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.     

Long-term outcome of replantation of proximal-third amputated arm: a worthwhile endeavor

We report a successful replantation of a proximal-third avulsed left arm in a 26-year-old female with maintenance of good functional, clinical, Short Form 36, and the Disabilities of the Arm, Shoulder, and Hand outcomes results at 10 years. An organized approach combining staged surgical reconstruction and intense hand therapy allowed for both successful replantation and outcome. There exist no clear guidelines in making the decision between replantation and revision amputation. Controversy regarding the value of upper limb replantation seems to increase with ascending levels of amputation. A case report cannot provide guidelines, but several points can be made that may be of help to hand surgeons confronting this uncommon situation. In a highly motivated patient with realistic expectation, a preoperatively intact functioning shoulder should be considered an indication for attempt at replantation. With further staged reconstruction, a helper arm can still be achieved even in an avulsion-type amputation. Current operative and perioperative aspects of microsurgical replantation and subsequent reconstruction are discussed.     

Microvascular ear replantation

Microvascular ear replantation is a rare event, having been reported only 25 times since the first case in 1980. It requires a lengthy operative time and hospital stay, results in multiple blood transfusions, and has a significant failure rate. Nevertheless, a successful ear replantation is a dramatic demonstration of the power of microsurgery to restore a lost part. When successful, it obviates the need for other complex reconstructive efforts and provides an unsurpassed aesthetic result. This article reviews the history of microsurgical and nonmicrosurgical ear replantation and presents recommendations for treatment.     

Successful replantation of the ear as a venous flap

Successful microvascular ear replantation is well described, and often involves the use of arterial inflow anastomoses with leeches and systemic anticoagulation to augment outflow. Failed replantation attempts have also been published, with most of the failures attributed to venous drainage problems. A case of successful replantation of an ear is presented using a single 0.5-mm arteriovenous anastomosis, as no suitable artery could be identified in the amputated part. Postoperatively, dextran and leech therapies were employed to promote adequate venous drainage. We report a 100% successful ear replantation using a single arterialized vein as the inflow. In situations where no adequate artery is identifiable in the amputated part, an arteriovenous anastomosis may be a suitable alternative.     

Rehabilitation after the replantation on a 2-year-old girl with both amputated legs.

We had an opportunity to perform replantation of both legs on a 2-year-old girl, and our decision to perform replantation rather than amputation surgery was carefully made taking her age, degree of crushing injury, ischaemic time and level of the amputation into consideration. Painstakingly designed rehabilitation treatments were continuously performed on this girl from the early stage after the operation, and the treatments were comprised of four parts; that is, flexion and extension exercise for the ankle in order to prevent it from stiffness or contracture, functional electrical stimulation (FES) in order to prevent muscular atrophy on the lower extremities, muscle strengthening exercise for the lower extremities, and electrical stimulation to regenerate the damaged nerves and to prevent muscular atrophy from occurring. For an objective assessment of the postoperative conditions, total active motion angles of the ankle joint were measured, and also EMG and NCV were conducted at the end of the first month as well as at the end of the 6th month. Total active motion angles of the ankle joint were increased progressively as time went on, from 15 to 60 degrees on the right and from 10 to 45 degrees on the left. NCV did not show any sensation or response from motor nerves, or amplitude decreased considerably 1 month after the operation; however, at the end of the 6th month conditions improved a great deal with both amplitude and latency. And most muscles that did not show any signals on EMG or showed less than normal at the end of the first month after the operation eventually recovered at the end of the 6th month. The patient had no particular difficulties in walking after 6 months or rather she started running in small steps showing her legs functioning superbly. An infant with both of lower extremities amputated is quite a rare case. We believe that the replantation surgery was successful due to the fact that carefully selected preoperative factors were taken into consideration and well designed postoperative rehabilitation program consisted of four parts was carried out continuously.     

Successful microvascular replantation of a completely amputated ear

A case of successful microvascular replantation of a traumatically amputated ear is presented. The postoperative course was complicated by venous thrombosis requiring the use of medicinal leeches and systemic heparinization for salvage. This is the tenth successful microvascular ear replantation reported in the literature. © 1993 Wiley-Liss Inc.     

Replantation of the upper extremity in children

Since Malt and McKhann performed the first successful replantation of a traumatically amputated extremity in 1962, there has been a flurry of case reports and articles debating the pros and cons of the various technical aspects of replantation. There have been three case reports of children, under the age of 15, who have successfully undergone replantation of the upper extremity transected through the humerus. The first case report in this article is the fourth. The factors involved in selecting replantation or amputation, and the technical aspects of the operation which are felt to be important, are briefly reviewed. Because the mechanics of limb replantation are rather straightforward, we feel that the pediatric surgeon should be familiar with the preoperative and intraoperative factors to be weighed, and that this alternative to stump closure be carefully considered when one is presented with an upper extremity transection.     

Microvascular salvage of a thrombosed total ear replant

Microvascular replantation, when possible, is the treatment of choice for total ear amputations. Both arterial and venous reconstruction should be attempted. The present case report describes a successful total ear replantation in a 45‐year‐old woman whose ear was amputated due to a horse accident. Venous thrombosis subsequently occurred and was managed with anticoagulation and leech therapy. Eighty hours after the replantation, arterial thrombosis took place. The posterior auricular artery thrombosed anastomosis was resected and reconstructed with an interposition vein graft. This report illustrates the feasibility of the successful microvascular salvage of a thrombosed total ear replant. It suggests the need for close clinical monitoring of the replanted ear and prompt microvascular reexploration in an event of the loss of arterial flow. © 2013 Wiley Periodicals, Inc. Microsurgery 33:396–400, 2013.     

Replantation of an excised segment of radial forearm tissue

A report on a case of successful replantation of an excised segment of forearm tissue is presented. An 18 year old man was admitted to hospital with a completely excised segment of the radial side of his forearm and wrist as a result of a circular saw injury. The best reconstructive option was replantation of the excised radial forearm tissue thus providing both soft tissue cover and bony stabilization.     

Successful replantation of the heel pad: a seven-year follow-up

The authors present a case of successful replantation of the soft tissue of the heel. Circulation was restored by the use of a vein graft from the posterior tibial artery to an arterial branch of the subcutaneous plexus found on the medial aspect of the heel. Two small veins were anastomosed at the edge of the defect. The heel lacks sensation, but the patient has been able to return to work as a heavy laborer in a steel foundry and is walking without the use of orthotics or modified shoes seven years later. This is the first reported case of successful replantation of only the soft tissue of the heel.     

Scalp replantation by arterialised venous network flow-through.

A successful clinical case of scalp replantation is presented where a suitable artery could not be identified in the amputated part. Reperfusion of the flap was achieved by an arteriovenous inflow anastomosis and a conventional venous anastomosis for drainage. The aesthetic and physiological success of this case suggests that arteriovenous scalp replantation is a potential avenue for treatment where arterio-arterial repair is not possible. The possible explanation for the success in this patient is the paucity of valves that exist in the venous network of the scalp and forehead, noted in our previous anatomical studies. Knowledge of the replanted tissue venous architecture provides an anatomical basis to understand the potential limitations of arteriovenous replantation.     

Hand replantation after 54 hours of cold ischemia: a case report.

A number of case reports and series have reported successful replantation after prolonged periods of ischemia. However, the acceptable range of normothermic and hypothermic ischemic storage remains controversial. There is little question that the tolerance of composite tissue for ischemia is dependent on the quantity of contained skeletal muscle. We report a successful hand replantation after 54 hours of cold ischemia. We believe that this case documents the longest anoxic period yet reported for successful hand replantation. We further believe that the functional results obtained confirm the value of hand replantation even after such a prolonged ischemic interval.     

Above-the-knee replantation in a child: a case report with a 24-year follow-up

Replantation of an amputated limb is generally contraindicated in crushing and traction injuries. Injury to muscle tissue and skin also creates difficulties in coverage, and bony fractures may shorten limb length which can impede lower extremity function. Numerous cases have been reported on the successful replantation of the lower limb in children; however, review of previous English literature has documented only very few replantation at the thigh level, and those with severe crushing injury resulted in subsequent amputation. We report a case of successful thigh-level replantation in a 3-year-old child who sustained a crushing–traction type of injury with a follow-up of 24 years. After the replantation, early and late complications developed but these were successfully managed. On her last visit, the patient had pain-free ambulation without assistance, had intact protective sensation distal to the injury, and was very satisfied with the outcome. Replantation of the lower limb in children with crushing or avulsion type of injuries is still a worthwhile procedure. However, both the patient and the family should be aware that multiple surgeries may be needed to accommodate to long-term complications such as joint stiffness, scar contractures, and limb length discrepancies.     

Successful penile replantation with adjuvant hyperbaric oxygen treatment

Penile amputation and successful replantation is very uncommon, and routine standardized procedures for dealing with this medical condition do not exist. A case of a penile amputation and successful replantation is presented. This report presents the microsurgical procedure and postoperative care that led to successful engraftment and function. Of particular interest was the use of hyperbaric oxygen to accelerate the healing process. A review of the published data and future methods of increasing success of such surgical procedures is provided.     

Fingertip replantation

Fingertip replantation is now an established technique. Although successful replantation is an ideal method for treatment of fingertip amputation, various other methods still are widely used and may be functionally acceptable. The indications for replantation to treat fingertip amputation is still controversial. This article presents a global view of the current status of replantation for the treatment of fingertip amputation. The surgical technique, strategies to overcome postoperative congestion, and overall results are discussed.     

The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation

From January 1990 to December 1998, 631 consecutive single-digit replantations were reviewed retrospectively to determine the essential number of vascular anastomoses and the artery-to-vein ratio for successful finger replantation. The correlations between the number and the ratio of anastomosed vessels and the survival rate were examined according to the amputated digital levels, and all of the correlated results were compared with each other statistically. In zone I, the survival rate of the digits with a vein repaired was higher than that of digits treated with the external bleeding method. In zone II, repairing more arteries than veins led to venous congestion and resulted in a failure of replantation. Thus, the ratio of an equal or greater number of veins repaired to the arteries repaired was an important factor in successful replantation in zone II, which may be due to the large amount of arterial input relative to the small volume of venous drainage via small veins in the replanted digit. In zone III, the equal number of arteries and veins repaired was also an important factor in successful replantation. However, unlike zone II, even when more arteries were repaired than veins, venous congestion occurred rarely because the vein in this area was larger, providing sufficient venous drainage. In zone IV, repair of two veins was needed to yield good results. Because the volume of the amputated part in zone IV was larger than in other zones, it was desirable to repair both arteries, even though repairing one artery yielded good results. In conclusion, it is desirable to repair as many vessels as possible to increase the possibility of a good result. However, digital amputations and their conditions for replantation differ. Therefore, the number and ratio of vessels that need to be repaired should be modified and adjusted in each case.     

Successful replantation of a totally amputated penis by using microvascular techniques

A rare case of successful replantation of a totally amputated penis is reported. By using microvascular techniques a superior result was achieved. Not only were all tissue preserved, but also urination, sensation and erection returned to normal. Specific points to be considered in penile replantation are discussed.     

阴茎离断再植成功一例报告并文献复习

报告一例阴茎离断病例，应用显微技术再植再功并复习文献，对阴茎离断的处理方法及术后并发症等进行讨论，认为成功的血管神经显微吻合是提高成活率，降低术后并发症的关键。     

Replantation of the penis: a patient report

Replantation of the penis is an unusual case in this country and it is unlikely that most plastic and reconstructive surgeons or urologists will see one during their career. A successful repair of a self-inflicted amputation of the penis is presented. The unique anatomy of the penis pertinent to replantation is reviewed, and current concepts and recommendations in performing replantation of the penis are presented.     

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.