Surgical treatment of severe frostbite and its alternative

The significant risk of permanent impairment, such as the loss of fingers in frostbite, poses a challenge for for doctors and prompts them to use all available treatment options to avoid or reduce disability. At the same time, doctors' average practical knowledge of frostbite is archaic and anecdotal. To date, the practice of treating third- and fourth-degree frostbite boils down to diagnosis, desmurgery and surgical treatment - amputation. It is extremely rare for patients to be referred to specialized departments for dealing with reconstructive surgery. Meanwhile, techniques using stapled and free flaps often allow to reduce the level of amputation and reduce the degree of disability.

The author would like to present examples of the possibilities, tactics and technique of surgical reconstruction in cases of severe grade IV frostbite of the hands and legs using methods of conventional reconstructive surgery and microsurgery. At the same time, it should be emphasized that progress in understanding the pathophysiology of frostbite at the microsurgical level, the role of the endothelium and the arachidonic acid cascade are fundamentally changing views and should alter therapeutic measures at the level of prevention and treatment in both early and late stages. Key is that the process of tissue destruction begins as soon as the tissues are thawed, and until some time it is possible to inhibit it and reverse the negative effects of frostbite or significantly reduce them. The main mechanism leading to tissue necrosis in frostbite is damage to the endothelium of the vessels leading to local thrombosis. When heated, platelet aggregation and clot formation occur, which blocks the blood supply to the still salvageable tissues within the frostbite. This process is further stimulated by PGF 2a and thromboxane A2 (pro-aggregative and vasoconstrictive effects), which is abundantly is present in frostbitten tissues, especially in the fluid filling the blisters formed after thawing. The above pathomechanism should imply a course of therapeutic measures including thrombolysis, inhibition of platelet aggregation, vasodilation, improvement of the rheological properties of blood. Early supplementation of at-risk tissues with oxygen in a hyperbaric chamber often makes it possible to avoid or significantly reduce the extent of amputation. Therefore, it seems expedient to implement as early as possible after thawing implementation of modern methods of comprehensive treatment of frostbite - from the use of rTPA and prostaglandins beginning and ending with oxygen hyperbaria - already in the ED.

Encouraging results of frostbite treatment obtained in Western centers in preventing the development of necrosis and in the treatment of late conditions at the Department of Trauma and Hand Surgery, the Department of Hand Surgery in Trzebnica, as well as reports from plastic surgery from Krakow and the Mazovian Center for Hyperbaric Therapy, and conclusions from ICAR MEDCOM and PTMiRG symposia authorize the authors to present a proposal for a new comprehensive treatment of frostbite.