Bilateral lower leg replantation versus prosthetic replacement: long-term outcome of amputation after an occupational railroad accident

BACKGROUND: This retrospective study investigated three very similar cases of bilateral lower leg amputation. The aim was to determine which of two therapeutical procedures is associated with better long-term outcome: replantation or primary treatment of the stumps and subsequent prosthetic replacement. METHODS: Evaluation included clinical examination, gait analysis, and a workup of the psychosocial background. Health problems were documented using the Nottingham Health Profile. Follow-up assessments were performed 6, 7, and 18 years after the trauma. RESULTS: One patient underwent successful bilateral lower leg replantation and continued to work for the same employer. Two patients underwent prosthetic replacement. One became a social outcast confined to a wheelchair. The other patient had a good psychosocial background, similar to that of the patient who underwent replantation. He showed a better gait analysis on even ground than the replantation patient, but the findings were vice versa for uneven ground. CONCLUSIONS: The decision between replantation and prosthetic replacement after bilateral lower leg amputation is case related and cannot be generalized. Patients who have undergone these procedures require long-term psychological and physiotherapeutic care to achieve a good long-term surgical outcome.     

Replantation at lower leg level]

INTRODUCTION: Replantation in reconstructive surgery is an established procedure due to microsurgical techniques. It can be routinely performed in unilateral lower leg amputation. In some cases of bilateral amputation, in which orthotopic replantation is not possible due to the complex trauma, heterotopic replantation is a therapeutic option. This avoids prosthetic fitting. METHODS: We report five cases of orthotopic and two of heterotopic lower limb replantations. Functional outcome concerning sensibility, mobility, pain, and aesthetic result were assessed clinically and using a questionnaire. RESULTS: Functional outcome and patient satisfaction were good. The psychological situation of the patients as well as mobility and stability of the replanted limbs were satisfying. Heterotopically replanted patients found the replanted legs superior to the prostheses. CONCLUSIONS: We conclude that, in lower leg amputation, attempts should be made to replant the extremity. In bilateral lower leg amputations, at least one limb should be reconstructed, even if "only" a heterotopic replantation can be performed.     

Crossover replantation of the foot after bilateral traumatic lower extremity amputation

BACKGROUND: Bilateral traumatic amputation and limb-threatening injury of the lower extremities is more challenging than the unilateral amputation. Successful replantation of both lower extremities has been reported previously. However, orthotopic implantations may not be possible when amputation of both lower limbs with different levels of section and degrees of damage to surrounding tissues occurs. It was reported that the crossover replanted foot in combination with prosthetic limb is better than 2 artificial limbs. Hence, crossover replantation should be considered when anatomic replantation of both lower extremities is not possible as a result of bilateral total or subtotal amputation. To our knowledge, there are few reports about the crossover replantation of the lower extremity in the literature. CASE REPORT: A 30-year-old engineer being run over by the train had crushed the bilateral lower limbs in different anatomic levels. We decided to perform the crossover replantation of the right foot to the stump of the left leg to provide the patient with at least 1 weight-bearing sensate extremity. At the latest follow-up examination, 30 months after the operation, he had mild pain, especially in toes of the replanted foot. There was no ulceration in both the replanted extremity and the right amputation stump. The sole has maintained complete protective sensation. The patient described the functional result of the reimplanted leg as satisfying and better than the prosthesis that has caused much more problems than the replanted extremity. He had no complaint about the cosmetic result. He stated that he would have the crossover replantation again under the same condition. He was able to return to his previous job. Moreover, he affirmed that he is able to carry on his all social activities as he had done before the accident except for playing football. In conclusion, the possibility of the crossover replantation should be considered while evaluating the patient with bilateral lower limb injuries to allow the patient to stand on their own foot and still touch ground.     

Lower leg replantation--decision-making, treatment, and long-term results

OBJECT: The aim of this article is to review the results of replantation at the lower leg after total and subtotal amputation injury. Although subtotal and total lower leg amputations have been successfully replanted in the past, nowadays there is a common opinion that these operations do not justify their efforts, and therefore most of those patients are amputated. METHODS: To clarify this hypothesis we carried out an extensive literature research. The following criteria were evaluated: 1) survival rate, 2) individual motor and sensory functions and global lower extremity function judged according to the classification of Chen, 3) socioeconomic aspects (operation time, number of operations per patient, time of hospitalization, and return to normal life), and 4) number and nature of local and/or systemic complications. RESULTS: The success rate of lower leg amputation, which only means perfect restoration of viability, is reported between 62.5% and 100%. Using Chen's classification the functional results can be given as follows: A "functional extremity" (grade I and grade II) can be reconstructed in 82.6% to 92.7%. A non-functional extremity (grade III and grade IV) will result in one tenth to one fifth of cases. Complications can be classified in local or systemic and occur depending on the quality of the decision-making process. CONCLUSION: Our results as well as those of other large series show that lower leg replantation is still worthwhile in a well selected patient group, contrary to what is believed by an increasing number of orthopaedic and trauma surgeons.     

Replantation surgery

Summary In the early days of replantation surgery, if viability was restored the operation was judged a success. Nowadays restoration of viability alone is not sufficient to fulfill the criteria of successful replantation, which are as follows: Lack of severe systemic disturbances due to the replantation, a “functional extremity” according to the definition of Chen et al. (1978), no or little pain at the site of the replantation, good aesthetic results, and an acceptable length of time for rehabilitation and return to normal life. Successful replantation needs a therapy concept that is based on an exact definition of the amputation injury from the viewpoint of the amount of severance, the level of the amputation, and the type of amputation mechanism, complete knowledge of current replantation indications, and exact selection of patients amenable for replantation.      

Replantation and Lengthening of a Lower Leg in a 7-Year-Old Child: A Case Report

Replantation of the lower leg has controversial indications, but it may be considered in carefully selected patients. Although the function of prosthetic lower legs has been improved in recent decades, leg salvage remains a laudable goal. We present the case of a 7-year-old child who sustained a traumatic amputation at the level of the middle tibia with loss of the middle portion of the lower leg. We performed successful replantation, and tibia lengthening was performed starting 10 days after replantation and lasted 6 months.     

Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation

The advent of microsurgery has allowed the replantation of traumatically amputated limbs. Replantation of a severed limb to the contralateral stump in bilateral traumatic amputation, however, is rarer, and criticisms include a prolonged hospital stay and complications. A 54-year-old man was caught in a paper-pulping machine and suffered bilateral lower limb amputation rendering his left lower leg unsalvageable. The right lower leg, after debridement however, was suitable for replantation to the left stump. This replantation was performed successfully. The patient was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. At 11-year follow-up the patient has a preference for his replanted leg in contrast to his contralateral prosthesis and has suffered no long-term complications. In addition, from a psychological perspective, he has experienced restoration of perceived body length with the cross-leg replantation.     

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation

BackgroundAfter major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.MethodsAt three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.ResultsNine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p < 0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p = 0.03), ADLs (28.3 vs. 6.0, p = 0.03), and patient satisfaction (46.0 vs. 24.4, p = 0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p = 0.08).ConclusionsPatients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.     

Lower extremity replantation.

Replantation of the traumatically amputated lower extremity is a technically feasible surgical undertaking. Successful outcome must be judged by functional achievements of the patient toward returning to the preinjury level. Appropriate patient selection significantly increases the potential for obtaining a satisfactory outcome. Patients in whom peripheral nerve injury precludes return of sensation in the extremity or in whom severe joint destruction will yield an immobile extremity will have marginal results. The risks of replantation, including blood transfusions, sepsis, and prolonged hospitalization, must be weighted heavily against prosthetic substitution as an alternative. If the lower extremity can be successfully replanted, however, this provides a superior functional and aesthetic result for the patient. Salvage replantation to preserve maximal functional length and durability of an extremity must always be considered when assessing a patient with a traumatic amputation. Free-tissue transfer to salvage a threatened replanted limb must be similarly a part of the armamentarium of the replantation surgeon. Although lower limb replantation may continue to be controversial, improved surgical techniques and increasing experience make it an excellent alternative to prosthetic substitution. In the well-motivated patient, an excellent result may be achieved.     

Lower leg replantation in children: railroad amputation

Replantation in the lower leg, although technically feasible, still remains a complicated clinical issue in terms of the decision-making process. In children, a limb salvage or replant procedure would seem preferable; however, in crush amputations from railroad injury, a very severe trauma, difficulties in treatment should be thoroughly weighed against prosthetic possibilities: for example, only a fair or good functional outcome would justify an attempt to replant a severed shin. Unfortunately, the outcome in most cases is unpredictable at the time of initial evaluation, and even during the replantation procedure itself. To facilitate prognosis, the authors determine four typical variants of replantation course and outcome, based on local patient conditions, although they stress that no clear indications for replantation vs. prosthesis can be derived from the variants listed. Rather, general guidelines for the surgeon's decision at a very early stage of treatment are presented. Choice of procedure and tactics cannot be determined once and for all, because the prognosis for functional outcome can change during the course of treatment. Among a few well-defined situations are clean amputations (replantation is indicated) and traumas with very extensive crushing of the whole lower leg (replantation is contraindicated). In the majority of cases, replantation is a worthwhile attempt, but this does not imply that a replanted extremity must be preserved at any cost. The surgeon must consider the possibility of re-amputation, in case of an unfavorable variant in the postoperative course. A successful case of replantation, involving two lower leg railroad amputations in a child, is presented.     

Double level amputation: should it be replanted?

Multiple level amputation has been described as a contraindication to replantation. This is a case report of a patient with a double level amputation through the palm and forearm that was successfully replanted. Because of the need for multiple stages of reconstructive surgery, it was not clear until the end result that the replantation was worthwhile. The patient developed an acute respiratory distress syndrome that was probably caused by the reperfusion phenomenon. The stages of reconstruction are described in detail, as are the problems encountered. The final result included a reasonably functional hand that was far superior to the prosthetic alternative.     

Replantation von Extremitäten – Indikation,Vorgehen und Funktionsergebnisse

Forty years ago,Malt and McKhann in Boston and Chen, Chien, and Pao in Shanghai successfully replanted a severed arm for the first time. Nevertheless, the technique was regarded as sensational surgery of doubtful value to patients. The western world became aware of successes in Chinese replantation after the 1973 report entitled “American replantation mission to China”. Owen's report from Australia contributed to the development of replantation surgery in a few centers in central Europe. The objective of any replantation is restoration of the function of the severed member. In view of the innumerable uses to which a hand is put, replantation of an arm appears to be more important than that of a leg. A leg serves for locomotion, but an arm must perform diverse activities. The function of a leg amputated below or even above the knee can be adequately replaced by a modern prosthesis. In contrast, no single prosthesis can even approximately replace a functional hand. Restoration of an adequate gripping function and of feeling are therefore the most important features of successful replantation. The most favorable conditions for the replantation of limbs are clean-cut injuries located as peripherally as possible. The higher the level of amputation, the larger the amputated part and the larger the muscular portion, the greater are the dangers of ischemia. Patients and results. Between November 1975 and December 1999 we performed 72 arm replantations. A total of 58 of the reattached upper extremities healed without major complications. Functional results were graded according to Chen's classification (World J Surg 1978, 2: 513–524): grade I: the patient resumes original work, grade II: resumes some suitable work, grade III: carries on daily life, grade IV: (almost) no functional recovery. Regained function was found in 38 out of 41 of our patients followed for 3–18 years. Indeed, 29 showed very good or good functional results (grade I or II). The rate of healing was about 80%, the rate of functioning about 90%, and good to very good functional results were obtained in about 70% of patients. Work in the profession for which they had been trained or similar occupations was taken up by 60% of the patients. Conclusion. Replantation of the upper limb has definitely passed beyond the stage of experimental exploration.The technical problems, in general,have been solved. In the hands of experienced surgeons functioning as a team,adequate upper extremity function can today be obtained. A rate of healing of nearly 80% was achieved, and a good functional result obtained in 60% of the patients. We conclude that the risks attributed to replantation surgery are avoidable. Since functional results were far better than anticipated at the beginning of the project, replantation should be considered the appropriate treatment for traumatic arm amputations.     

Amputationen am Mittelfuß

The aim for amputation of the midfoot is to achieve a stump that is as painless as possible which can be treated prosthetically under full weight-bearing skin. For this purpose, the plantar skin is perfectly suitable. These stumps may also be suitable for barefoot walking. However, patients with sensory disorders should be advised not to walk barefoot because of the increased risk of injury. In addition, amputations in the metatarsal region up to the Chopart's joint level do not lead to any difference in leg length and consequently do not require a compensation of the leg length. The resection of metatarsal bones while preserving the toes is comparable to a transmetatarsal amputation in function. As the physical integrity is preserved, the procedure is also known as ”internal amputation”. This procedure and other amputations of the midfoot have still partially the prejudice, that the fitting of shoes or prosthesis is difficult. Recent advances in surgical technique and prosthetic fit have addressed these problems but are still not well-established.     

Daumenreplantation nach traumatischer Amputation

Introduction

Replantation using microsurgical techniques is a fairly new procedure in Vietnam. We reviewed and evaluated our 7-year results of thumb replantation in Vietnamese patients following traumatic thumb amputation.

Material and methods

Traumatic thumb amputations between September 1999 and July 2006 were reexamined and evaluated. Postoperative functional results were evaluated based on four main criteria: 1) the patient’s subjective attitude regarding the replanted thumb, 2) the degree of mobility of the replanted thumb compared with its counterpart, 3) the level of sensitivity of the replanted thumb, and 4) the objective ability to perform daily tasks.

Results

A total of 26 patients were documented. The duration of follow-up averaged 22 months (range 6–72 months). The success rate of replantation was 81%. A rating of either “good” or “very good” was obtained for 81% of the replanted thumbs.

Discussion

Vascular thrombosis was the cause of all failures. Proper debridement, standardized microvascular techniques, timely detection of thrombosis formation, and reoperation using vein grafts play a decisive role in the final success.     

A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations

PURPOSE: To compare the functional outcome of successful microsurgical replantation versus amputation closure for single fingertip amputations. METHODS: Forty-six fingertip amputations in 46 patients (23 were replanted successfully, 23 had amputation closure) were included in this study. Thumb amputations were excluded. Grip strength and active range of motion of the proximal interphalangeal joint were evaluated. The patients were questioned about their symptoms of pain, paresthesia, and cold intolerance. The Disabilities of the Arm, Shoulder, and Hand questionnaire was given and the disability/symptom score was evaluated. Patients' satisfaction with the surgical result was assessed. Time spent in the hospital and time off from work were reviewed. RESULTS: Active range of motion of the proximal interphalangeal joint was greater in the successful replantation group. Although the existence of paresthesia and cold intolerance were not statistically different between the 2 groups, pain in the affected fingers was more frequent in the amputation closure group. The average Disabilities of the Arm, Shoulder, and Hand score of the successful replantation group was statistically better. All patients in the successful replantation group were highly or fairly satisfied with the surgical results, whereas 14 patients in the amputation closure group were highly or fairly satisfied. The time spent in the hospital and the time off from work for the successful replantation group were longer. CONCLUSIONS: Successful replantation of single fingertip amputations can result in minimal pain, better functional outcome, better appearance, and higher patient satisfaction. We recommend attempting fingertip replantation not only to obtain the best appearance but also to gain better functional outcome. If the patient requests the simple surgery and earlier return to work amputation closure is an accepted method despite the disadvantage of digital shortening and the risk for a painful stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Replantation of a crush amputation of distal tibia followed by lengthening with Ilizarov circular external fixator: two-year follow-up

A 20-year-old male sustained a severe crush injury to his left leg, resulting in amputation of the foot at the level of the distal tibia. Despite 12-h warm ischemia, replantation was attempted after radical debridement, bone shortening, and proximal fasciotomies. The replanted part survived totally. Four months later, a 13-cm shortness of the extremity was managed by 10-cm lengthening with distraction osteogenesis, using Ilizarov's circular external fixator and by means of a special shoe. Two-year follow-up of the patient revealed acceptable functional and sensorial recovery. Success of replantation despite the excessive warm-ischemia time was attributed to the sparse muscle content of the distal tibia and foot. Fasciotomies performed on the proximal segment of the leg ensured the patency of anastomoses by maintaining adequate blood flow distally despite increasing edema after the crush injury. Debridement and bone shortening at the proximal stump eliminated the vein and nerve grafts to bridge the gap. In conclusion, considering the functional outcome of our case, replantation of distal parts of a lower extremity should be attempted first, even if the nature of the injury is unfavorable and the ischemia time is longer than the documented ischemia-tolerance.     

Prosthetic usage following major lower extremity amputation

There were 157 patients following major lower extremity amputation who were evaluated to determine functional prosthetic ambulation. Twenty-eight patients were evaluated in the amputee clinic and found not to be candidates for prosthetic fitting. Forty-one patients were fit with a prosthesis but did not become functional prosthetic ambulators. Eighty-eight patients became functional prosthetic ambulators. Of all above-the-knee amputees, 46% became functional prosthetic ambulators. Only 19% of bilateral lower extremity amputees became functional prosthetic ambulators. Of all below-the-knee amputees, 66% became functional ambulators. The presence of coronary artery disease decreased the ambulatory potential in above-the-knee or bilateral amputees but not in below-the-knee amputees. A screening method for elderly, dysvascular amputees should be instituted prior to prosthetic fitting.     

Use of the labial artery for replantation of the lip and chin

A 12-year-old boy suffered from a full-thickness traumatic amputation of his lower lip and chin following a horse bite. Microsurgical technique was used to reanastomose the inferior labial artery and a vein of the chin. The replanted flap remained viable, and the patient has done well despite some early problems with eating and drooling. The patient is now able to purse his lips and has regained sensation and the use of his orbicularis oris and musculus mentalis, even though no attempt was made to repair the motor nerves or sensory nerves. Because of the potential superior cosmetic and functional results following replantation, we recommend aggressive microsurgical attempts at arterial and venous anastomosis not previously described following traumatic amputation. The inferior labial artery may be considered for use as a nutrient artery for replantation and in future elective maxillofacial reconstruction and free-flap transfer.     

Lower limb stump reconstruction with a functional calcaneo-plantar unit free flap. A series of 16 cases]

The main objective of surgery, once amputation is inevitable, is to preserve a functional stump. This report describes the immediate reconstruction of 16 leg stumps in children by transfer of a functional calcaneo-plantar unit. Of these, 3 were thigh and 13 were lower leg reconstructions. Amputation was performed for tumor in 4 cases, and was due to accidents in the remaining twelve. The main technical features of flap preparation are preservation of the calcaneum branch and attachment of the heel skin to the greater tuberosity of the calcaneum. One case resulted in failure due to vascular thrombosis. The other 15 cases resulted in bone consolidation after an average of 45 days, sensitive protection by 70 days, and very good trophic and protective results. The provision of good distal pressure area encourages overall development of the child. There was no morbidity at the donor site, and because there is no major muscle mass in the distal fragment, the overall risk is very low compared to that of total proximal leg replantation. The transfer of functional calcaneo-plantar tissue as a single unit is the best strategy for one-step restoration of good distal support area for the stump. All surgeons liable to perform leg amputations should be aware of this technical approach.     

Prosthetic replacements for the thumb.

Optimal management of thumb loss necessitates individual consideration of all options, including prosthetic fitting, in relation to the needs and circumstances of each patient. Increased availability and substantial technical improvements in hand prostheses are resulting in their more frequent utilization, alone or in conjunction with surgical reconstruction. It has been found, contrary to general recommendations, that digital prostheses do in fact follow the basic rule of upper limb prostheses: the more distal the amputation, the more benefit a prosthetic fitting will be as there is a corresponding increase in automatic control. The benefit of digital prosthetic fitting is most striking in activities such as playing the piano or typing. The success of prosthetic fitting depends greatly on the defining of realistic goals and on the prosthesis being developed to very high standards with efficient follow-up service arrangements.