Major Upper Extremity Replantation

The usual mechanism of a major amputation involves crush, avulsion, and traction, thus creating a mutilating injury. Although the survival rate is usually high, the functional results are guarded. According to Chuang's classification, there are 4 types of major amputations: type 1: disruption at the musculotendinous junction, the entire normal muscle remains in the proximal stump; type 2: amputation through the muscle but distal to the neuromuscular junction; type 3: amputation proximal to the neuromuscular junction; type 4: elbow or shoulder disarticulation.

The authors revised their results with major upper extremity replantations according to this classification. Between the years 1987 and 2004, they replanted 7 arms and 12 forearms and elbows. All but one replanted part survived. One replanted arm had to be amputated 5 days following replantation due to severe post reperfusion syndrome and infection. Of 6 patients with arm replants, 3 gained useful extremities and one had a poor result. Two patients are still in rehabilitation.

Of 12 replanted forearms, after a long rehabilitation period and 30 operations, a useful extremity was achieved in 9 patients and poor results in 3.

The main factor influencing functional results of a major upper extremity replant is the type and extent of injury. Other factors are patient's age, the level of amputation, and patient's motivation. The classification of the type of injury proposed by Chuang and colleagues is pertinent and predictive in terms of expected results. Functioning muscle transfers are always indicated in types 3 and 4 injuries.