[Considerations on the management of subtotal and total macro-amputation of the upper extremity]

Between 1982 and 1993, 65 amputation and amputation-like injuries in the upper arm (n = 18), proximal and middle forearm (n = 32) and distal forearm and wrist level (n = 15) were treated in our institution. The overall survival rate in our series was 92.3% (60/65). In 3 of 65 cases early secondary amputation because of vascular failure was necessary. There was one reamputation because of deep infection with beginning sepsis. Severe systemic disturbances were seen in one patients, requiring early reamputation. Twenty-five patients with a follow-up of more than 2 years were reviewed in a retrospective clinical study and evaluated according to the Chen classification. Of 8 patients with upper-arm involvement, 2 had a grade II result, 4 a grade III and 2 a grade IV result. There were 1 grade I, 2 grade II, 2 grade III and 5 grade IV results in the proximal forearm group. In the distal forearm group 2 patients each showed a grade I, II and III result and 1 a grade IV. Taking grades I and II results together, a "functional extremity" could be reconstructed at the upper arm level in 25%, proximal forearm 30%, and the distal forearm in 58%. The main advantage of replantation/revascularization of the upper limb is the possibility of restoring some sensitivity to the hand in addition to partial motor recovery, which always provides twice as much individual motor function as is offered by any type of prosthesis currently available. The higher cost and number of operations needed, as well as the longer postoperative care and longer disability time after replantation/revascularization are nevertheless justified by the significant increase in quality of life.