October 19, 2022
By Levon R. Karamanoukian
Surgeons in Artsakh Republic performed complex microsurgery to reattach the right arm of a 20 year-old male after a traumatic and life-threatening industrial injury. According to surgeons at the Central Republic Hospital in Stepanakert, Tigran Vladmira Musayelyan sustained a mechanical avulsion injury that spared his life, but completely amputated the upper right arm on September 8, 2022.
The patient was transported by the medical transport team, equipped with military life support equipment, in critical condition to the trauma unit where he was immediately evaluated by reconstructive surgeon Dr. Igor Zakaryan, Chief of Plastic and Reconstructive Surgery at Central Republic Hospital. “A decision was made to perform complex reconstruction and microsurgical reattachment of the upper limb to improve his long-term functional outcome,” reports Dr. Igor Zakaryan. Organizing a critical care team composed of trauma surgeons, anesthesiologists, orthopedic surgeons, vascular surgeons, and medical specialists, Dr. Zakaryan recognized a unique window to salvage the severely mutilated limb and reattach it to the body. “The decision to perform limb replantation is crucial and time-sensitive; even small delays in timing can mean the difference between success and failure…we were faced with the life-changing decision to restore function to this young man,” adds Dr. Zakaryan.
Dr. Igor Zakaryan, Chief of Plastic Surgery at Central Republic Hospital. Stepanakert, Artsakh Republic 
Tigran Musayelyan, recipient of a right arm replantation in Artsakh. Taken one month after injury.
Limb replantation requires complex microsurgery to reattach an amputated limb after acute trauma. “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,” says 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. The surgical collaboration between U.S. and Artsakh surgeons allows for a high level of expertise in the management of severe tissue trauma.
As a result of 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, where an on-call trauma surgery team was prepared to resuscitate and stabilize the patient for surgery. As the medical transport team evacuated the patient, experienced paramedics with military trauma expertise, 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,” reports 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 adds.
The microvascular repair and replantation procedure lasted a total of four hours, with Dr. Zakaryan’s reconstructive surgery team successfully re-approximating and stabilizing the skeletal bone, re-establishing vascular perfusion to the limb, and re-attaching crucial nerves and tendons back together. The patient remained in critical condition as a result of cardiovascular shock and remained in the intensive care unit under the direction of the critical care team at the hospital. After several weeks of inpatient care, Tigran is discharged from the hospital and will require long-term rehabilitation 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,” reports Dr. Zakaryan. “Our decision to restore function to this young man remains a duty and sacrifice to our nation.”
