Long-Term Results after Macroreplantation at the Upper Extremity

Emergency management of a total or subtotal upper limb amputation poses a complex problem for the therapy team (surgeon, anesthesiologist, nurses, physiotherapist, social service, family doctor) and the patient. With current therapeutic and technological advances, the surgeon has the ability to salvage viability in most severe upper limb injuries. Nowadays, restoration of viability alone is not sufficient to fulfill the criteria of successful replantation.

Using a series of 65 patients operated on between 1981 and 1993 (upper arm: n = 18, proximal and middle forearm: n = 32, distal forearm and wrist level: n = 15), and the results of an extensive literature review, the following criteria were evaluated: 1) survival rate, 2) possible individual motor and sensory functions of the extremity, 3) global upper extremity function judged according to Chen's classification, 4) socioeconomic aspects, and 5) number and nature of local and/or systemic complication and subjective judgment by the patient.

The survival rate of upper limb replantation, which means only perfect restoration of viability, was about 76 to 92.3%. With the amputation level going distally, there was an increase of individual motor and sensory functions of the “functional chain upper extremity.” Taking Grades I and II results together, a “functional extremity” could be reconstructed at the upper arm level in 22 to 34% of patients; at the proximal forearm level, in 30 to 41%; and at the distal forearm level, in 56 to 80% of patients. All patients needed at least two secondary operative procedures. Five of 65 patients were re-amputated because of postoperative complications.

As the functional results after replantation are at least equal (proximal level) or even far superior (distal level), some protective sensibility at the hand can be expected even at the most proximal levels. Considering the psychological impairment caused by missing body integrity, reconstruction should be carried out with regard to the expected function, and with estimation of a low risk for the patient. The high costs and the number of operations needed, as well as the extensive postoperative care and longer time of disability after replantation, are justified by a significant increase in life quality.