title: Severe mutilating injuries with complex macroamputations of the upper extremity - is it worth the effort?
abstract: BACKGROUND
  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.
authors.affiliation: Department of Plastic and Hand Surgery, OKM Orthopädische Klinik Markgröningen gGmbH, Markgröningen, Germany.
authors.forename: Katrin
authors.initials: K
authors.lastname: Stanger
authors.affiliation: Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
authors.forename: Raymund E
authors.initials: RE
authors.lastname: Horch
authors.affiliation: Department of Plastic and Hand Surgery, Klinikum St. Georg gGmbH, Leipzig, Germany.
authors.forename: Adrian
authors.initials: A
authors.lastname: Dragu
keywords: Avulsion; Complex macroamputation; Functional outcome; Multiple injuries; Replantation; Upper extremity