Results

The case examples shown in Figs. 5 and 6 are from our experience with nine major limb replantations and represent the best possible outcomes

Fig. 6. (A) This 4-year-old boy sustained bilateral upper extremity amputations when his arms were caught in the power winder of a fuel truck. The left upper extremity was avulsed from the roots of C5,6,7 and the ulnar nerve avulsed from the forearm muscles. There were multiple fractures and the limb was not replanted. The right upper extremity had a much narrower zone of injury, with the only irreparable injury being the radial nerve that was avulsed from the forearm. Bony fixation is shown in Fig. 4C. Twenty-four months after injury he under went transfers for finger and wrist extension. (B) Range of motion 3 years after injury.

Fig. 6. (A) This 4-year-old boy sustained bilateral upper extremity amputations when his arms were caught in the power winder of a fuel truck. The left upper extremity was avulsed from the roots of C5,6,7 and the ulnar nerve avulsed from the forearm muscles. There were multiple fractures and the limb was not replanted. The right upper extremity had a much narrower zone of injury, with the only irreparable injury being the radial nerve that was avulsed from the forearm. Bony fixation is shown in Fig. 4C. Twenty-four months after injury he under went transfers for finger and wrist extension. (B) Range of motion 3 years after injury.

from replantation surgery. The results attest more to the patients, who were young and healthy than to the expertise of the surgeons who followed the basic tenets taught by their mentors, Kleinert and colleagues [16], Lister and Scheker [17], and God-ina [10]. These individuals championed the basic principles of replantation, which are immediate aggressive debridement, rigid internal fixation, limited warm ischemia, and a disciplined sequence of soft tissue reconstruction.

Similar to these cases, Hoang [18] reported the outcomes of five consecutive hand replants at the level of the radiocarpal joint. These all resulted from clean-cut amputations in young Vietnamese males and were replanted within 9 to 14 hours of injury. With an average follow up of 33 months, the patients had 70% to 80% Total Active Motion (TAM) of the digits and thumb opposition compared with the contralateral hand and 8 to 12 mm of two-point static discrimination. Meyer in 1985 [19] and Scheker and colleagues in 1995 [20] also reported good to excellent results in a majority of wrist-proximal amputations, noting that the best results were seen in the more distal cases, injured by a sharp object and subjected to early aggressive range of motion programs. The best outcomes were of course in children, who were found to recover 5 to 7 mm of static two-point discrimination and 90% of active range of motion [21]. These reports support the continued recommendation for wrist-proximal replantation efforts for patients in whom the mechanism allows adequate debridement, the ischemia time is less than 12 hours, and whose general health and comorbi-ties allow the patient to tolerate the rigors of surgery and postoperative recovery.

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