Lower Limb Replants

Dr Lip Teh

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

Lower limb amputations

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

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)

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.

Lower limb replants

• Indications– Young age– Bilateral amputations– Clean amputations

• MESS– Energy, Shock, Ischaemia, Age

• Short ischaemic time

Lower limb replants

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

Lower limb replants

• Bone shortening is not a contraindication

• Crossover replantation – bilateral total or

subtotal amputations, when anatomic replantation is not possible.

Amputate or Replant

• Data from limb salvage in lower limb injuries• J Trauma. 2002 Apr;52(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.

Amputate or Replant• J Trauma. 1997 Sep;43(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 < or = 9 exhibited a significant difference in achieving

adequate function compared with limbs with MESS > 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.

Amputate or Replant

• Surgery. 1990 Oct;108(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%.

Amputate or Replant• J Reconstr Microsurg. 2004 Nov;20(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.

Outcomes

• Microsurgery. 1991;12(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+

Outcomes

• J Reconstr Microsurg. 1995 Mar;11(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.

Outcomes

• Ann Plast Surg. 1982 Apr;8(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).

Outcomes

• J Bone Joint Surg Am. 1990 Oct;72(9):1370-3.• Replantation of the distal part of the leg.

Usui M, Kimura T, Yamazaki J.

• five legs replants.• >2 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.

Outcomes• J Bone Joint Surg Br. 2003 May;85(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.

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

A world’s 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 Jan;28(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.