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

Abstract

IntroductionAn 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.MethodsBetween January 1st 2003 and December 31st 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).ResultsThe 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.ConclusionsSevere 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.

Long-Term Quality of Life after Free Flap Upper Extremity Reconstruction for Traumatic Injuries

“…26 Following microsurgical reconstruction of severe upper extremity injuries, the affected limb often keeps suffering from functional impairment, 8,10,27 which has been previously found by other studies using PROMs. [28][29][30][31][32] Although the reported DASH scores (8-71) and MHQ scores (47-77) ranged considerably, all authors emphasized limb preservation as the treatment of choice. [28][29][30][31][32] Our results corroborate these findings and support the statement that extensive reconstruction is the preferred and often the only treatment possible for limb and/or function preservation.…”

“…[28][29][30][31][32] Although the reported DASH scores (8-71) and MHQ scores (47-77) ranged considerably, all authors emphasized limb preservation as the treatment of choice. [28][29][30][31][32] Our results corroborate these findings and support the statement that extensive reconstruction is the preferred and often the only treatment possible for limb and/or function preservation. Although the mean DASH scores (24) and the mean total MHQ scores (66) from the present study imply significant functional impairment, over half of the patients reported to be satisfied.…”

Odległe wyniki replantacji rąk

“…Mechanizm urazu i stopień uszkodzenia amputowanej kończyny rzadko stanowią powód odstąpienia od próby replantacji [3,4,5]. Jednak wyniki czynnościowe tych operacji nie zawsze są zadowalające i w części przypadków pacjenci nie odzyskują sprawności w zakresie umożliwiającym powrót do pracy i/lub normalnej aktywności życiowej [6,7]. Wyniki leczenia pacjentów po replantacji rąk od poziomu śródręcza i amputacji wielu palców są rzadziej publikowane niż wyniki po replantacji pojedynczych palców i kciuków.…”

“…W podsumowaniu uzyskanych w niniejszej pracy wyników można stwierdzić, że w większości przypadków długotrwała i pracochłonna operacja pozwoliła na odzyskanie zadowalającej sprawnościowo kończyny, pozwalającej na dobre funkcjonowanie w życiu codziennym. Zarówno wyniki własne, jak i opinie z piśmiennictwa wskazują na zasadność podejmowania prób replantacji utraconej kończyny, niezależnie od mechanizmu urazu i stopnia jej uszkodzenia, jeżeli tylko stan ogólny chorego pozwala na bezpieczne jej wykonanie [1,3,6,7].…”

Measuring Functional and Patient-Reported Outcomes After Treatment of Mutilating Hand Injuries

“…Unlike the lower extremity, the prosthetic options for the upper extremity remain limited and inadequate as compared to preserving a functional limb, even if not at full capacity. 31,32 Salvage treatment for patients with mutilating upper extremity injuries remains a top priority so that outcomes can be optimized and patients can return to function and gainful employment as often as possible. Measuring and understanding outcomes after mutilating upper extremity injuries is critical for improving care and quality of life for these injured patients.…”