Replantation of Severed Limbs: Analysis of 40 Cases

Department of Traumatology and Orthopedics, Peking Chishueit'an Hospital, Peking

A report of interest from the Chinese Medical Journal, No. 6. June 1973. This English abstract from the Journal reprinted with the kind permission of the publisher, Chinese Medical Association, Peking, Peoples Republic of China.

During an 8-year period beginning from September 1964 altogether 40 cases of replantation of severed limbs have been carried out in the Department of Traumatology and Orthopedics, Peking Chishueit'an Hospital, with success in 27 cases and failure in 13 as tabulated below:

Table 1

The following aspects of replantation of severed limbs are analyzed and discussed: (1) The relationship between the type of injury and success of replantation. (2) Time limit of ischemia of the severed limb for successful replantation. (3) Should arteries or veins be anastomosed first? How many should be anastomosed? (4) Problems encountered during and following blood vessel anastomosis. (5) Causes of failures of replantation. And (6) Functional recovery after successful replantation.

Success of limb replantation is closely related to the type of injury. In sharply severed extremities, where amputation is brought about by a single blow from a sharp instrument, the rate of success is higher. Of 13 such cases in the present series, 10 cases were successfully replanted. Amputations caused by crushing or avulsion injuries have a lower rate of success; among 27 cases with such injury, replantation was successful in 17, failed in 10. When the extremity is avulsed at a level where muscles and blood vessel branches are numerous, such as the proximal portion of the forearm, and the muscles and blood vessels are extensively damaged, attempts at replantation are usually futile.

In the 27 successful replantations, the average time of ischemia of the severed limb was about 8 hours. The longest time of ischemia was in a case of near-complete severance above the wrist, in which tissue continuity was maintained only by a 3-4 cm wide strip of badly bruised skin and a single thrombosed small vein. This case arrived at the hospital 30 hours after injury (early autumn in Peking area); blood circulation of the severed extremity was restored 3 hours later, making the total time of ischemia 33 hours. The replantation was successful.

In 11 earlier cases in the series, the arteries were anastomosed first and when blood supply to the reattached limb was restored, the arterial flow was again obliterated to facilitate anastomosis of the veins. In 11 subsequent cases, however, the veins were anastomosed before the arteries, thus eliminating the need to obliterate blood supply to the replanted limb once it is established. Experience with these 2 methods has shown that to anastomose the veins first is the method of choice. With this method the incidence of arteriospasm and vascular occlusion at the site of anastomosis, occurring so often when the arteries are repaired first, can be avoided. Less blood is required for transfusion and a cleaner operation field is easily maintained.

Restoration of good blood supply to the reattached limb is of primary importance to successful replantation. Every blood vessel amenable to repair should be anastomosed; sometimes vascular grafting should be used to restore continuity of a blood vessel. Preferably, more veins than arteries should be anastomosed. Attention should be paid to the quality of vascular repair. When the main veins are anastomosed with good patency attained, then even if their number is equal to that of the arteries repaired, sufficient venous return can be expected. 4 successful replantations in this series illustrate this point: In each case only 2 arteries and 2 veins were anastomosed.

Vascular spasm and thrombosis at the site of anastomosis are the 2 commonly met difficulties after vascular anastomosis. Vascular spasm causing obliteration of blood flow occurred in 3 earlier cases in the series. In 2 cases the spasm was relieved after application of warm saline pads for 20 minutes, in another case the spasm was overcome after injection of saline into the spastic vessels under pressure. In subsequent cases hydraulic dilatation of blood vessels prior to anastomosis was routinely adopted with markedly reduced incidence of vascular spasm.

Thrombosis at the site of anastomosis occurred in 9 cases; resection of the thrombosed segment and reanastomosis or grafting with a segment of vein were carried out with successful reestablishment of blood flow in all cases. The main cause of thrombosis was failure in performing a thorough debridement at the severed ends of the blood vessels.

Impairment of blood supply to the reattached limb several hours to one week after replantation was observed in 9 cases in the series. In such instances the skin of the limb became pale or dusky red, skin temperature dropped rapidly to that of the environment. No improvement was obtained after conservative measures and reexploration had to be carried out in each case. Findings at the second operation were as follows: Obliteration of veins in 5 cases; obliteration of arteries in 1 case. In 2 of the remaining 3 cases evidence of compression of veins resulting in thrombosis of arteries was discovered. In 6 cases the replanted limb survived after the second operation. The above observations seem to indicate that compression of veins leading to thrombosis is the main cause of circulatory disturbances to the reattached extremity after replantation. Timely discovery of such condition and prompt effective measures may save many replanted limbs that will otherwise be lost.

Among the 13 failures in the series, the injury in 5 cases was very severe and complicated and blood vessel anastomoses at the time of replantation were not successful. In 2 cases the failure was due to postoperative infection. One patient, an infant, died postoperatively of pulmonary complication. 2 cases were avulsion injuries; in one of them replantation was successful initially with good blood supply to the reattached limb, but it failed eventually owing to infection and necrosis of the severely damaged soft tissues. Recurrent venous thrombosis was the cause of failure in another case.

There were 3 failures among the cases with clean-cut wound. In 1 case the time of ischemia was 30 hours. Although the immediate result of replantation was good, 3 days later the reattached limb gradually became necrotic because of impaired blood supply. In another case, both arterial and venous thrombosis occurred postoperatively. The patient's condition became critical during reexploration, so attempt at reanastomosis of blood vessels had to be abandoned. In the third patient, the severed hands had been immersed in saline previous to replantation and the skin was crumpled. In this case despite repeated efforts at anastomosis, extensive thrombosis persisted, resulting in failure.

23 of the 27 successfully replanted cases were followed up. All but 2 of these cases had satisfactory or near-satisfactory functional recovery. The main factors influencing the functional outcome of replantation were: wound infection, impairment of blood supply, high level of nerve severance with bad functional recovery after repair. To attain good functional results after replantation, efforts should be made to improve the quality of debridement and vascular anastomosis. All tissues amenable to repair should be repaired initially, and remedial exercises should be carried out following operation.

Department of Traumatology and Orthopedics, Peking Chishueit'an Hospital, Peking