Some Second Thoughts On Replantation

Like many other good things, the replantation of severed limbs can be overdone, according to a recent editorial in the Journal of the American Medical Association. Since 1962, when the right arm of Little League pitcher Everett Knowles was successfully reattached at Massachusetts General Hospital, the procedure has frequently been used- sometimes ill-advisedly. In fact, JAMA claims, there have been only a dozen or so of these operations "in which both the patient and the time were right."

Among instances where the procedure is ill-advised, the Journal cites the patient with one good leg. "The chances of neurologic recovery are poor, the handicap of a shortened extremity is severe, and the value of a prosthesis is great enough that the patient will do best with a good stump and an artificial limb." Similarly, in a patient over 40 an entire arm should usually not be replanted if he has one good arm. "Recovery of protective sensation in the fingers will seldom be worth the prolonged disability and the rehabilitative operations."

The ideal candidate for replantation, JAMA states, is under 30, with a clean amputation distal to the midforearm-the more distal, the better the prognosis. Innervation of most muscles will be intact, and return of tactile distinction is likely. In general, the Journal concludes, "in certain patients with no major injuries other than an amputation, if the severed part is chemically intact, the medical facilities adequate, and the surgeon and patient willing to assume the responsibilities that go with lengthy rehabilitation, replantation is an important alternative to a prosthesis."