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Severe mutilating injuries with complex macroamputations of the upper extremity - is it worth the effort?

Stanger K, Horch RE, Dragu A - World J Emerg Surg (2015)

Bottom Line: Although our results show a very high DASH-Score, those achievements justify time and person consuming operations.In most cases a replanted extremity is still superior to a secondary allotransplantation.Usually the use of prosthesis is not favored by the treated patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic and Hand Surgery, OKM Orthopädische Klinik Markgröningen gGmbH, Markgröningen, Germany.

ABSTRACT

Introduction: An amputation of the upper extremity and the following replantation is still one of the most challenging operations in the field of reconstructive surgery, especially in extremely severe cases of combined mutilating macroamputations including avulsion and multilevel injuries. Specialists agree that macroamputations with sharp wound edges are an absolute indication for replantation. However, there is no agreement in disastrous cases including avulsion and multilevel injuries. The outcome of the operation is depending on several factors, including the type of accident, age and pre-existing disease of the patient, as well as time of ischemia and appropriate physical therapy.

Methods: Between January 1(st) 2003 and December 31(st) 2011 six patients underwent a macroreplantation with disastrous combined and complex injuries of the upper extremity in our department. We performed a follow up and evaluated the functional outcome of the upper extremity function using the DASH questionnaire (average follow up of 3.1 years).

Results: The mean time of ischemia was 04:50 h (02:46 h-06:17 h). The mean time for the operation was 05:30 h (01:55 h-08:20 h). The mean operations needed per patient were 7 (2-16). The average hospital stay was 29d (16-59d). According to the DASH-Score from five out of six patients the functional outcome of the replanted extremity has a mean score of 71 points. The versatility of the replanted extremity in the field of work had 95, and sport, music was assessed with a mean score of 96 points.

Conclusions: Severe and disastrous combined and complex macroamputations of the upper extremity may also have an absolute indication for replantation even though the functional outcome is poor. Not only the feeling of physical integrity can be restored, but the replantation of an amputated upper extremity enables complete or partial recovery of function and sensibility of the arm which is important for the individual. Although our results show a very high DASH-Score, those achievements justify time and person consuming operations. In most cases a replanted extremity is still superior to a secondary allotransplantation. Usually the use of prosthesis is not favored by the treated patients.

No MeSH data available.


Related in: MedlinePlus

a: Amputated left hand of a 26 year old male at the level of the wrist preoperatively with a multilevel and avulsion injury through a plastic pellet machine. It shows additional subtotal amputation of the index finger and complete amputation of the middle- and ringfinger. The thumb was not injured; the little finger had a radial soft tissue defect. (PP) = black/white plastic pallets. (DRUJ) = distal radioular joint. (FT) = Flexor tendons. (M) = N. medianus. b: Preoperative situation of the stump of the distal forearm of the same 26 year old male. c: X-Rays of the left lower upper extremity and the left amputated amputated hand. (D1) = digit 1. (D5) = digit 5. The left picture shows a complete fracture of the distal radius and the distal ulna, with the distal radio ulnar joint lying transverse (DRUJ). The right picture shows the lower upper extremity with a fracture of the radius (R) and the ulna (U). d: Replanted hand postoperatively: thumb (D1) and little finger (D5) could be preserved, the index, middle and ringfinger were not re-plantable, the remaining defect (D) was temporarily covered by a negative pressure wound dressing and in a second operation 5 days later covered with split-skin-grafts. e: Replanted hand 9 months postoperatively: the patient is able to perform minimal flexion and adduction of the thumb in order to grip objects. f: X-Ray of the replanted hand 9 months postoperatively. (U) = ulna. (R) = radius. (RSL) = atypical RSL-arthrodesis of the left wrist
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Fig1: a: Amputated left hand of a 26 year old male at the level of the wrist preoperatively with a multilevel and avulsion injury through a plastic pellet machine. It shows additional subtotal amputation of the index finger and complete amputation of the middle- and ringfinger. The thumb was not injured; the little finger had a radial soft tissue defect. (PP) = black/white plastic pallets. (DRUJ) = distal radioular joint. (FT) = Flexor tendons. (M) = N. medianus. b: Preoperative situation of the stump of the distal forearm of the same 26 year old male. c: X-Rays of the left lower upper extremity and the left amputated amputated hand. (D1) = digit 1. (D5) = digit 5. The left picture shows a complete fracture of the distal radius and the distal ulna, with the distal radio ulnar joint lying transverse (DRUJ). The right picture shows the lower upper extremity with a fracture of the radius (R) and the ulna (U). d: Replanted hand postoperatively: thumb (D1) and little finger (D5) could be preserved, the index, middle and ringfinger were not re-plantable, the remaining defect (D) was temporarily covered by a negative pressure wound dressing and in a second operation 5 days later covered with split-skin-grafts. e: Replanted hand 9 months postoperatively: the patient is able to perform minimal flexion and adduction of the thumb in order to grip objects. f: X-Ray of the replanted hand 9 months postoperatively. (U) = ulna. (R) = radius. (RSL) = atypical RSL-arthrodesis of the left wrist

Mentions: In the period from January 1st 2003 and December 31st 2011 six patients were replanted in our department after total or subtotal disastrous and complex macroamputation including additional injuries such as avulsion or multilevel injuries of the upper extremity. All patients have been treated by 4 senior plastic surgeons working in the same department with a standardized microsurgical treatment protocol. The only major changes within this period have been the implementation of new techniqual devices, e.g. new microscope or new microsurgical instruments. This retrospective clinical evaluation was approved by the local ethics committee of the University Hospital of Erlangen. The amputation was once at the level of the upper arm, once at the level of the elbow, three times the forearm was affected and once the wrist. All six patients were male. The average age was 49 years (25–73 years). Four patients had an accident at work, two of the patients were already pensioners who had an accident while performing private domestic work (Table 2). The accidents happened as followed: one patient had a smooth cut injury, one a convulsion injury, in three patients an avulsion injury was present with severe bruising and additional complex injuries of the amputated limb, one patient suffered a multilevel injury, a convulsion and avulsion injury of the forearm in addition to the amputation of three fingers (Fig. 1a–f).Table 2


Severe mutilating injuries with complex macroamputations of the upper extremity - is it worth the effort?

Stanger K, Horch RE, Dragu A - World J Emerg Surg (2015)

a: Amputated left hand of a 26 year old male at the level of the wrist preoperatively with a multilevel and avulsion injury through a plastic pellet machine. It shows additional subtotal amputation of the index finger and complete amputation of the middle- and ringfinger. The thumb was not injured; the little finger had a radial soft tissue defect. (PP) = black/white plastic pallets. (DRUJ) = distal radioular joint. (FT) = Flexor tendons. (M) = N. medianus. b: Preoperative situation of the stump of the distal forearm of the same 26 year old male. c: X-Rays of the left lower upper extremity and the left amputated amputated hand. (D1) = digit 1. (D5) = digit 5. The left picture shows a complete fracture of the distal radius and the distal ulna, with the distal radio ulnar joint lying transverse (DRUJ). The right picture shows the lower upper extremity with a fracture of the radius (R) and the ulna (U). d: Replanted hand postoperatively: thumb (D1) and little finger (D5) could be preserved, the index, middle and ringfinger were not re-plantable, the remaining defect (D) was temporarily covered by a negative pressure wound dressing and in a second operation 5 days later covered with split-skin-grafts. e: Replanted hand 9 months postoperatively: the patient is able to perform minimal flexion and adduction of the thumb in order to grip objects. f: X-Ray of the replanted hand 9 months postoperatively. (U) = ulna. (R) = radius. (RSL) = atypical RSL-arthrodesis of the left wrist
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4499889&req=5

Fig1: a: Amputated left hand of a 26 year old male at the level of the wrist preoperatively with a multilevel and avulsion injury through a plastic pellet machine. It shows additional subtotal amputation of the index finger and complete amputation of the middle- and ringfinger. The thumb was not injured; the little finger had a radial soft tissue defect. (PP) = black/white plastic pallets. (DRUJ) = distal radioular joint. (FT) = Flexor tendons. (M) = N. medianus. b: Preoperative situation of the stump of the distal forearm of the same 26 year old male. c: X-Rays of the left lower upper extremity and the left amputated amputated hand. (D1) = digit 1. (D5) = digit 5. The left picture shows a complete fracture of the distal radius and the distal ulna, with the distal radio ulnar joint lying transverse (DRUJ). The right picture shows the lower upper extremity with a fracture of the radius (R) and the ulna (U). d: Replanted hand postoperatively: thumb (D1) and little finger (D5) could be preserved, the index, middle and ringfinger were not re-plantable, the remaining defect (D) was temporarily covered by a negative pressure wound dressing and in a second operation 5 days later covered with split-skin-grafts. e: Replanted hand 9 months postoperatively: the patient is able to perform minimal flexion and adduction of the thumb in order to grip objects. f: X-Ray of the replanted hand 9 months postoperatively. (U) = ulna. (R) = radius. (RSL) = atypical RSL-arthrodesis of the left wrist
Mentions: In the period from January 1st 2003 and December 31st 2011 six patients were replanted in our department after total or subtotal disastrous and complex macroamputation including additional injuries such as avulsion or multilevel injuries of the upper extremity. All patients have been treated by 4 senior plastic surgeons working in the same department with a standardized microsurgical treatment protocol. The only major changes within this period have been the implementation of new techniqual devices, e.g. new microscope or new microsurgical instruments. This retrospective clinical evaluation was approved by the local ethics committee of the University Hospital of Erlangen. The amputation was once at the level of the upper arm, once at the level of the elbow, three times the forearm was affected and once the wrist. All six patients were male. The average age was 49 years (25–73 years). Four patients had an accident at work, two of the patients were already pensioners who had an accident while performing private domestic work (Table 2). The accidents happened as followed: one patient had a smooth cut injury, one a convulsion injury, in three patients an avulsion injury was present with severe bruising and additional complex injuries of the amputated limb, one patient suffered a multilevel injury, a convulsion and avulsion injury of the forearm in addition to the amputation of three fingers (Fig. 1a–f).Table 2

Bottom Line: Although our results show a very high DASH-Score, those achievements justify time and person consuming operations.In most cases a replanted extremity is still superior to a secondary allotransplantation.Usually the use of prosthesis is not favored by the treated patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic and Hand Surgery, OKM Orthopädische Klinik Markgröningen gGmbH, Markgröningen, Germany.

ABSTRACT

Introduction: An amputation of the upper extremity and the following replantation is still one of the most challenging operations in the field of reconstructive surgery, especially in extremely severe cases of combined mutilating macroamputations including avulsion and multilevel injuries. Specialists agree that macroamputations with sharp wound edges are an absolute indication for replantation. However, there is no agreement in disastrous cases including avulsion and multilevel injuries. The outcome of the operation is depending on several factors, including the type of accident, age and pre-existing disease of the patient, as well as time of ischemia and appropriate physical therapy.

Methods: Between January 1(st) 2003 and December 31(st) 2011 six patients underwent a macroreplantation with disastrous combined and complex injuries of the upper extremity in our department. We performed a follow up and evaluated the functional outcome of the upper extremity function using the DASH questionnaire (average follow up of 3.1 years).

Results: The mean time of ischemia was 04:50 h (02:46 h-06:17 h). The mean time for the operation was 05:30 h (01:55 h-08:20 h). The mean operations needed per patient were 7 (2-16). The average hospital stay was 29d (16-59d). According to the DASH-Score from five out of six patients the functional outcome of the replanted extremity has a mean score of 71 points. The versatility of the replanted extremity in the field of work had 95, and sport, music was assessed with a mean score of 96 points.

Conclusions: Severe and disastrous combined and complex macroamputations of the upper extremity may also have an absolute indication for replantation even though the functional outcome is poor. Not only the feeling of physical integrity can be restored, but the replantation of an amputated upper extremity enables complete or partial recovery of function and sensibility of the arm which is important for the individual. Although our results show a very high DASH-Score, those achievements justify time and person consuming operations. In most cases a replanted extremity is still superior to a secondary allotransplantation. Usually the use of prosthesis is not favored by the treated patients.

No MeSH data available.


Related in: MedlinePlus