Twenty-two consecutive major replantations carried out over a 5-year period were assessed with a minimum follow-up of 2 years. Only two patients suffered guillotine amputations. The remainders were either crush, or crush avulsion amputation. Replantation was successful in 20 cases. When analysed by Chen's criteria, there were three Grade I, nine Grade II, six Grade III and two Grade IV results. Most patients with successful replants put the hand to greater use with time and replantation greatly added to the overall well-being of the patient. We consider major replantation as a worthwhile procedure. Radical debridement, bone shortening and well laid out protocols to reduce the ischaemia time are important for success. The technical details which we believe to be important for success are outlined. With decreasing numbers of such injuries in most countries, this paper may help surgeons faced with an occasional patient with a major amputation to make the right decisions.

The current concepts of replantation surgery, a procedure that has been practiced for half a century, can be discussed in terms of patients' demands and expectations, present indications for the procedure, available evidence that influences decision making, and technical refinements practiced to produce better outcomes.

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Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

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