Replantation of Amputated Extremity
A 21-year-old female factory worker had her right arm torn off in an accident with a knitting machine. She was admitted to hospital at 7.15 a. m. and the operation was immediately performed. The arm was found to have been severed at a point just below the insertion of the deltoid. After the wound surfaces had been cleaned, osteosynthesis was first performed, after which arterial and venous anastomosis was carried out, the circulation being re-established
4 hours after injury had been sustained. The ends of the median and radial nerves were identified and approximated, but the proximal end of the ulnar nerve could not be found. The operation took 5 hours. It was performed by a team of orthopaedic, vascular and neurological surgeons. The team was divided into two groups and had to act swiftly. One group dealt with the stump and the other with the limb. Each ensured haemostasis and clean wound. The main vessels, nerves, muscles and tendons were identified and isolated. The patency of the vessels in the severed limb was ensured and the danger of thrombosis was avoided by careful arteriovenous flushing. This was done by slow infusion into the main artery of 500 cc of rheomacrodex and a like amount of ringer-lactate solution containing 200 mg of heparin and 10 million units of penicillin. The infusion was maintained for 15 minutes or until the fluid returned through the veins was clean.
It is obvious that the operation was very time-consuming and great attention had to be paid to many details because the best possible results, both immediate and long-term had to be achieved. Suturing of the nerves was carried out after a lapse of 3 to 4 weeks.
The inevitably long rehabilitation programme began on the first post-operative day and lasted for 2 or 3 years. Surgical corrective procedures like tendoplasty and arthrodesis may be needed to improve the final anatomical and functional result.
Successful reimplantation carried out under these prerequisites gives not only satisfactory anatomical and functional results but it endows the patient with a renewed zest for living.
Reimplantation of the completely severed extremity has for centuries been the Utopian dream of many generations of surgeons. During the last 7 years some 15 cases have been reported in literature, but there have only been ten well-documented accounts of successful anatomical and functional results. Experience, gained experimentally and clinically in various centres, has made it possible for the indications for reimplantation to be laid down with some degree of certainty, if the following conditions were taken into consideration:
1. There must be no co-existing major injuries — cerebral, abdominal, thoracic, etc., demanding surgical intervention.
2. Manifestly the viability of the severed limb is of paramount importance. Except in those few cases where it has been possible to preserve the limb under hypothermic conditions, operation must not be delayed more than 6 hours.
3. Reimplantation should only be undertaken in relatively young subjects (up to 30 years of age).