Long-term results after total and subtotal macroamputations of the upper limb

Using our personal series of 65 patients operated on between 1982 and 1993 (upper arm: n = 18, proximal and middle forearm: n = 32, distal forearm and wrist level: n = 15) and the results of an extensive literature review the following criteria were evaluated: (1) survival rate, (2) possible individual motor and sensory functions of the extremity, (3) global upper extremity function judged according to Chen’s classification, (4) socioeconomic aspects, and (5) number and nature of local and/or systemic complication and the subjective judgment by the patient. The survival rate of upper limb replantation, which only means perfect restoration of viability, is about 76–92.3%. As the amputation level proceeds distally there is an increase in individual motor and sensory functions of the “functional chain upper extremity‘’. Taking grades I and II results together, a “functional extremity” can be reconstructed at the upper arm level in 22–34%, at the proximal forearm level in 30–41% and at the distal forearm level in 56–80% of cases. All patients needed at least two secondary operative procedures. Five of 65 patients underwent reamputation because of postoperative complications. Since the functional results after replantation are at least equal (proximal level) or even far superior (distal level), some protective sensation of the hand can be expected even at the most proximal levels; together with the psychological impairment caused by disruption of body integrity, this justifies reconstruction being performed if possible. Reasonable function can be expected, the risk for the patient is low, and most wish to go ahead with the procedure. The higher cost and the number of operations needed, as well as the long postoperative care and longer time of disability after replantation, are justified by a significant incease in quality of life.