A serious complication after forearm replantation caused by a cord tightened on the stump during transportation – a case report

In amputations of an upper extremity, an adequate preservation of the amputated part during its transport to a replantation centre is very important: it needs to be maintained at about 4°C. Providing adequate haemostasis of the extremity stump is also important for the patient’s safety, to avoid bleeding on the journey. The article presents the case of a patient who had sustained a hand amputation at the forearm, in which bleeding from the stump was stopped with a cord that has been tightened on the forearm, 10 cm above the amputation site. Transport for the patient took over 6 h and resulted in a critical ischaemia ofthe forearm stump. Replantation was successfully performed, but an excessive oedema of the ischaemically injured part of the stump developed in the post-operative course, requiring a fasciotomy, resection of the necrotic muscles, following by coverage of the defects with skin grafts. No complications were observed in the replanted part of the forearm, and the prognosis towards recovery of good hand function is moderate, due to the loss of a portion of the forearm muscles.Keywords: hand replantation; postoperative complications; muscle ischaemia; malpractice.

Worsening renal failure due to renal steal by aortoiliac bypass

Aortoiliac bypass surgery is the gold standard strategy for removing persistent ischaemia resulting from bilateral aortoiliac occlusive disease, a condition known as Leriche syndrome. However, the impact of aortoiliac bypass surgery on the blood flow of the renal artery is not fully understood. Here, we report a case of worsening renal failure caused by renal steal immediately after aortoiliac bypass for Leriche syndrome. The revascularisation of bilateral renal arteries dramatically improved the patient’s renal function and allowed us to discontinue both haemodialysis and diuretics. This case demonstrates that in rare instances, haemodynamic change induced by aortoiliac bypass surgery affects the arteries feeding other organs. Careful preoperative evaluation for the corresponding branches of the aorta is indispensable. Optimal revascularisation should be performed to avoid serious complications after aortoiliac bypass if the patient is at risk of developing critical ischaemia.

Raynaud’s phenomenon

Raynaud’s phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud’s phenomenon is very common, affecting approximately 3%–5% of the general population. Although much rarer, systemic sclerosis–related Raynaud’s phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud’s phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis–related Raynaud’s phenomenon (which is the most researched form of Raynaud’s phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from ‘isolated’ to systemic sclerosis–related Raynaud’s phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both ‘uncomplicated’ and ‘complicated’ Raynaud’s phenomena (i.e. Raynaud’s phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5–10 years are highlighted.