Which of the statements about major limb replantations (amputation proximal to the hand or foot) is/are correct?

A. Bone shortening is usually necessary.

B. If the amputation occurred more than 6 hours before arrival in the operating room some type of temporary vascular shunting is indicated

D. Myonecrosis is a common cause of failure of the replantation.

E. There are few indications for replantation of the lower extremity in adults.

DISCUSSION: Bone shortening of at least 2 cm. is critical in most major limb replantations, to allow thorough débridement of injured structures and approximation of normal tissue to normal tissue (e.g., nerve, vessel, and tendon repair). If the anticipated cold ischemic time for an amputated limb will exceed 6 hours before circulation can be re-established, a temporary silicone shunt should be applied. This is usually the setting, for rarely can the artery be reconnected within 6 hours of the amputation. Primary closure of all of the skin is rarely recommended. Because of the edema associated with reperfusion of the ischemic limb, tight skin closure can compromise the circulation. Skin grafts and/or delayed closure is indicated. Some degree of myonecrosis occurs in all major limb replantations. Thorough surgical excision of damaged muscle tissue diminishes the amount of necrosis. Excessive myonecrosis leads to infection and failure. There are few indications for replantation of lower extremities in adults. The amount of débridement and shortening that is necessary to obtain a viable lower extremity replantation results in excessive leg length discrepancy. Prosthetic replacement can result in a nearly normal gait, especially when the amputation is below the knee.