Ectopic banking of amputated parts: a clinical review

Free fillet flap: Outcomes in emergency microsurgical reconstruction of upper and lower limb

INTRODUCTION

Despite its infrequency, 'spare-part surgery' represents a reconstructive strategy that uses segments of amputated limbs as donor tissue to preserve function in other injured anatomical regions. The purpose of this study was to review our 14-year experience in emergency microsurgical reconstruction of traumatised limbs using free fillet flaps obtained from non-salvageable amputated parts.

MATERIALS AND METHODS

A retrospective observational study was conducted on patients who underwent urgent free fillet flap transfer for upper or lower limb reconstruction between 2007 and 2021. The characteristics and levels of injury, as well as the flap designs, functional outcomes and complications were documented.

RESULTS

A series of eight clinical cases is presented. One osteo-tendino-cutaneous and seven fasciocutaneous flaps were filleted from non-replantable amputated limbs for free transfer. Stable coverage of the dorsal aspect of the hand and fingers was achieved in three patients, and limb shortening was avoided in five patients. An open thumb fracture with bone defect, three below-knee stumps and one trans-metatarsal level were preserved. The mean Quick-Disabilities of the Arm, Shoulder and Hand score for upper limb reconstructions was 16.75 points. In all the cases of lower limb reconstruction, the nerves were repaired, resulting in a protective sensitivity (S3 level) with no pressure ulcer development during the follow-up period. All patients were able to return to normal prosthetic ambulation with a mean Amputee Mobility Predictor Pro score of 45 points. Two haematomas, one surgical wound dehiscence and two immediate revisions of venous anastomoses were registered.

CONCLUSIONS

The microvascular filleted flap demonstrated versatility in the emergency reconstruction of complex limb injuries, providing stable coverage and optimising limb length preservation within a single major surgical procedure, while eliminating morbidity from any other uninjured donor site.

Complex Hand Reconstruction using a Novel Two-stage Temporary Ectopic Implantation of the Contralateral Upper Limb

Ectopic transplantation of the hand remains a rare, innovative yet valuable operation in select cases of trauma and amputation. We aim to describe a novel technique of complex hand reconstruction using a two-stage ectopic implantation of the contralateral upper limb. A male patient with a near complete avulsion amputation of the right upper limb at the level of the mid-forearm and a crushing injury to his left hand was admitted after a farming accident. The right palm was ectopically transplanted to the left lower limb and both upper limbs underwent debridement with vacuum assisted dressings (VACs). There was eventual dieback of the left thumb, ring and little finger with a large palmar soft tissue defect that was eventually reconstructed using segments of the ectopically transplanted limb in two separate operations. The patient made an uneventful postoperative recovery and managed to regain protective sensation and gross motor function of his reconstructed hand.

Salvage of Devascularized and Amputated Upper Extremity Digits with Temporary Ectopic Replantation: Our Clinical Series

BACKGROUND

One of the reasons for unsuccessful replantation is recipient site problems. In cases where proximal stump status cannot be predicted exactly, reamputation may be required depending on the result of infection and tissue necrosis. The ectopic banking method has been defined for this type of injury. In this study, we presented the amputated or devascularized upper extremity digit ectopic banking application results in our clinical practice.

METHODS

Nineteen digits (17 patients) banking ectopically were included in the study. All digits ectopically banked in the forearm volar of the non-injured upper limb. Transfers were made after waiting for the appropriate time. Ectopic banking periods, postoperative complications, and other descriptive data were recorded. In the postoperative 6th month, the range of motion (ROM) values of the digits were measured and compared with the ROM values of the same digit on the non-injured extremity.Also, in the postoperative 6th month, a questionnaire with a score of 1-5 was conducted for cosmetic results.

RESULTS

The mean follow-up time was 13.6 months. The mean patient age was 39.5 years. The ectopic banking success rate is 94.1% (16/17). The orthotopic/heterotopic transfer success rate is 100% (17/17). Ectopic banking time is, on average, 19.2 days (min 5-max 55). Average cosmetic scale is 3.54.

CONCLUSIONS

We think that the results of our study will shed light on surgeons who make ectopic banking applications.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

Emergency Hand and Reconstructive Microsurgery in the COVID-19-Positive Patient

The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.

Temporary Ectopic Implantation of an Amputated Leg Using the Distal Runoff Vessel of the Anterolateral Thigh Flap Followed by Subsequent Prefabricated Chimeric Replantation

AIM

Infrapopliteal replantation is indicated in selected patients. When the patient is hemodynamically unstable or the amputation site is severely contaminated, temporary ectopic implantation of the amputated limb is an option. To the best of our knowledge, this is the first case report using the distal runoff vessel of the anterolateral thigh flap for temporary ectopic implantation of an amputated leg followed by replantation with the prefabricated anterolateral thigh flap.

PATIENT AND METHODS

A 28-year-old male driver had left leg avulsion amputation after a car accident. Because of concerns about the high-energy trauma mechanism and extensive trauma zone, temporary ectopic implantation was planned to avoid a lengthy replantation procedure and to enable future replantation. The amputated leg was implanted to the thigh using the distal runoff vessel of the descending branch of the lateral circumflex femoral system in the preservation of proximal cutaneous perforator. When the patient became hemodynamically stable and the amputated stump was relatively clean and healthy, we replanted the amputated leg with the prefabricated anterolateral thigh flap on day 7.

RESULTS

The replanted leg and anterolateral thigh flap survived well after the procedure. At the 15-month follow-up, the patient could walk independently. There was no need for custom-made shoes because there was no obvious leg length discrepancy and the flap was not bulky.

CONCLUSIONS

We believe that the distal runoff vessel of the descending branch of the lateral circumflex femoral system can not only serve as a recipient site for temporary ectopic implantation but also enable the harvest of a prefabricated anterolateral thigh flap with the amputated part at the replantation stage. This prefabricated tissue containing the anterolateral thigh flap and the amputated part needs only 1 set of vascular anastomosis to accomplish replantation and simultaneous revascularization of the anterolateral thigh flap. Most importantly, this ectopically prefabricated chimeric tissue minimizes the need for extensive bone shortening after radial debridement by providing sufficient soft tissue coverage at the replantation stage.

Ectopic Banking and Implantation of an Amputated Hand

BACKGROUND

Ectopic banking includes techniques and indications used to bank amputated body parts for later replantation when a body part is amputated in its entirety. Immediate replantation is sometimes impossible due to hemodynamic instability, soft tissue loss, and extensive contamination of the amputated part. The first case of temporary ectopic banking of hand implantation was reported in 2015 by Xu Zhang in China which was not completely successful. The first replantation was reported almost 54 years ago, followed by a limited number of similar cases that were not successful. Xu could not restore the useful function of the replanted hand.

PURPOSE

In this study, we reported a case of hand replantation by the banking technique.

METHOD

We carried out a hand replantation by the banking technique using the right ankle as the recipient site.

RESULT

We restored the useful function of the amputated part and evaluated the function with standard tests.

CONCLUSION

Using right ankle as recipient site in ectopic banking can be a useful approach which helps and ensures the researchers and surgeons to decide if they intend to use this method.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

LEARNING OBJECTIVES

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

SUMMARY

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

Cross limb vessel transfer for salvage of the extremity with irreparable artery injury

PURPOSE

Complex injuries of the extremity can be very challenging to treat. In the setting of soft tissue infection and vascular defect, arterial reconstructions are at high risk of failure. Historically, there have not been good options to successfully salvage limbs with these serious injuries. We describe our experience of utilizing a cross limb vessel transfer to salvage the limb.

METHODS

Patients were identified retrospectively with complex vascular injuries of the extremity and wound infection, who were treated with a cross limb vessel transfer. Once the infection has successfully been cleared, flow-through flap transfer was performed for definitive reconstruction of the arterial injury. Data collated included patient demographics, injury and operation details, and post-operative outcomes including blood supply of the limb, wound infection and complications.

RESULTS

Between April 2014 and January 2017, 3 patients with an average age of 21 years (range, 16-29) were admitted. The median length of hospital stay was 62 days (range, 26-122). The average number of operation was 7.3 times (range, 6-10). Two patients' upper limb had survived with limited movement, relatively minor donor site morbidity and confirmed flow through the vessel reconstruction using CTA, while one patient had lower limb amputation due to severe infection and prolonged ischemia time.

CONCLUSIONS

This series of patients demonstrates that cross limb vessel transfer is an invaluable technique to salvage the limb in patients with complex vascular injury and wound infection. However, for lower limb with prolonged ischemia time and severe infection, limb salvage is not recommended.

Amputations versus Salvage: Reconciling the Differences

BACKGROUND

 There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation.

METHODS

 In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population.

RESULTS

 The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease.

CONCLUSION

 Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

Indications for Replantation and Revascularization in the Hand

The indications for upper extremity replantation are fluid, and it has long been appreciated that they change with time. Traditional strong indications for replantation include hand, thumb, or multiple digit amputation in adults, and almost any amputation in a child. Patients often desire replantation of single nonthumb digits based on aesthetic preference and personal/cultural values. Replantation in these situations is acceptable and rewarding, but individual consideration of patient, injury, and circumstantial factors is critical to avoid patient morbidity and unsatisfactory outcomes.

Revascularization and Replantation in the Hand: Ectopic Banking and Replantation

Traumatic amputation of the upper extremity remains a challenging problem for reconstructive hand surgeons. Temporary ectopic banking of amputated parts for subsequent replantation is an innovative and valuable surgical technique for patients who would otherwise be poor candidates for replantation. The applications of ectopic banking have evolved and expanded to include various clinical scenarios. Although there is considerable variability within the literature, this article summarizes the optimal banking locations and duration, while also highlighting several treatment considerations when performing this technique.

Usefulness of ectopic implantation in multiple finger amputation injury

Replantation combined with simultaneous ectopic implantation can be considered in patients with multiple finger amputation injury. This technique has the advantages of reducing the operating time and optimizing hemodynamic stability. However, it is only possible when multiple hand and microsurgery team can be organized at short notice.

"Damage Control" Hand Surgery: Evaluation and Emergency Management of the Mangled Hand

Mangled hand injuries are defined as those with significant damage to multiple structures, which may be limb threatening. Historically these injuries resulted in amputation or death, but modern surgical and perioperative advances allow for complex reconstruction and the possibility of a sensate and functional limb. Evaluation begins with surveying for life-threatening injuries followed by a systematic approach to identify injured structures; management begins with preserving all parts, minimizing warm ischemia time, performing débridement, and planning an operative approach to optimize the chance of a functional limb. With careful surgical planning and a well-executed reconstruction, most limbs can be salvaged.

Primary Thumb Reconstruction in a Mutilated Hand

The thumb should be preserved at all costs, and major efforts to preserve it are justified. If nothing can be done (or desperate measures fail), classic procedures or a toe-to-hand are indicated. This article will not only discuss some tips to succeed in extreme acute scenarios, but will also consider the indications of other alternatives in the acute or subacute setting.

Ectopic banking of amputated great toe for delayed thumb reconstruction: case report

Ectopic banking of amputated parts is a recognized technique for delayed replantation of an amputated part when the amputation stump will not permit immediate replantation. This is conventionally performed with the intent of transferring the injured part back to its anatomic position when the amputation stump is more appropriate for replantation. Current warfare conditions have led to a commonly encountered military trauma injury pattern of multiple extremity amputations with protected trunk and core structures. This pattern poses many challenges, including the limit or absence of donor sites for immediate or delayed flap reconstructive procedures. We describe a case in which we ectopically banked the great toe of an amputated lower extremity for delayed thumb reconstruction.

The free fillet flap after traumatic amputation: a review of literature and case report

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.

Macroreplantations of the upper extremity: a series of 11 patients

INTRODUCTION

Micro- or macroreplantation is classified depending on the level of amputation, distal or proximal to the wrist. This study was performed to review our experience in macroreplantation of the upper extremity with special attention to technical considerations and outcomes.

MATERIALS AND METHODS

Between January 1990 and December 2010, 11 patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4 ± 18.2 years (range 19-76 years). There were two elbow, two proximal forearm, four mid-forearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5 ± 6.3 years (range 2-21 years).

RESULTS

All but one were successfully replanted and regained limb function: Chen I in four cases (36 %), Chen II in three cases (27 %), Chen III in two cases (18 %), and Chen IV in one patient (9 %). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries.

CONCLUSION

Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at specialist replantation centers.

LEVEL OF EVIDENCE

Level IV.