Infrapopliteal Lower Extremity Replantation:

Ten-Year Follow-Up of Lower Limb Replantation: Objective Evaluation With Gait Analysis

ABSTRACT

The decision-making process for lower limb replantation involves several critical factors, such as age, comorbidities, ischemia time, type of injury, and psychosocial considerations. Advances in microsurgical techniques have led to a greater focus on enhancing functionality through limb salvage. To improve functional outcomes, it is essential to gain a better understanding of the current challenges in reconstruction and address them in future cases. Objective functional analysis of lower extremity replantation cases holds the potential to guide us in this endeavor. In this report, we present a lower limb replantation case with a 10-year follow-up, including objective functional evaluation with gait analysis.

Rotationplasty with Tibial Nerve Coaptation: A Case Report

CASE

We present the case of a 14-year-old adolescent boy with a distal femoral osteosarcoma partially encasing the tibial nerve. He underwent rotationplasty with resection and coaptation (end-to-end repair) of the tibial nerve. By 1 year postoperatively, he had recovered sensation on the plantar aspect of his foot and Medical Research Council scale 4+/5 gastro-soleus contraction that powered extension of the new knee.

CONCLUSION

Tibial nerve resection is not an absolute contraindication for rotationplasty, even in an adolescent. Nerve coaptation allows for well-functioning rotationplasty as an alternative to endoprosthetic reconstruction or above-knee amputation.

Modified Borggreve-Van Nes-Winkelmann rotationplasty for surgery in developing countries

BACKGROUND

Amputation is still the most common therapy for patients suffering from osteosarcoma in Myanmar, despite the fact that limb salvage surgery e.g. Borggreve-Van Nes-Winkelmann rotationplasty for malignant tumors located within the distal femur or proximal tibia is the current state-of-the-art reconstructive procedure. A safe and reliable operation technique is crucial in order to perform a complex surgical procedure like the rotationplasty in lower-middle income economies with limited infrastructure and resources. The authors present seven cases of patients with osteosarcomas that received a Borggreve-Van Nes-Winkelmann rotationplasty with an evaluation of the procedures focusing on safety and sustainability.

METHODS

From 2019 until 2020, seven young patients with osteosarcomas of the distal femur or proximal tibia were treated with Borggreve-Van Nes-Winkelmann rotationplasties in the Orthopaedic Hospital in Mandalay, Myanmar. As modification of the standard procedure the dissection and subsequent clamping of the femoral artery in order to minimize blood loss as well as the formation of an adipocutaneous flap that minimizes swelling and decreases the pressure on the vessels were successfully performed. This modified procedure resembles a safe and simplified surgical technique that is feasible under the circumstances of lower-middle income economies with good outcomes.

RESULTS

All patients showed good functional and aesthetic results. One of the seven patients needed secondary wound closure due to wound dehiscence.

CONCLUSIONS

A simplified and safe operation technique for the performance of the Van Nes-Borggreve rotationplasty was adapted to the given constraints in lower-middle income economies and proved to be successful. Trial registration All patients approved to participate in the study and have given consent to publication.

Ten-year outcome of unilateral leg replantation after bilateral lower leg amputation following traumatic injury: A case report

The absolute indications for lower limb replantation are not unequivocally established; rather, this procedure is still challenging and controversial. We report a case of a young male who underwent bilateral leg amputation, followed by unilateral replantation. The patient demonstrated good 10-year outcomes. A 23-year-old man had both of his lower legs crushed by heavy machinery that fell from the back of a truck, leading to amputation of bilateral lower limbs. Although bilateral amputation was recommended due to severe contusion on both sides, the patient and his family strongly requested replantation of the right leg, and surgery was started approximately 3 h after the injury. In addition to the emergency replantation, six surgeries were performed thereafter. Five months after the first surgery, the patient was fitted with a left lower leg prosthesis and started gait training. He was discharged 8 months later. Ten years after the replantation, the patient is satisfied with his leg. He has a normal gait with a prosthesis and has integrated into society with no functional deficit. There are still no clear standards for replantation after leg amputation, and individual decisions must be made based on the severity of the injury and the patient's general condition. In this case, we respected the patient's strong will to preserve the right leg and decided on the treatment plan. As a result, the patient was highly satisfied, and the spared right leg facilitated the patient's physical and mental recovery.

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Lower limb replantation after amputation is challenging and controversial.

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We report unilateral replantation after bilateral amputation in a young male.

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Seven surgeries, including debridement and skin and nerve grafting, were required.

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The patient demonstrated good 10-year outcomes with no functional deficit.

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The spared right leg facilitated the patient's physical and mental recovery.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Successful Lower Limb Replantation of Knee-Level Amputation in a Child: A Case Report

Replantation of a lower extremity amputated at the knee joint level in a child is rare. We present a case of a 3-year-old child with his right leg totally severed from the knee joint in a traumatic accident. After 5 hours of cold ischemia time, together with antishock therapies, the child underwent leg replantation under stable conditions. The replanted lower limb finally survived after several surgical procedures. The patient was discharged 4 weeks after admission and had restored partial motor and sensory functions 6 months after surgery. During follow-ups, the patient underwent sustained rehabilitation and recovered well. Two years after replantation, secondary knee reconstruction was performed and yielded favorable aesthetic and functional improvement. In brief, a successful knee-level replantation in a child is attributed to correct preoperative first aid, excellent microsurgical skills, and intensive postoperative management.

Lower limb replantation: 27 years follow up

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

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.

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.

Successful ankle replantation in two cases with different presentations

We report our experience of treating two patients with ankle amputation with different presentations. The first case was a clean-cut sharp amputation. The second case was an avulsion injury following a motor vehicle accident in a patient who arrived 8 hours after the injury. Replantation was successful in both cases. In avulsion injuries, a secondary operation for wound coverage is required at a later stage. With good strategy and a support team, encouraging limb survival outcomes are possible post-replantation.

Free microvascular rotationplasty with nerve repair for rhabdomyosarcoma in a 18-month-old patient

Rotationplasty is a limb-sparing surgical option in lower limb malignancies. Sciatic or tibial nerve encasement has been considered an absolute contraindication to this procedure. We report a case of an 18-month-old girl with a rhabdomyosarcoma that affected the leg and popliteal fossa, with neurovascular involvement. Knee and proximal leg intercalary resection was performed followed by reconstruction with free microvascular rotationplasty and neurorraphy from tibial division of sciatic nerve to sural and tibial nerves, and from saphenous nerve to superficial peroneal nerve. Postoperative course was uneventful and ambulation with a provisional prosthesis was restarted during the sixth week after surgery. Bone consolidation was observed after two months. Eighteen months later, the patient had a good gait pattern with a below-knee prosthesis and had recovered sensation in the whole foot and ankle area. This case shows that rotationplasty with nerve repair may provide a sensate stump, which is vital for successful prosthetic adaptation. We believe it may be considered as an alternative to above-knee amputation in tumors with sciatic involvement.

Distraction osteogenesis and arthrodesis as a new surgical option for chondrosarcoma in the distal tibia

Recent advances in the management of bone tumors have led to a significant increase in the survival rates of patients with malignant bone tumors. Thus, limb salvage surgery has gained importance for preserving limb function in the management of bone tumors. However, surgery presents unique difficulties in terms of the biomechanics and obtaining a soft-tissue cover, such as when the ankle is involved in the primary malignant bone tumor. We report a case of chondrosarcoma of the distal tibia treated with wide en bloc resection arthrodesis and reconstruction of the defect using distraction osteogenesis, which offers an effective alternative protocol for limb salvage. The patient has remained disease free for 3 years since the initial surgery and can maintain normal limb athletic function.

Long term follow-up of a successful lower limb replantation in a 3-year-old child

Replantation of the lower extremity has controversial indications but nevertheless it may be considered in carefully selected patients who present early and are expected to show good functional recoveries. Here we present a successful replantation in a 3-year-old boy who has made excellent recovery with no functional deficit evident at 12 years of follow-up. He sustained a traumatic amputation at the level of distal tibia when he fell of a “Qing Qi” (motorcycle rickshaw). Replantation was attempted at 8 hours cold ischemia time with the tibia shortened 4 cm and all tendons, vessels, and nerves repaired. Patient required a second procedure during the same hospital stay for skin coverage. Patient made good recovery with ambulation without support at 6 months, less than 3 cm limb length discrepancy, plantar and dorsiflexion power 4/5, and recovery of sensation over the foot. Now at 12 years of follow-up patient has a normal gait and has integrated into society with no functional deficit. Considering the functional outcome of our case, replantation should be attempted whenever possible and feasible especially in children.

Bilateral transfemoral lower extremity transplantation: result at 1 year

Upper limb transplantation has become a treatment option for upper limb amputees with good midterm results. Lower extremity transplantation has never been considered for fear of poor results. The authors present a bilateral transfemoral transplantation of lower extremities performed to a 22-year patient at 12 months of follow-up. The donor was a full HLA-mismatched female multiorgan donor. CMV status was D-/R-. A primary CMV infection coincident with an acute rejection occurred at 3 months and responded to treatment. At 1 year, the Tinel's sign is at malleolar level, there is active knee extension and active plantar flexion of the foot. The patient is walking between parallel bars. Further substantial improvements are expected with longer rehabilitation and follow-up.

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.

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.

Early or delayed limb lengthening after acute shortening in the treatment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: The results of a case series

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.