Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review

Patient-reported significant disability after major traumatic upper extremity amputation

The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.

[Macroreplantation of the upper extremity: Inventory in 2024]

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.

Limb Preservation and Functional Reconstruction after Complete Amputation and Replantation of the Upper Arm and Thigh

A 26-year-old man was admitted to our hospital due to the replantation of the severed right upper arm and right thigh injury 6 days before. The patient received emergency treatment at a local hospital. He underwent amputation and replantation for the right upper arm and right thigh. After surgery, he experienced fever, limb swelling, and wound pain. At the time of admission to our hospital, the patient exhibited stable vital signs. An infection was found at the replanted wound, and the culture results showed Pseudomonas aeruginosa. After admission, the patient underwent symptomatic antiinflammatory treatment. In addition, he received fracture reduction and external fixation with a bracket, radial nerve exploration and release of the upper and lower limb external fixation with a bracket, upper femur osteotomy, and external fixation with a bracket. He also received reconstruction of elbow flexion functions with biceps femoris tendon transplantation; reconstruction of wrist joint fusion, finger extension function, and palm function; removal of the femoral external fixation with a bracket; and tibiofibular osteotomy and leg lengthening surgery. Moreover, the anterior tibial tendon was fixed to correct foot drop deformity, and the external fixation bracket was removed. Owing to these efforts, the patient achieved limb preservation with well-reconstructed functions.

Elbow Flexion Reconstruction after Traumatic Amputation Using Hinged External Fixator and Muscle Transfer: A Case Report

CASE

A 40-year-old man sustained a traumatic elbow disarticulation without any fracture, accompanied by severe damage of the biceps and brachialis. After replantation, passive elbow motion was used with a hinged external fixator to facilitate elbow joint reduction and mobility. Eight months after the injury, a functional latissimus dorsi transfer for elbow flexion restoration was performed. Ten years postoperatively, he achieved antigravity elbow flexion and 120° of flexion and -15° extension of the elbow.

CONCLUSION

This reconstruction technique was useful for reconstructing elbow flexion after traumatic elbow disarticulation.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach

BACKGROUND

Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT).

METHODS

A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications.

RESULTS

Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria.

CONCLUSIONS

For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Role of microsurgical techniques combined with Ilizarov techniques in limb salvage and functional reconstruction of thermal‑crush injuries of the hand: A case report

The Ilizarov technology was proposed by Former Soviet orthopedic physician Ilizarov. It is a medical method to reconstruct missing tissues. Ilizarov technology combined with soft tissue stretching technology is of great significance in the treatment of common orthopedic problems like bone defects, finger absence, joint contracture and joint stiffness following thermal-crush injuries of the hand. In the present study a 25-year-old male patient sought for limb salvage treatment 1 month after sustaining thermal-crush injuries of the right hand and forearm. The patient had been treated by another hospital with multiple procedures of debridement, and recommended for forearm amputation. The patient was diagnosed with: i) Postoperative infection of thermal-crush injuries of the right hand and right forearm; ii) comminuted open fractures of the proximal and distal phalanges of the right thumb; iii) osteomyelitis; iv) palm skin defects with exposed tendons; and v) skin defects of the opisthenar and the forearm. After a series of treatments including debridement, removal of necrotic tissue, tissue transplantation, skin pedicle, bone lengthening, external shaping, tissue release, joint fusion, traction and rehabilitation exercises, the patient recovered some hand function. Overall, thermal-crush injuries of the hand are severe, complicated combined injuries composed of both heat burn and compression injury and their treatment is challenging. Overall, microsurgery combined with Ilizarov technology can effectively reconstruct the function of complex thermal-crush injuries of the hand.

CAN TEMPORARY ARTERY CATHETERIZATION EXTEND LIMITS OF ISCHEMIA TIME FOR MACROREPLANTATION?

We observe delayed referrals to appropriate Microsurgery Unit and definitive treatment of traumatic limb amputations. Cases with wrist proximal amputations have a deadline for surgical replantation as these configure life-threatening injuries.

Objective

To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results.

Methods

A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021.

Results

In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours).

Conclusion

Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

Replantation versus transplantation: Where do we stand?

PURPOSE

Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss.

METHODS

Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation.

RESULTS

Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use.

CONCLUSION

While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.

Positive psychological suggestions improve the self-efficacy, social functioning and mood of patients undergoing replantation

OBJECTIVES

This study aimed to investigate the effect of positive psychological suggestions on self-efficacy and social functioning of patients undergoing replantation.

METHODS

The clinical data of 80 patients treated with replantation in our hospital were retrospectively selected and divided into two groups according to the different intervention methods. The control group (n=40) received conventional healthcare interventions, and the study group (n=40) received additionally positive psychological suggestions. The changes of self-efficacy, quality of life and moods were compared between the two groups before intervention, as well as at 7 d, 15 d, 30 d and 60 d after intervention. The effect of positive psychological suggestions on the incidence of complications and satisfaction rate of nursing intervention was also analyzed.

RESULTS

At 15 d, 30 d and 60 d after intervention, patients in the study group had higher self-efficacy scores, lower scores of the Social Functioning Deficit Scale as well as lower scores of Self-Rating Anxiety Scale and Self-Rating Depression Scale than those in the control group (P<0.05). The total scores of social support in the study group were higher than those in the control group 60 d after intervention (P<0.05). In addition, the SL-90 scale scores in the study group were lower than those in the control group 60 d after intervention (P<0.05).

CONCLUSIONS

Positive psychological suggestions could improve the self-efficacy, social functioning and mood of patients undergoing replantation.

Major traumatic amputations and replantations of the upper extremity in Germany – National Quality Reports 2014 – 2018

The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe.

In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period.

Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres.

The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres.

The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care.

Level of evidence IV.