Lower Limb Replants

1
Lower Limb Replants

• Dr Lip Teh

2
History

• William Balfour (1814) - fingertip reattachment
• Thomas Hunter(1815) thumb reattachment
• William Halstead and Alexis Carrel (1880s) -
  canine replantation experiments limbs
• Nobel Prize in 1912(Carrell) for his work on
  vascular anastomoses and renal transplantation.
• Ronald Malt(1962) first successful replantation
  of an entire limb
• 12-year-old boy severed arm.
• Komatsu/Tamai (1968) first microscopic digit
  replantation

3
Lower limb amputations

• Most commonly due to
• High speed MVA
• Train accidents
• Occupational accidents

4
Lower limb replants

• Surgical options
• Amputation
• Fillet /composite flaps (Jupiter PRS 1982)
• Flap banking (Godina PRS 1986)
• Replantation
• Limb banking and secondary replantation
  (Hidalgo 1987)

5
Lower limb replants

• decision not to replant is much more compelling
  in lower limb
• function of the lower extremity can be replaced
  by a prosthesis
• the injury is more severe/multitrauma
• the unpredictable recovery of repaired nerves
• severe general complications or local
  complications such as necrosis, infections,
  nonunions
• the need for secondary lengthening, or other
  reconstructive procedures
• the economic cost to the patient and community is
  less.

6
Lower limb replants

• Indications
• Young age
• Bilateral amputations
• Clean amputations
• MESS
• Energy, Shock, Ischaemia, Age
• Short ischaemic time

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Lower limb replants

• Goals
• Functional
• Sensate
• Pain free
• Stable
• Aesthetically pleasing

8
Lower limb replants

• Bone shortening is not a contraindication
• Crossover replantation
• bilateral total or subtotal amputations, when
  anatomic replantation is not possible.

9
Amputate or Replant

• Data from limb salvage in lower limb injuries
• J Trauma. 2002 Apr52(4)641-9.
• Factors influencing the decision to amputate or
  reconstruct after high-energy lower extremity
  trauma.MacKenzie EJ, Bosse MJ, Kellam JF, et al
• 527 patients with Gustilo type IIIB and IIIC
  tibial fractures, dysvascular limbs resulting
  from trauma, type IIIB ankle fractures, or severe
  open midfoot or hindfoot injuries.
• CONCLUSION Soft tissue injury severity has the
  greatest impact on decision making regarding limb
  salvage versus amputation.

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Amputate or Replant

• J Trauma. 1997 Sep43(3)480-5.
• The functional outcome of lower-extremity
  fractures with vascular injury.Lin CH, Wei FC,
  Levin LS, Su JI, Yeh WL
• 36 revasularisations for IIIC Fractures
• overall secondary amputation rate 25 and the
  salvage rate 75
• 80 required secondary coverage procedures that
  included 12 free flap transfers
• Every patient needed subsequent reconstructive
  surgery to achieve an acceptable functional
  result. In this series,
• MESS was able to predict the secondary amputation
  rate and the functional result.
• salvaged limbs with MESS lt or 9 exhibited a
  significant difference in achieving adequate
  function compared with limbs with MESS gt 9.
• onclusions are (1) more severely injured limbs
  have poor functional results, (2) every patient
  needs subsequent reconstructive surgery, and (3)
  the MESS may be helpful in decision-making.

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Amputate or Replant

• Surgery. 1990 Oct108(4)660-4
• Combined orthopedic and vascular injury in the
  lower extremities indications for
  amputation.Odland MD, Gisbert VL, Gustilo RB,
  Ney AL, Blake DP, Bubrick MP.
• 25 patients with vascular repairs
• The risk factors associated with amputation
• shock on admission (10 of 19 patients p less
  than 0.02)
• a crushed extremity (10 of 18 patients p less
  than 0.01).
• The overall amputation rate 35.2.

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Amputate or Replant

• J Reconstr Microsurg. 2004 Nov20(8)621-9.
• Can indications for lower limb replantation and
  revascularization be expanded with simultaneous
  free-flap transfer for limb salvage?Akoz T,
  Yildirim S, Akan M, Gideroglu K, Avci G, Cakir B.
• replanted or revascularized five lower limbs all
  had free tissue transfers
• 1 latissimus dorsi muscle, 2 TRAM, and 2
  anterolateral thigh flap.
• 1 total failure necrosis/infection
• Indications for lower limb salvage may be
  enhanced and successful results may be obtained
  in one stage, with low complication rates and
  shorter hospital stays.

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Outcomes

• Microsurgery. 199112(3)221-31
• Major limb replantation in children.Daigle JP,
  Kleinert JM.
• 7 lower extremity replant
• 87 of patients had a sensory recovery of more
  than S2

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Outcomes

• J Reconstr Microsurg. 1995 Mar11(2)89-92.
• A 17-year follow-up of replantation of a
  completely amputated leg in a child case
  report.Masuda K, Usui M, Ishii S.
• 4 year old lower leg replant
• maintained good cosmesis and function
• foot size on the affected side was 1.5 cm smaller
  
• leg length was 1.2 cm shorter than on the normal
  side
• half-standard strength of the evertors and of the
  plantar flexors
• replantation in a growing child apparently has
  adverse influences on skeletal growth and muscle
  strength around the ankle joint.

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Outcomes

• Ann Plast Surg. 1982 Apr8(4)305-9 Lower
  extremity replantation-two and a half-year
  follow-up.Mamakos MS.
• 11 year old above knee level
• regained protective sensation to her foot.
• fully ambulatory and uses a brace to stabilize
  her ankle
• growth of the severed extremity ( 10 cm
  discrepancy to 5.5 cm).

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Outcomes

• J Bone Joint Surg Am. 1990 Oct72(9)1370-3.
• Replantation of the distal part of the leg.Usui
  M, Kimura T, Yamazaki J.
• five legs replants.
• gt2 year followup (average six years).
• Difficulties in squat and run because of joint
  contractures, muscle weakness, or deformities of
  the foot.
• None had significant pain or any intolerance to
  cold, and all were satisfied with the results.

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Outcomes

• J Bone Joint Surg Br. 2003 May85(4)554-8.
• Orthotopic and heterotopic lower leg
  reimplantation. Evaluation of seven patients.
• Daigeler A, Fansa H, Schneider W.
• five patients (orthotopic), two (heterotopic)
• assessed cutaneous sensation, mobility, pain,
  cosmetic result.
• Functional outcome, patient satisfaction - good,
• Mobility, stability, and psychological state -
  satisfactory.
• Patients with heterotopic reimplantations
  preferred the replanted leg to a prosthesis.
• Asensate foot not a contraindication
• Improves the patient's quality of life.

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Conclusion

• Lower limb replant
• Should be tried in
• Children
• Bilateral lower limb amputations
• Compared to amputation, expect
• prolonged hospital stay
• delays mobilisation
• secondary procedures.
• Amputation with severe soft tissue injuries or
  other systemic injuries

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A worlds first?

• Herald Sun 29 Mar 05 Prof Wayne Morrison,
  director of the Bernard O'Brien Institute of
  Microsurgery and head of plastic and hand surgery
  at Melbourne's St Vincent's Hospital, said he
  believed the operation was a world first. "We
  have had some cases of both legs, or a foot and a
  leg taken off, but we haven't had three limbs,"
  Prof Morrison said. "To have three all combined,
  I think it must be certainly a first in Australia
  and I would think a first in the world."
• Injury. 1997 Jan28(1)73-6
• Replantation of four severed limbs in one
  patient.Pei GX, Kunde L, Chuwen C, Dengshong Z,
  Fuyi W, Songto W, Minsheng W, Lie G, Qing L, Lui
  CK, Zhang LL.