BY LEVON R. KARAMANOUKIAN
Almost two years after performing a successful arm replantation on a pregnant female during the 44-Day War, trauma surgeons in Stepanakert, Artaskh succeeded in reattaching the upper limb of a 20 year-old male who sustained severe mechanical injury to the right arm at the level of the shoulder on September 8, 2022.
The patient, Tigran Vladmira Musayelyan, suffered life-threatening vascular injuries when his upper arm was mechanically avulsed and completely amputated as a result of an industrial accident. The actions of the Artsakh medical transport team, equipped with advanced military life support equipment, facilitated the transport and resuscitation of the patient to the Central Republican Hospital for management.
“A decision was made to perform complex reconstruction and microsurgical reattachment of the upper limb to improve his long-term functional outcome,” said Dr. Igor Zakaryan, an experienced plastic surgeon with advanced training in microsurgery. As Chief of Plastic and Reconstructive Surgery at Central Republic Hospital in Stepanakert, Dr. Zakaryan exercised an executive decision to replant the arm in concert with a team of trauma surgeons, anesthesiologists, orthopedic surgeons, vascular surgeons, and medical specialists. “Faced with a potentially life-threatening injury, we were faced with the life-changing decision to restore function to this young man,” added Dr. Zakaryan.
Arm replantation is a complex microsurgical process that is usually performed in an acute trauma setting when a decision is made to salvage an amputated limb. “The chance of success is severely reduced in patients with avulsion rather than sharp cutting injuries to the soft tissue. The actions of Dr. Zakaryan and the trauma team at Central Republic Hospital in Stepanakert are nothing short of spectacular,” said plastic surgeon Dr. Raffy Karamanoukian, who authored a paper on the feasibility of robotic microsurgery in the Journal of Reconstructive Microsurgery. “Replanting an upper arm in an avulsion injury requires expertise and coordinated trauma protocols that can help resuscitate and stabilize a potentially life-threatening injury.” Over the last decade, Dr. Karamanoukian performed many reconstructive surgeries in Stepanakert, Artsakh Republic and collaborated with the plastic surgeon Dr. Zakaryan at Central Republic Hospital.
Due to a quick trauma response time, the patient was transported to Central Republic Hospital with the severed limb in a record one hour from the time of injury, wherein a trauma surgery team was waiting and prepared to resuscitate and stabilize the patient for surgery. As the medical transport team evacuated the patient, experienced paramedics retrieved and prepared the limb for possible transplant.
The goal of replantation was to restore vital blood circulation first, followed by complex and staged repair of bone, tendons, muscles, and nerves that maintain upper limb function. “This surgery is complex from the standpoint of cardiovascular shock,” reported Dr. Hratch Karamanoukian, a board certified cardiothoracic surgeon in the United States. “The acumen of these surgeons attests to the highest level of medical and surgical achievement in trauma critical care,” he added.
The entire surgical procedure lasted four hours, with Dr. Zakaryan’s reconstructive surgery team successfully reapproximating and stabilizing the skeletal injury, reestablishing vascular perfusion to the limb, and reattaching crucial nerves and tendons back together. The patient was then transferred in critical care to the intensive care unit and stabilized. After several weeks of inpatient care, Tigran is discharged from the hospital and will require long-term physiotherapy with physical therapy and occupational therapy experts to restore function to the limb, according to chief surgeon Dr. Zakaryan.
“The work of the trauma team at Central Republic Hospital supports the social and cultural framework of our homeland,” said Dr. Zakaryan. “Our decision to restore function to this young man remains a duty and sacrifice to our nation.”