Long-term utility of replanted arms

Hand and Wrist Amputation: A Demographic Analysis Using the National Inpatient Sample

BACKGROUND

Traumatic hand and wrist amputations are rare but debilitating injuries. Surgical replantation of the hand provides a unique alternative to revision surgery but requires appropriate access to necessary medical resources. This study aims to understand the national practice of replantation of traumatic hand amputation and to determine whether disparities exist in accessing surgical treatment.

METHODS

International Classification of Diseases, 10th Revision codes for replantation and revision amputation surgeries were used to gather data from the National Inpatient Sample from 2016 to 2019. Summary statistics were calculated on demographic, hospital, and outcome variables, with subanalysis performed for effect on replantation and revision rates.

RESULTS

Seventy-two patients were identified. The average patient was 35 years old with a strong male predominance (90%). The racial distribution of the cohort roughly mirrored the demographic proportions of race in the US population. Fifteen (21%) patients underwent replantation. This rate was similar between sexes, races, and income brackets. Hand replantation was primarily performed at large bed size (87%), private not-for-profit (73%), and urban teaching hospitals (94%). The most common insurance status for these patients was private, followed by Medicaid, Medicare, and self-pay. Forty-seven patients underwent revision amputation (65%) with no association between demographic characteristics. The patients remained hospitalized for significantly longer periods (P = .0188) and paid significantly more (P = .0014) if replanted. The patients were most frequently discharged home (65%), followed by skilled nursing facilities (18%).

CONCLUSION

This study describes the current state of hand amputation management and finds no evidence of sociodemographic factors influencing the surgical care provided.

Pediatric Replantation and Revascularization

Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications.

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.

[Major upper limb trauma: patients' outcomes in 22 cases]

In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.

[Macro-replantation of the upper limb: long-terms results and quality of life]

OBJECTIVES

The authors suggest standardized questionnaires of quality of life to perform a long term evaluation of patients who underwent a replantation of the proximal upper limb.

METHODS

This retrospective study is about patients who underwent a replantation of the proximal upper limb between 1979 and 2011. The functional assessment was conducted using several tools including the 400 points test, the sensory tests, the Disabilities of the Arm, Shoulder and Hand questionnaire and the CHEN's classification. Some questionnaires, like the Medical Outcome Study Short Form-36 dealt with the physical and the psychological sides of the quality of life. Other questionnaires were more specific, like the Body Image Scale.

RESULTS

Sixteen patients were included. The survival rate of the replanted limb was 75%. The mean follow-up was 12.7 years. We noted 20% good results with a mean DASH score to 24.5%. The quality of life was similar to the general population in most of 50% of cases. Some patients had depressive symptoms or body image troubles.

CONCLUSIONS

In our eyes, the evaluation of quality of life seems essential for these patients. Survival rates, functional results, follow-up, professional activity, gender and body image troubles influence the quality of life. Besides, the physical side and the psychological side must change together to affect the overall results of the quality of life.

Long-term results of major upper extremity replantations

We analyzed the long-term functional outcome in patients with major upper extremity replantations. Two patients had amputations proximal to the elbow joint, two had elbow disarticulations and five patients had amputations at the forearm. The mean age was 24 and the mean follow-up time was 18 years. Six patients have undergone secondary operations. The mean grip strength was restored to 34% of the contralateral extremity. Protective sensation was restored in all patients. According to Chen's functional recovery scale, five patients had excellent, two had good, and two had fair results. Grip strength, two-point discrimination, ranges of motion and Chen's scale did not improve after 5 years. However, Semmes-Weinstein monofilament testing and cold intolerance continued to improve up to 10 and 12 years, respectively. Replantation of an upper extremity proximal to the wrist joint satisfactorily restored the upper extremity function.

An overview of limb replantation

This review aims to provide an overview of the complex topic of limb replantation. The historical developments in limb replantation are detailed and the technical considerations of this surgery are discussed. Specific concerns relating to limb replantation surgery such as total ischaemic time and the amputation level are considered. It is important for rehabilitation to be tailored to the individual and the level of the injury. Attempted upper limb replantation is advocated in most cases but lower limb replantation is rarer. Lower limb replantation may have successful outcomes provided careful selection of patients takes place. Future improvements in replantation surgery may be influenced by developments in limb allograft surgery and nerve regeneration. Despite varying outcomes following successful replantation surgery, patients generally prefer to retain their own limbs rather than have a prosthesis and this should be considered as part of the informed decision making process by clinicians.

Limb preservation for reimplantation. a review

Although reimplantation of severed limbs and other parts of the body has become prevalent in recent years, the questions of how best to preserve limbs for reimplantation and how to determine if a transected part is viable have not been fully answered. The problem of preservation involves combating direct anoxic damage to tissue as well as combating the changes in the vascular system that lead to the "no reflow phenomenon." Current information concerning kidney preservation as well as experimental and clinical reports on limb preservation are reviewed in this article, and suggestions are made for further investigations.

Replantation in the mutilated hand

With the evolution of surgical techniques and scientific technology, replantation has become more refined, establishing specific indications for replantation, rituals for preparation, efficient techniques to ultimately minimize ischemia times, improved survival rates, guidelines for postoperative care, strategies for treating complications, and goals for outcomes. Patient satisfaction hinges on their level of expectation as defined and explained in the preoperative discussion and informed consent. Studies have demonstrated patients can be expected to achieve 50% function and 50% sensation of the replanted part. Initially all that was amputated was replanted, as surgeons adopted the philosophy of George C. Ross (1843-1892): "Any fool can cut off an arm or leg but it takes a surgeon to save one." Forty years after the first replant (1962-2002), however, we recognize the ultimate goal: not merely to preserve all living tissue through nonselective replantation, but rather to preserve one's quality of life by improving their function and appearance. This objective to care for the patient with the intent to optimize function and appearance is important not only to the replantation of amputations but to all mutilated hand injuries.

Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction

Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.

Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study

The functional outcomes of amputated arms that were either replanted or had a prosthesis were compared. In addition, factors that influenced the functional outcome of replants were evaluated. The Carroll test was used to evaluate functional capacity of 22 successful upper extremity replantations at or proximal to the wrist as well as 22 amputees (at similar levels) fitted with a variety of prosthetic devices. The outcome was excellent or good in 8 (36%) replanted limbs. This proportion was statistically higher than those grades in the prosthetic group. When the groups were more closely matched (adults with below elbow injuries), the replantation group had 6 (50%) good or excellent outcomes and the prosthetic group had none. An analysis of covariance of the replantations demonstrated a statistical association between a better outcome in younger patients with more distal injuries. This study indicates that replantation produces superior functional results compared with amputation and a prosthesis.

Preservation of the amputated canine hind limb by extracorporeal perfusion

The hind limbs of six dogs were reimplanted immediately after amputation. Another nine were conserved by extracorporeal circulation for 24 h, and then examined histologically. A further six were conserved by the same method and then reimplanted after 24 h. Conservation by extracorporeal circulation maintained the limbs in good condition. Less than 5% of the muscle fibres showed abnormality when examined, and the lesions were reversible.

Major limb replantation in children

This retrospective study evaluated patients under 18 years of age who underwent major limb replantation between 1976 and 1989 at Louisville Hand Surgery. The age of the 15 patients followed for between 1 and 8.5 years (mean 4.2 years) ranged from 2 to 17 years (mean 9.8). Of amputations, 40% were guillotine, 40% were limited crush-avulsions, 7% were extended crushing, and eight were of an upper extremity and seven of a lower extremity. Average warm/total ischemia times were 4.8/14.8 hr in failures and 1.1/7.5 hours in successful replantation. Overall limb survival was 87%. Among the patients, 93% felt that their replanted limb functioned and looked better than a prosthesis; 87% of patients had a sensory recovery of more than S2+ in the lower extremity or S3 in the upper extremity; and 38% of upper extremity replantation patients had two-point discrimination of less than 15 mm.

Upper Limb Replantation: Does the Patient Benefit?

Although the operations to reattach amputated limbs are, without doubt, great technical achievements, it could be argued that the patient may be more handicapped, in some instances, with a replanted upper extremity than with an amputation. The literature reviewed in this article indicates that there is no guarantee that a replanted limb will have good functional recovery. However, the evidence is not conclusive that, in the majority of cases, amputation is preferable to replantation.

Above elbow limb replantation: functional results

Seven patients with a complete transhumeral limb amputation had their limb replanted. In all seven limbs the mechanism of injury was avulsion, and the ischemic time was relatively prolonged, with a range of 10 to 14 hours. The five patients with surviving limbs achieved useful elbow control. Of these patients, two achieved useful distal function to the wrist and hand and one had a below elbow amputation. All but one patient required multiple secondary operative procedures, with an average of 2.8 procedures for those patients with surviving limbs. We did not encounter any significant life-threatening problems. Less serious complications were encountered in all but three patients during the postoperative period. We suggest that limb replantation at transhumeral levels may be of value for recovery of elbow function in most of these patients. In some instances, this may permit the conversion of an above elbow level amputation to a functional below elbow level. In a few patients, recovery of useful hand function may be achieved.

Effect of different irrigating solutions on the endothelium of small arteries: experimental study in rats

The effects of four different irrigating solutions (normal saline, Ringer's solution, renal transplantation solution, and C solution) on the endothelium of small arteries were studied, with the femoral artery of rats being used as an experimental model. Perfusion was carried out for 30 minutes in all groups and the influence of exposition and clamping alone was also studied for control, the animals being killed 48 hours, and 1, 2, and 4 weeks postoperatively, depending on the subgroup. A total of 116 rats was operated upon. Morphological studies included light microscopy and transmission and scanning electron microscopy. Increasing degrees of lesion, namely cytoplasmic alterations in the endothelial cells, focal discontinuity of the endothelium, various degrees of subendothelial edema, blood cell aggregation, and blood clotting, were observed consecutively with normal saline, Ringer's, renal transplantation unit (RTU), and C solutions. Normal saline and C solutions were concluded to have the least and the most deleterious effects, respectively.

Upper limb motor and sensory recovery after multiple proximal nerve injury in children: a long term review in five patients

Five children who had sustained multiple proximal upper limb nerve injury were reviewed at 18 months to 3 1/2 years after primary repair had been carried out. The findings show that nerve regeneration occurred significantly more rapidly than in adults, with good return of motor and sensory function to the hand, resulting in each of the patients having a useful, painfree and functionally capable upper limb. In two of the cases, the limb had been completely severed. The findings support the view that primary repair of severed proximal nerves in this age group--even in avulsion type injuries--can give good results.

The late functional results of upper limb revascularization and replantation

The functional results in 25 of 30 patients after successful upper limb revascularization or replantation were evaluated by subjective-patient surveying and objective measurements. Young patients with complete, sharply amputated extremities at the wrist level or those with incomplete injuries and uninjured peripheral nerves had the best functional results. Multiple-level, diffuse crush, or avulsion injuries, even if the injuries were incomplete, and patients with high-level nerve injury had less return of function.

The effects of cooling on experimental free flap survival

Cooling to 6-7 degrees significantly increases ischaemic tissue survival to 48 and, probably, 72 hours. Inflammatory changes develop in direct proportion to the duration of the cold ischaemia time. The skin and vessels within the flap appear to be minimally affected by cold ischaemia while fat and muscle demonstrate significant necrosis, inflammation and ultimate fibrosis. Very little, if any, muscle survives the ischaemic insult studied in this model.

Replantations surgery following self-inflicted amputation

Four cases of self-inflicted amputation of the upper limb which were surgically replanted are described. Three of the four patients are psychiatrically well, employed and pleased with the surgical result. The fourth patient committed suicide. The literature of self-mutilation and replantation surgery is reviewed and psychological factors and the role of the psychiatrist in replantation surgery are discussed.

Replantation of the upper extremity in children

Since Malt and McKhann performed the first successful replantation of a traumatically amputated extremity in 1962, there has been a flurry of case reports and articles debating the pros and cons of the various technical aspects of replantation. There have been three case reports of children, under the age of 15, who have successfully undergone replantation of the upper extremity transected throught the humerus. The first case report in this article is the fourth. The factors involved in selecting replantation or amputation, and the technical aspects of the operation which are felt to be important, are briefly reviewed. Because the mechanics of limb replantation are rather straightforward, we feel that the pediatric surgeon should be familar with the preoperative and intraoperative factors to be weight, and that this alternative to stump closure be carefully considered when one is presented with an upper extremity transection.

Saving amputated digits. Current status of replantation of fingers and hands

Since the advent of microsurgery in the 1960's it has become possible to sucessfully repair vessels as small as 0.5 mm in diameter, which makes the replantation of totally severed digits possible. Some centers have reported 50 to 60 percent survival of completely severed digits and up to 100 percent survival of amputated hands and of partially amputed but otherwise non-viable digits that were reattached. In view of this success, severed members should be considered as potentially replantable.THE RECOMMENDED INDICATIONS FOR REPLANTATION ARE: (1) multiple digital amputations at or proximal to the proximal interphalangeal joint; (2) amputation of the thumb; (3) amputation of the wrist or hand; (4) partially attached digits that are non-viable without reattachment.The surviving replanted digits give functional improvement to the hand and prove cosmetically acceptable.