Results of Major Upper Extremity Replantation or Revascularization

Abstract

Objectives: Major upper extremity replantation is defined as replantation of limbs proximal to the wrist. Advancements of microsurgical techniques and equipment have improved functional results of major replantations. The goal of the treatment is to obtain a nearly normal functioning extremity with an acceptable cosmetic result. This study is to review our experience with major upper extremity replantations or revascularizations after complete or incomplete amputation injury performed from 2000 to 2013. This report provides an indirect comparative analysis of the functional results after major replantation versus previously published reports of arm transplantation in upper extremity. Materials and Methods: Twenty-five consecutive patients who underwent major upper extremity replantations or revascularizations were evaluated retrospectively in this study. The mean age at the time of surgery was 35.6 (range, 14-70) years. The mean follow-up was 34.4 (range, 7-85) months. There was no bilateral amputation. There were 4 complete amputations and 21 incomplete amputations. The mechanism of injury was crush-avulsion in 5, guillotine or deep laceration in 16, crush in 2, and avulsion in 2. There were 8 shoulder and upper arm level, 7 elbow and forearm level, and 10 distal forearm and wrist level amputations in upper extremities. Functional results were assessed using the Korean version of the Disabilities of the Arms, Shoulder and Hand (DASH) and the Chen criteria. Results: The mean ischemic time was 380.1 (range, 120-600) minutes. A total of 23 of 25 limbs survived. There were no significant differences in ischemia time between the 2 groups of patients with respect to limb survival. ( P = .273) The type of amputation and level of injury had no significant association with limb survival ( P = .65 and P = .076, respectively). In the upper extremity, the mean 2-point discrimination test result was 7.7 (range, 4-15) mm, mean visual analog score was 2.91 (range, 1-7), and mean DASH score was 13.2 (range, 2-85). When analyzed by the Chen criteria, there were 15 grade I, 3 grade II, 3 grade III, and 2 grade IV results. One of 2 patients with reperfusion events had proximal amputation. None of the patients developed nonunion or osteomyelitis. Twelve of the successful 23 replants underwent at least 1 secondary procedure. Ten of the successful replants had pain or cold intolerance, but improved with time, and all used the replanted arm for daily activities. Conclusions: The promising results achieved in our major upper extremity replantation or revascularization patients, which was in some respects superior to those in arm transplantation patients, lead us to recommend that replantations or revascularizations continue to be considered as first-line treatment.