Crossover Replantation and Fillet Flap Coverage of the Stump after Ectopic Implantation: A Case of Bilateral Leg Amputation:

Reconstruction of a severely crushed leg with interpositional vessel grafts and latissimus dorsi flap

We present a case of a near total amputation at the distal tibial level, in which the patient emphatically wanted to save the leg. The anterior and posterior tibial nerves were intact, indicating a high possibility of sensory recovery after revascularization. The patient had open fractures at the tibia and fibula, but no bone shortening was performed. The posterior tibial vessels were reconstructed with an interposition saphenous vein graft from the contralateral side and a usable anterior tibial artery graft from the undamaged ipsilateral distal portions. The skin and soft tissue defects were covered using a subatmospheric pressure system for demarcating the wound, and a latissimus dorsi myocutaneous free flap for definite coverage of the wound. At 6 months after surgery, the patient was ambulatory without requiring additional procedures. Replantation without bone shortening, with use of vessel grafts and temporary coverage of the wound with subatmospheric pressure dressings before definite coverage, can shorten recovery time.

Ectopic banking of amputated parts: a clinical review

Since its first clinical description by Marco Godina in 1986, the technique of temporary ectopic banking of amputated parts has been employed in a growing body of reported cases. This installment provides a review of the reported cases in the international literature to date, focusing on our evolving understanding of clinical indications, operative timing, and surgical technical consideration. Two illustrative cases are provided to highlight these concepts.

Crossover replantation as a salvage procedure following bilateral transhumeral upper limb amputation: a case report

Cross-over replantation is a salvage option for cases with bilateral extremity amputations where the wound conditions do not enable an orthotopic replantation. Here, we present a 24-year-old patient who applied to our center with bilateral transhumeral amputations. Due to the wound conditions, a cross-over replantation was performed. 24 months after the initial operation, the patient exhibits good protective sensation at the distal levels and function to some degree, whereas the active range of motion is not as promising as previously expected. In this article, we present this case together with its immediate and long-term outcomes and the consequences of the cross-over replantation.

Secondary ectopic transfer for replantation salvage after severe wound infection

BACKGROUND

Ectopic transfer has been described as a salvage procedure in failing replants. The experience in three cases of infected failing replantations treated with secondary temporary ectopic transfer of the replanted part is presented.

METHODS

Three patients with replanted traumatic amputations (one transhumeral, one transmetacarpal, and one transtibial) that developed severe wound infections and thrombosis of the anastomoses were treated with urgent ectopic transfer of the replanted part. The ectopic recipient vessels were the femoral, posterior tibial, and the descending branch of the lateral femoral circumflex arteries. The stumps were surgically cleansed and the ectopically replanted parts were retransferred some days later.

RESULTS

The infection reccurred in one case and the replant (transmetacarpal) was lost. The two other cases were successfully retransferred orthotopically, 9 and 20 days later, respectively. In one case (transtibial) multiple additional surgical procedures were necessary. Functional results in these two cases were acceptable.

CONCLUSIONS

Delayed ectopic transfer is a useful, yet demanding technique for the salvage of complicated replants in the context of severe wound infection and vascular thrombosis or impending failure. Given the complexity of the procedure it should only be considered in selected cases.

Application of a fasciocutaneous free flap for treatment of a severe soft tissue injury of the foot and ankle: a case report

The authors report an unusual case wherein a fasciocutaneous free flap from an amputated upper limb was used to repair a severe soft tissue injury of the ipsilateral forefoot and ankle. After amputating the nonviable portions of the forefoot, a residual limb flap from the patient's forearm, pedicled with the brachial artery, was used to cover the lower extremity defect. Three years after the injury, the patient was able to maintain balance and ambulate without assistance on the reconstructed lower extremity.

LEVEL OF CLINICAL EVIDENCE

4.

Amputation stump salvage using a free forearm flap from the amputated part

Upper extremity amputations are not as common as lower extremity amputations, but they present unique challenges to the surgeon, prosthetist and amputee. The tissues of amputated or non-salvageable limbs may be used to reconstruct complex defects resulting from tumour removal or trauma, i.e. the 'spare parts' concept. The use of a free fillet flap to treat massive trauma of the upper extremity is reported here for two cases. These patients were treated with a pedicled fillet of whole forearm flaps to achieve primary stump closure and to preserve upper arm length.

Temporary ectopic implantation of digits prior to reconstruction of a hand without metacarpals

Temporary ectopic implantation has been described for a variety of injuries, with several different implantation sites used. Although varied results have been achieved, many feel this technique has a role to play under special circumstances. We describe the ectopic implantation of digits to the contralateral forearm, with subsequent reconstruction of the injured hand when combined with microvascular toe transfer. The outcome was a functionally useful hand which could be incorporated into daily life, and a cosmetic appearance preferable to that of amputation. We feel ectopic implantation still has a valuable role to play in carefully selected cases.

Salvage of impending replant failure by temporary ectopic replantation: a case report

Temporary ectopic replantation of amputated parts has been reported previously as an alternative to orthotopic replantation in difficult cases. We report a case in which the left arm initially was replanted orthotopically with subsequent development of extensive infection. The impending vascular failure of the replanted arm was salvaged by reamputation and temporary ectopic transfer of the arm to the groin region. Nine days later the arm was transferred back to the clean humeral stump. The functional result was similar to that of a standard transhumeral replantation, with 30 degrees to 120 degrees of active range of elbow motion, basic grip pattern, and S3 sensibility.