Aeromonas hydrophila infection complicating digital replantation and revascularization

Two cases of thumb replantation and one of finger revascularization complicated by Aeromonas hydrophila infection are reported. Two digits were lost because of infection in soft tissue and osteomyelitis. One thumb had extensive necrosis. In all cases the infection was difficult to eradicate, probably because of ischemia. All three patients sustained their injuries while cutting meat or fish. These infection sources have not been previously reported. Note is made of Aeromonas hydrophila in medicinal leeches that are used in microvascular surgery and the potential for iatrogenic infection.     

Venous flaps in digital revascularization and replantation

This is a report on 15 patients who underwent replantation/revascularization of a single digit with a substantial dorsal soft tissue defect. The dorsal defect was covered with a venous flap, a free flap that has only venous inflow and outflow. Postoperatively, the venous flaps were warm, pink, and appeared to exhibit a blanch and refill phenomenon, clinically resembling capillary filling. The flaps from the dorsal aspect of an uninjured digit had a survival rate of 100 percent, with no partial necrosis, while the flaps from a forearm or dorsal foot donor site failed. The advantages of using venous free flaps are twofold. Not only does this technique provide for venous drainage, but it also provides flap coverage and avoids complications, such as vessel occlusion or hematoma formation, associated with skin grafting over a venous anastomosis, with subsequent loss of the skin graft.     

Aeromonas hydrophila upper extremity infection

A severe soft tissue infection of the upper extremity caused by Aeromonas hydrophila followed a water skiing injury in which a tow rope caused degloving of a portion of the skin and severe contusion to underlying muscle. Infection was established within 36 hours of the injury, accompanied by fever, leukocytosis, and a foul odor. Rapid clinical improvement occurred following radical debridement of all nonviable tissue and antibiotic therapy. In cases involving water contamination, Aeromonas hydrophila infection should be suspected with the onset of a rapidly developing infection with a febrile response. Rapid surgical intervention and treatment with an aminoglycoside or a third-generation cephalosporin antibiotic is the treatment of choice.     

Twelve simple maneuvers to optimize digital replantation and revascularization

Trauma can result in either complete amputation of fingers or devascularization of parts. Microsurgical techniques have made the salvage of devascularized digits possible. Although algorithms for digital replantation and revascularization exist, these procedures remain technically difficult and tedious. In multiple digit injuries, the complexity of replantation and revascularization is significantly increased. From our combined experience, we have found many "tricks" that have optimized digital replantation. In this paper, the current indications and contraindications for digital replantation and the technique of replantation are presented with specific reference to 12 simple maneuvers designed to maximize simplicity and efficiency.     

Aeromonas hydrophila wound infection in elective surgery

Patients with diabetes mellitus are subject to wound infection with unusual pathogens. A patient who had colonic surgery developed Aeromonas hydrophila wound infection, which mainly results from contamination by water or soil.     

Parapharyngeal soft-tissue infection with Aeromonas hydrophila.

Parapharyngeal soft tissue infections may be rapidly progressive and life-threatening. Prompt institution of appropriate antimicrobial therapy is of paramount importance. This report highlights the potential virulence of Aeromonas hydrophila in infection of the head and neck and the need to consider this organism in selected patients.     

Long-term effects of sensory reeducation following digital replantation and revascularization

The long-term maintenance of sensory gain following sensory reeducation is still unknown for replanted digits. Ten patients with 18 replanted or revascularized digits, who had received a formal sensory reeducation program for 1.5 years postoperatively, were reevaluated with moving two-point discrimination and Semmes-Weinstein pressure threshold test after discontinuing sensory reeducation for 1 year. Another four patients with seven replanted or revascularized digits, who have never received sensory reeducation after surgery, were also followed up in the same way. After cessation of sensory reeducation, the degree of moving two-point discrimination became significantly worse in the formal sensory-reeducated group (P < 0.05) and significantly improved in the group without sensory reeducation initially (P < 0.05), whereas it showed a nonsignificant change of Semmes-Weinstein threshold both in the group with formal sensory reeducation and without sensory reeducation. Sensory retraining did influence the progressive change of moving two-point discrimination, but not in a parallel way with the Semmes-Weinstein threshold test. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:334–336, 1998     

Cefotaxime-sensitive Aeromonas hydrophila infection in a revascularized foot

Three days following revascularization of a foot injured in a boating accident, Aeromonas hydrophila cellulitis developed in the victim's foot and leg. The infection resolved with debridement and 10 days of cefotaxime therapy. A. hydrophila infection has not previously been reported in a revascularized extremity. Clinical response of an A. hydrophila cellulitis to cefotaxime is likewise undescribed. Our findings of a cefotaxime-sensitive Aeromonas infection and its successful treatment suggests that the organism should undergo further evaluation of cefotaxime sensitivity and that cefotaxime and other third-generation cephalosporins may have a role as broad-spectrum antibiotic agents in fresh-water trauma.     

Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery.

Aeromonas hydrophila infections are a recognized complication of postoperative leech application, and can occur with measurable frequency in populations of patients treated with leeches. We review 11 previously reported leech-related Aeromonas infections and analyze seven unreported cases. These infections range from minor wound complications to extensive tissue loss and sepsis. Often, these infections followed leech application to tissue with questionable arterial perfusion. Onset of clinical infection in these patients ranged from within 24 hours of leech application to 10 days or more after leech application. Late infections may represent bacterial invasion from colonized necrotic tissue. Based on these observations, we recommend that leech applications be restricted to tissue with arterial perfusion to minimize contamination of necrotic tissue. We also recommend that patients treated with leeches receive antibiotics effective against Aeromonas hydrophila before leech application. Patients treated with leeches and discharged with eschars or open wounds might benefit from oral antibiotic therapy until wound closure. These precautions may minimize or eliminate this complication of leech use.     

Evaluation of the effectiveness of sensory reeducation following digital replantation and revascularization

Sensory recovery following digital replantation plays an important role in the restoration of hand function. Twelve patients with twenty-four replanted or revascularized digits were randomly selected to enter a program of sensory reeducation, and another 15 patients with 22 replanted or revascularized digits were selected as controls who did not receive sensory reeducation. A moving two-point discrimination and a Semmes-Weinstein pressure threshold test were evaluated for monitoring the sensory recovery. The period of sensory reeducation was 18.83 weeks on average, and the mean follow-up time was 11.94 months. The group that received sensory reeducation significantly improved to a better degree of moving two-point discrimination and Semmes-Weinstein threshold level by both univariate and multiple regression analysis. We suggest that sensory reeducation should be an integral part of the postoperative rehabilitation protocol following digital replantation and revascularization. © 1995 Wiley-Liss, Inc.     

Enterobacter asburiae and Aeromonas hydrophila: soft tissue infection requiring debridement

Enterobacter asburiae and Aeromonas hydrophila are gram-negative bacilli that have been isolated in soil and water. Enterobacter asburiae can cause an array of diseases, and exposure to A hydrophila can cause soft tissue infections, including necrotizing faciitis.A healthy-appearing 22-year-old man presented with an innocuous soft tissue injury to his leg due to an all-terrain vehicle crash. He received intravenous antibiotics and was discharged with prophylactic oral antibiotics. After the rapid onset of high fevers (102°F-103°F) <24 hours postinjury, he returned to the emergency department. Emergent surgical debridement was performed, and broad-spectrum intravenous antibiotics were started. Fevers persisted, and the patient underwent repeat extensive surgical debridement and antibiotic bead placement <30 hours after the initial surgical debridement and broad-spectrum antibiotics. Intraoperative cultures found E asburiae and A hydrophila in the wound. Following a long course of antibiotics and a skin graft, he fully recovered and had no functional deficits 1 year postoperatively.Extensive research revealed that these organisms are rare in soft tissue infections. E asburiae is opportunistic but has not been reported as a primary wound organism, and A hydrophila infections have been reported following motor vehicle crashes involving wound contamination. At presentation, it is challenging to determine rare organisms in a timely fashion; however, emergent extensive surgical intervention of an accelerated aberrant disease process should be considered to avoid catastrophic outcomes.     

Prostacyclin analogue (beraprost) relief of cold intolerance after digital replantation and revascularization

Cold intolerance frequently occurs after successful digital revascularization and replantation. A series of 11 patients with cold intolerance 6 to 24 months after digital revascularization/replantation were treated daily for 2 weeks with beraprost, a stable prostacyclin analogue. That pain was reduced in 9 of 11 cases after treatment and digital thermography showed significantly increased surface temperature after the 2-week course of beraprost. These findings support the use of beraprost to relieve symptoms of cold intolerance under these clinical conditions.     

Pediatric microsurgery: revascularization and replantation

Pediatric microvascular surgery has received little attention in the literature until recently. The demonstrated feasibility with successful results represents a disproportionately small patient population when compared with adults. One reason for this delayed growth in pediatric revascularization and replantation appears to be a lack of awareness on the part of both referring physicians and microvascular surgeons as to its present indications and outcome. Several cases are presented along with a review of the current literature to clarify this issue. A protocol for managing these patients from a triage standpoint is also included.     

Intravenous heparin use in digital replantation and revascularization: The Quebec Provincial Replantation program experience

Background: No consensus exists among microsurgeons regarding the role of intravenous (IV) heparin in digital replantation/revascularization. The current experience of the Provincial Replantation Center in Quebec was reviewed over a 4‐year period. Methods: An initial retrospective review of all revascularized or reimplanted digits at our Replantation Center from April 2004 to April 2006 was conducted. Then, data of all patients treated at our center from January 08 to September 08 were prospectively collected. The two cohorts were compared with regards to demographics, injury characteristics, postoperative thromboprophylaxis medication as well as complication and success rates. Proportions were compared using χ² tests/Fisher's exact tests. Multivariate analysis was conducted with logistic regression. Results: 175 digits were treated from April 2004 to April 2006, including 104 revascularizations and 71 amputations. IV heparin was used in 35.1% of the cases and was associated with a 3.59‐fold (95% CI, 1.55–8.31) increase risk of developing a complication compared with cases where heparin was not used (P = 0.001). In 2008, 106 digits were treated. IV heparin was used in 14.6% of the cases and was not significantly associated with a higher complication rate compared with cases where heparin was not used (P = 0.612). Both cohorts' success rates were very similar (P = 0.557). The number of complications decreased from the first period (20.5%) to the second one (12.8%). Conclusion: Routine use of IV heparin following digital replantation and revascularization is not warranted. Surgical technique and type of injury remains the most important predictors for success in these complex procedures. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Brace and rehabilitation after replantation and revascularization

Although most reports of the functional results of replantation at the metacarpal level have been poor, the author (LRS) has reported good functional results with the early use of the dynamic crane outrigger splint with a MCP joint extension block, as described in this article (Fig. 8). Promoting early protective active motion and blocking MP joint extension [figure: see text] help achieve a hand with an intrinsic-plus posture and coordinated grasping. Although this protocol does not show an improvement over the functional results at the wrist and distal forearm reported by Meyer, its use can help prevent intrinsic-minus deformity, which is a concern in most amputations proximal to the MCP joint, according to Russell et al. With this technique, the need for subsequent surgery is reduced. Tenolysis may be needed in some patients, but it should not be performed until 6 months postoperatively.     

Transpositional digital replantation

When a functionally important digit is injured as part of a multiple digit injury, transpositional digital replantation is worth considering to preserve greater hand function and to avoid or minimize the necessity for secondary reconstructive procedures. We present two such cases with transpositional digital replantation. The indications for this technique are: 1) multiple digit injury, 2) severe crush injury, 3) the possibility of preserving more and better joints in some fingers, and 4) injury distal to Tamai's zone V (11). The benefits of this procedure are that function can be better with the more completely preserved digits replanted into the most useful positions and of similar lengths. Difficulties are encountered when there are large discrepancies in size of surviving digits, and problems with soft-tissue coverage, tendon repair, a 'step' at the fracture site after bone fixation, and with vessel anastomosis. Use of this procedure can result in preservation of hand function and fewer secondary reconstructive procedures.