aggregation in the interstitial arteries or infarction (Fig. 4). The appearances of reimplanted muscle were similar, although more marked. However less than 5% of fibres were affected. Interstitial oedema was more obvious (Fig. 5). The appearance of the fibres was similar to that seen in the specimens which had not been reimplanted. There was minimal evidence of microfibrillar infarction, and no cicatricial fibrosis (Fig. 6). Fig. 7. Normal arterial vessel. HE 100 x Group 3 (6 dogs). The limbs were treated with the same regime as those in Group 2. They were then reimplanted and 6 h later the dogs were killed. In all groups biochemical studies on the blood were undertaken every two hours, and biopsies were obtained for histological study at the end of the experiment.
Results
In Group 1 the pH was maintained at a normal level, but there was a considerable rise in the muscle enzymes SGOT and CPK. In Groups 2 and 3 there was a metabolic acidosis in the extracorporeal phase which was corrected by infusion of sodium bicarbonate. Oedema was treated with a peripheral vasodilator (Nitroglycerin), Prednisolone and by lowering the temperature in the infusion circuit. By the end of the experiment in the third group the macroscopic appearance of the limb appeared healthy, there was an increase in weight of between 20 and 50% due to oedema, and the peripheral vessels were well perfused. Histological study of the biopsy specimens showed that extracorporeal circulation produced only minor changes in muscle fibres which were easily reversible and affected up to 5% of fibres only (Fig. 1). There was little evidence of fibre destruction, but progressive interstitial oedema was
Discussion
Immediate reimplantation of a severed limb is only possible as an experiment. In practice extracorporeal perfusion should aim to keep the limb in prime condition for reimplantation, which may be delayed. In order to preserve a limb for 24 h by this method we have found that it is necessary to treat the oedema with peripheral vasodilators, steroids and by cooling the perfusate. Acidosis is controlled by infusion of bicarbonate. These measures have produced minimal damage to muscle fibres and preserved vascular permeability (Fig. 7), enabling maintenance of the limb in good condition. References 1.
2.
3. 4.
5.
Ch'En Chung-Wei, Ch'Ien Yun-Ch'Ing, Pao Yfieh-Se (1963) Salvage of the forearm following complete traumatic amputation. Chinese Med J 82:632-638 Inoue T, Toyoshima Y, Fukusumi H, Uemichi A, Inui K, Harada S, Hirohashi K, Kotani T, Shiraha Y (1967) Replantation of severed limbs. J Cardiovasc Surg 8 : 3 1 - 3 9 Malt RA, Remensnyder JP, Harris WH (1972) Long-term utility of replanted arms. Ann Surg 176:334-342 Smith AR, Van Alphem B, Faithfull MS, Fennema M (1985) Limb preservation in replantation surgery. Plastic and reconstructive surgery. 75 (2): 227-237 Usui M, Sakata H, Ishii S (1985) Effect of fluorocarbon perfusion upon the preservation of amputed limbs. J Bone Joint Surg 67-B: 473-477
