When a stone wall severed the right arm of twelve-year-old Everett Knowles, Dr. Ronald Malt (1932 – 2002) and a team of twelve specialists determined they would attempt to reattach the boy’s arm — a bold decision, considering the only successful limb reattachment surgeries prior to May 1962 were performed on limbs that were still partially attached to the individual.[i] At the time, Dr. Malt was a thirty-year-old chief surgical resident at Massachusetts General Hospital.[ii] Immediately before Knowles came into the emergency room, Malt and his colleagues had been discussing limb regeneration.[iii] It is uncertain whether this discussion inspired them to proceed with the decision to reattach Knowles’ arm; however, the surgeries to reattach Knowles’ arm began the day he was admitted to the hospital and continued over the course of several years.[iv]
The first surgery occurred on May 23, 1962, hours after Knowles’ arm was severed.[v] During this vital surgery, Dr. Malt and his team reattached the bone, arteries, muscles, and skin.[vi] In an article Dr. Malt co-authored in 1972, it appears this procedure remained more or less unchanged in the ten years that followed Knowles’ surgery.[vii] For example, Dr. Malt and his co-authors explain that surgeons should take the following steps in attempting reattachment surgery: shorten the bones, repair arteries and veins, and repair the skin if possible. The authors also maintain that surgery on the nerves should typically be performed after the previous steps are taken, which is what Dr. Malt did in the case of Knowles’ surgery, as discussed below. Early signs of this first surgery’s success appeared when the surgeons felt a pulse in Knowles’ right arm.[viii]
Everett with Mrs. Knowles, his mom . . . and friend, 1962
The second surgery took place about four months after the accident, and the team indeed reattached the nerves in Knowles’ arm.[ix] Dr. Malt acknowledged that some of the nerves in Knowles’ arm were permanently damaged when the wall severed his arm.[x] Over the next three summers, Dr. Malt performed the following surgeries on Knowles: a tendon transfer, a surgery to fuse his wrist, and a procedure to allow Knowles to extend his fingers and thumb. The third surgery did not allow Knowles to regain the intended function of his fingers according to Dr. Malt in his 1972 article; however he revealed that eight years after his first surgery, Knowles worked successfully as a mechanic and won multiple drag races.
In the ten years that followed Knowles’ replantation surgery, Dr. Malt and his co-authors describe six additional cases of attempted replantation surgery that occurred from 1963, one year after Knowles’ first surgery, to 1970.[xi] In their article, they explain that those individuals were selected for replantation surgery of 30 or 40 potential cases due to several factors, including but not limited to (1) the patients’ physical injuries aside from the severed limb, and (2) potential injury to internal organs. The authors conclude that five of the seven replantation cases, including Knowles’ case, described in their article were successful. When evaluating future replantation surgeries, they conclude that if (1) the patients’ primary injuries are those resulting from the severed limb, and (2) the limb is well-preserved (either on ice, or with Ringer’s solution), a patient of any age could be a potential candidate for reattachment surgery.
Knowles’ accident happened when he and friends decided to jump a freight train as a fast way to get to baseball practice !
Dr. Malt’s pioneering contributions to the field of replantation surgery in the early 1960s served as a catalyst for replantation procedures performed today. As Eric Nagourney of the New York Times described in a 2002 tribute to Dr. Malt, “none of the individual steps taken [the day of Knowles’ surgery] were new. The novelty lay in their choreography.”[xii] It appears that the foundation of Dr. Malt’s approach is still followed today. Massachusetts General Hospital describes a three-step procedure for a replantation surgery that shares qualities with the surgery performed by Malt and his team: (1) remove the damaged tissue, (2) shorten and reattach the bone, and (3) repair the muscles, tendons, arteries, nerves, and veins.[xiii] Though the first surgeons to attempt what we know today as microsurgery performed said surgeries prior to Dr. Malt’s replantation surgery in 1962, he played a role in the advancement of microsurgery in that his surgery on Knowles allowed him to learn “the importance of proper transportation of amputated extremities, bone stabilization, and tension-free anastomoses.”[xiv] Dr. Malt’s successful first replantation surgery and his subsequent research provided surgeons with the tools needed to evaluate the types of patients suitable for replantation surgery, and a general approach to replantation surgery that is practiced nearly 60 years later.
Mr. Knowles, with whom this bold achievement began, died in Wellesley, Massachusetts in 2016 after a short illness. He was 67.
ENDNOTES
[i] Pearce Wright. 2002. “Ronald Malt.” The Lancet. doi:https://doi.org/10.1016/S0140-6736(02)11493-0.
[ii] Eric Nagourney. 2002. The New York Times. October 17. Accessed August 8, 2020. https://www.nytimes.com/2002/10/17/us/ronald-a-malt-70-is-dead-innovator-in-reattaching-limb.html.
[iii] Wright. 2002. “Ronald Malt.” The Lancet.
[iv] Ronald A. Malt, John P. Remensnyder, and H. William Harris. 1972. “Long-Term Utility of Replanted Arms.” Annals of Surgery 176 (3): 334. Accessed August 16, 2020. doi:10.1097/00000658-197209000-00009.
[v] Malt et al. 1972. “Long-Term Utility of Replanted Arms.” Annals of Surgery 176 (3): 334.
[vi] Wright. 2002. “Ronald Malt.” Lancet.
[vii] Malt et al. 1972. “Long-Term Utility of Replanted Arms.” Annals of Surgery 176 (3): 340.
[viii] Wright. 2002. “Ronald Malt.” Lancet.
[ix] Steven N. Jacobs. 2002. The Harvard Crimson. October 15. Accessed August 8, 2020. https://www.thecrimson.com/article/2002/10/15/surgeon-first-to-replant-severed-limb/.
[x] Malt et al. 1972. “Long-Term Utility of Replanted Arms.” Annals of Surgery 176 (3): 334.
[xi] Malt et al. 1972. “Long-Term Utility of Replanted Arms.” Annals of Surgery 176 (3): 334–342.
[xii] Eric Nagourney. 2002. New York Times.
[xiii] Massachusetts General Hospital. 2020. Replantation. Accessed August 23, 2020. https://www.massgeneral.org/orthopaedics/hand/conditions-and-treatments/replantation.
[xiv] Kevin C. Chung and Amy K Alderman. 2002. “Replantation of the Upper Extremity: Indications and Outcomes.” Journal of the American Society for Surgery of the Hand 2(2): 79. Accessed September 6, 2020; Wing-Yee, C.W. 2015. “Evolution and clinical application of microsurgery.” BMC Proc 9, A53. https://doi.org/10.1186/1753-6561-9-S3-A53. Accessed September 6, 2020.