Functional Results after Upper Limb Replantation with Flap Transfer

The authors presented a retrospective study that reported three cases of upper limb replantation with flap transfer. The objective was to show that the best limb survival and functional results were produced when all necessary microsurgical and orthopaedic reconstructions were performed in a first surgical procedure.

The first patient was a 15-year-old male with an arm amputation from a bike vs. truck crash. There was a crush and avulsion mechanism, but the part was well preserved. Cold ischemia was 6 hr at admission. The severity of the trauma created extensive muscular necrosis. Agressive debridament was performed in the limb and stump. The neurovascular bundles were dissected. Ostheosynthesis was performed with a standard DCP plate. A saphenous graft bypass was dissected. Revascularization was performed with a brachio-ulnar saphenous bypass. Two cutaneous veins were anastomosed with brachial comitant veins with the graft. The median nerve was sutured primarily and neurotization from the proximal radial to the distal ulnar nerve was performed. A latissimus dorsi pedicled transfer was done for coverage of vessels and for elbow flexion. Bone healing, elbow flexion by latissimu dorsi, and excellent functional median nerve muscle recovery allowed tendon transfers and good hand function 1 year after initial surgery.

The second patient was a 7-year-old boy who underwent a thumb amputation by a bread machine in association with hand degloving. Ostheosynthesis was performed with two Kirschner wires. The blood flow was reestablished with long venous grafts. A microsurgical contralateral cutaneous lateral arm flap was transferred Excellent pinch and hand functional results were achieved.

The third patient was a 44-year-old man who sustained an amputation through the proximal third of the forearm from a car crash. Replantation was performed after 12 hr of cold ischemia, because of observation of cranial trauma. All the forearm muscle underwent surgical resection. Osteosynthesis was performed with a reconstructin plate. The bíceps was transferred to the flexor digiti profundus with a graft. A pedicled latissimus dorsi flap covered the anterior elbow. After 6 months, the patient had elbow flexion but very poor wrist and hand function. Despite the poor functional results, an assistant hand was considered better than a prosthesis, and patient satisfaction justified the procedure. Additional reconstruction procedures are planned.

The authors considered that the best functional results are obtained when all necessary procedures are performed at the first surgery, which usually requires flap transfer for good soft-tissue coverage. Additional immediate, continuous, and lasting rehabilitation is also essential. The presence of a flap also supports indications for later procedures.