- Email: [email protected]
Lower limb replantation: 27 years follow up
Journal Pre-proof
Lower limb replantation:27 years follow up Bumbaˇsirevi´c Marko , Leˇsi´c Aleksandar , Palibrk Tomislav , Georgescu Alexandru Valentin , Matei Ileana Rodica , Tabakovi´c Dejan , Mati´c Slađana , Gliˇsovi´c Jovanovi´c Ivana , Petrovi´c Aleksandra , Manojlovi´c Radovan PII: DOI: Reference:
S0020-1383(20)30187-X https://doi.org/10.1016/j.injury.2020.02.113 JINJ 8669
To appear in:
Injury
Accepted date:
21 February 2020
Please cite this article as: Bumbaˇsirevi´c Marko , Leˇsi´c Aleksandar , Palibrk Tomislav , Georgescu Alexandru Valentin , Matei Ileana Rodica , Tabakovi´c Dejan , Mati´c Slađana , Gliˇsovi´c Jovanovi´c Ivana , Petrovi´c Aleksandra , Manojlovi´c Radovan , Lower limb replantation:27 years follow up, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.02.113
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Highlights
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.
1
Lower limb replantation:27 years follow up
Bumbaširević Marko a,b,c, Lešić Aleksandar a,b, Palibrk Tomislav a,b, Georgescu Alexandru Valentin d,e, Matei Ileana Rodica d,e, Tabaković Dejan a, Matić Slađana a,b, Glišović Jovanović Ivana a, Petrović Aleksandra a, Manojlović Radovan a,b a. Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia b. Faculty of Medicine, University of Belgrade, Belgrade, Serbia c. SANU - Serbian Academy of Sciences and Arts d. Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania e. Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
Funding: No funding was received for this study. Conflict of interest: The authors have no conflicts of interest to disclose.
Corresponding author: Marko Bumbaširević Address: Stojana Novakovića 25 11000 Belgrade, Serbia e-mail: [email protected] Key words: replantation, lower limb amputation, functional results
2
Abstract 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.
3
Introduction There are limited reports in literature regarding lower limb replantations. There are papers reporting an 11, 17, 23 and even 25 year follow-up1-4. Reports mostly regard children, whereas replantations in elderly patients are much less common. This type of surgery still continues to be controversial and technically challenging. It is considered that the tibial nerve lesion results in significant morbidity and those bad results after replantation can only bring difficulties for patients. It is thought that a prosthetic device with excellent functional and cosmetic appearance is better than a poorly functional replanted limb5. Indications for replantation are generally based on ischemia time; the severity of soft tissue damage, patient’s age and prediction of functional result. If we decide to do a replantation, the goal is a painless, functional extremity/limb with adequate sensibility and sufficient length6.
Case Report A 41-year-old patient sustained a traumatic below-knee amputation of his left leg in April, 1989. He was injured in the woods working as a logger. He arrived at a hospital 2.5 hours after the injury. The amputated part was draped in saline soaked gauze, placed in a bag and brought in a bucket of water and ice. Surgery began 3.5 hours after the injury, in a two-team approach, where one worked on the amputated part and the other on the leg stump. Initially, the leg was thoroughly cleaned and a debridement of the severely damaged soft and bone tissue was performed. The tibia was shortened about 3 cm and fibula about 4 cm in order to approximate soft tissue. After a rigid osteosynthesis of the tibia with a plate and six screws, the posterior tibial artery was sutured. After tourniquet deflation, good arterial flow was gained. Ischemia time from the moment of injury to successful revascularization was 5.5 hours. We sutured the Achilles tendon, tibialis anterior and posterior muscle, extensor digitorum longus, extensor hallucis longus 4
and peroneal muscles. We also sutured the tibial nerve, superficial sensitive branch of femoral and peroneal nerve, concomitant vein of posterior tibial artery, two superficial veins and great saphenous vein. After skin closure, a 3x4 cm defect, which remained over the sutured muscles was covered with a split thickness skin graft. Total operating time was 5 hours. (Figure 1). Continuous monitoring of the patient’s vital functions and replanted part was carried out. The acid-base balance and urine analysis were constantly controlled. His leg was kept warm with lamps, elevated just above the heart level, and a continuous Heparin infusion was administered. We treated the patient with three antibiotics and pain medications. Physical therapy was started on the 10th postoperative day. 40 days after the surgery partial weight bearing was allowed and after 82 days, the patient put away his crutches and started walking without support. We had no major complications and there were no clinical and laboratory signs of infection in the postoperative period (Figure 2). The plate was removed 18 months after the operation. Now, 27 years after the replantation, the patient is satisfied with his leg. He is able to perform his everyday activities as a farmer and he had no problem with performing normal daily activities. He can perform stair climbing, moderate running, jumping and squatting. His leg is 3.5 cm shorter, but he is compensating the difference with high heel orthopedic shoes. Circulation of the foot is good, without cyanosis, but mild intolerance to cold was noticed. Claw toe deformity is present and on the plantar side of the first and second toe he has a small clavus. At the knee joint he has a full range of motion. At the ankle joint his active and passive plantar flexion, measured with goniometer is 30°, and compared to his right leg, that is about 10° less. Passive dorsal flexion is about 15°, but he can’t actively dorsiflex his foot. As a result, during the walk he had a slightly noticeable peroneal walk. Ankle joint is stable with limited eversion and inversion and he can stand on his toes (Figure 3). We were quite surprised when we marked and sketched sensibility impairment. He regained full sensibility, without zones of 5
paresthesia. He has two-point discrimination of 4 mm on his entire foot and he can tell the difference between cold and warm. Assessment of functional result is done using Clinical Rating System for the Ankle-Hind foot, by American Orthopedic Foot and Ankle Society, Olerud and Molander score and the MOS (Measures of Quality of Life Core Survey) 36-item short-form health survey (SF-36).7-9 We decided to use these tests because of the close proximity of the amputation level to the ankle joint and because all functional deficiencies in our case are linked to anatomical structures around the ankle. Clinical Rating System for the Ankle-Hind foot was 74 points, which is a fair result by the grading scale. Olerud and Molander score was 65 points, which is a good result. The MOS 36item short-form health survey (SF-36) results are shown in Table 1.
Discussion 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 our decision, but the conclusion is that statistics cannot replace clinical judgment. 10, 13, 14
Systemic and local complications, technical difficulties and possible poor functional results
discourage surgeons from performing this complex procedure. 10 We must consider the patient’s general health, his habits (smoking, alcohol abuse, hygiene), financial, social and occupational implications and the difficulty when it comes to reintegrating to society. 11, 12 But mostly we consider patient’s determination and motivation to go through the difficult and demanding treatment protocol. The patient’s age is an important factor when deciding on treatment. Most successful replantations are performed with children, while patients older than 50 have a considerably greater number of complications. 10 Numerous experimental studies have shown that the maximum warm ischemia time for 6
macroreplantation is about 6 hours, although successful attempts were reported even after a much longer ischemia time.15 Muscle destruction, oxygen-derived free radicals and other catabolites can induce life threatening complications.16 Proper transportation of amputated parts play a significant role in the decision for replantation. In our case, the amputated part was adequately transported and fast revascularization resulted in a success. The tibial nerve is the most important for lower leg function. Its postoperative recovery affects thermal modulation capacities, vasodilatation and cold intolerance. Sensibility of the foot and foot sole must give adequate feedback to the patient, which is important for work and protection.17 In our case, the patient has full sensitive recovery that provides him adequate feedback, protection and functionality. Adequate length is also important for function, but moderate shortening can be compensated with an orthopedic shoe.18, 19 In our case, 3.5 cm length deficiency isn’t debilitating for the patient. In the beginning, amputation seems to be more adequate, especially if we have a good functional, prosthesis result in mind, which has been reported.1 Less hospital time, fast rehabilitation, early return to functional life and social integration are very appealing to the patient and surgeon. Financial reasons are also of a great significance. But we must consider some drawbacks. Patients with amputations often deal with amputation stump problems. Prosthesis fitting after muscle volume reduction or weight gain, skin ulcerations, and neuroma formation are just few reasons for frequent ambulatory evaluations. On the other hand, a replantation in the beginning, requires much more: a complex operation, prolonged hospitalization, functional reeducation and cost effectiveness. But if it is successful, later we don’t have to see this patient often. In this case, the patient did not have ambulatory checks for more than 25 years. Also, body integrity preservation can be of a great importance for patients, especially in some cultures. 7
We always ask is replantation worth it? Results achieved with this patient give us a hope to proceed with lower limb replantations, although a lot of controversies exists. One of the most important factors is proper patient selection. The decision of whether to do an amputation or a replantation should be made patient-related and no generalization is appropriate. Complications are high, but with motivated patients, dedicated and competent teams, results can be rewarding 20, 21, 22
Disclosure
This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM).
8
References 1. Ricketts S, De Steiger R, Breidahl A. Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation. J Reconstr Microsurg 2009;25(2):11-5. 2. Masuda K, Usui M, Ishii S. A 17-year follow-up of replantation of a completely amputated leg in a child: case report. J Reconstr Microsurg 1995;11(2):89-92. 3. Datiashvili RO. Simultaneous replantation of both lower legs in a child: 23 years later. J Reconstr Microsurg 2009;25(5):323-9. 4. Vilkki S, Mustonen P, Huopio J. Replantation of amputated leg. First case in Finland, how is the patient doing 25 years later? Duodecim 2005;121(6):617-21. 5. Muneuchi G1, Suzuki S, Ito O, Kurokawa M. Successful replantation of an amputated leg with severe crush and avulsion injury in an elderly patient: case report. J Reconstr Microsurg 2003;19(2):87-92. 6. Tukiainen E, Suominen E, Asko-Seljavara S. Replantation, revascularization, and reconstruction of both legs after amputations. J Bone Joint Surg Am 1994;76(11):1712-6. 7. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-53. 8. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473-83. 9. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg 1984;103(3):190-4. 10. Battiston B, Tos P, Pontini I, Ferrero S. Lower limb replantations: indications and a new scoring system. Microsurgery 2002;22(5):187-92. 11. Zubairi AJ, Hashmi PM. Long term follow-up of a successful lower limb replantation in a 9
3-year-old child. Case Rep Orthop 2015. 2015: 425376 doi:10.1155/2015/425376. Epub 2015 Apr 2. 12. Liverneaux P, Delattre O, Thoreux P. Long-term follow-up after leg replantation. Rev Chir Orthop Reparatrice Appar Mot 2005;91(5):482-6. 13. Jupiter JB, Tsai TM, Kleinert HE. Salvage Replantation of Lower Limb Amputations. Plast Reconstr Surg 1982;69(1):1-8 14. Russell WL, Sailors DM, Whittle TB, Fisher DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213(5):473–481. 15. Datiashvili RO, Chichkin VG. Successful Replantation of the Lower Leg after 42-Hour Ischemia: Case Report. J reconstr Microsurg 1992;8(6):447-453 16. Ferrari RP, Battiston B, Brunelli G, Cassela A, Caimi L. The role of allopurinol in preventing oxygen free radical injury to skeletal muscle and endothelial cells after ischemia-reperfusion. J Reconstr Microsurg 1996;12:447-50. 17. Tudosie A, Popescu S, Cinteza D, Romanescu S, Popa R, Sandu A, et al. Rehabilitation in a patient with replantation of amputated distal leg. Maedica (Buchar) 2011;6(1):36-44. 18. Hierner R, Berger AK, Frederix PR. Lower leg replantation-decision-making, treatment, and long-term results. Microsurgery 2007;27(5):398-410. 19. Chen ZW, Qian YQ, Yu ZJ. Extremity replantation. J World Surg 1978;2:513. 20. Cavadas PC, Landín L, Ibáñez J, Roger I, Nthumba P. Infrapopliteal lower extremity replantation. Plast Reconstr Surg 2009;124(2):532-9. 21. Schmidhammer R, Nimmervoll R, Pelinka LE, Huber W, Schrei K, Kroepfl A, et al. Bilateral lower leg replantation versus prosthetic replacement: long-term outcome of amputation after an occupational railroad accident. J Trauma 2004;57(4):824-31. 10
22. Hierner R, Betz AM, Comtet JJ, Berger AC. Decision making and results in subtotal and total lower leg amputations: reconstruction versus amputation. Microsurgery 1995;16(12):830-9.
11
Legends
Figure 1 - a and b: Findings during operation, after osteosynthesis; c: preoperative radiography.
12
Figure 2 – a and b: Appearance 7 months after the operation. Skin graft on a medial side is completely healed. Noticeable clawing of the toe; c: Radiography, 7 months after the surgery.
13
Figure 3 – 27 years after; a: he regained full range of motion of the knee joint and good ankle function but with limited dorsiflexion; b: full weight bearing on the injured leg; c: stand on the toes with noticeable shortening of the leg.
14
Table 1. The MOS (Measures of Quality of Life Core Survey) 36-item short-form health survey (SF-36).
Physical functioning (PF)
100.0
Role limitations due to physical health (RP)
50.0
Role limitations due to emotional problems (RE)
100.0
Energy/ fatigue (VT) Emotional well being (MH)
70.0 92.0
Social functioning (SF) Pain (BP)
100.0
General health (GH)
72.0
32.0
15
Lower limb replantation:27 years follow up Bumbaˇsirevi´c Marko , Leˇsi´c Aleksandar , Palibrk Tomislav , Georgescu Alexandru Valentin , Matei Ileana Rodica , Tabakovi´c Dejan , Mati´c Slađana , Gliˇsovi´c Jovanovi´c Ivana , Petrovi´c Aleksandra , Manojlovi´c Radovan PII: DOI: Reference:
S0020-1383(20)30187-X https://doi.org/10.1016/j.injury.2020.02.113 JINJ 8669
To appear in:
Injury
Accepted date:
21 February 2020
Please cite this article as: Bumbaˇsirevi´c Marko , Leˇsi´c Aleksandar , Palibrk Tomislav , Georgescu Alexandru Valentin , Matei Ileana Rodica , Tabakovi´c Dejan , Mati´c Slađana , Gliˇsovi´c Jovanovi´c Ivana , Petrovi´c Aleksandra , Manojlovi´c Radovan , Lower limb replantation:27 years follow up, Injury (2020), doi: https://doi.org/10.1016/j.injury.2020.02.113
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Highlights
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.
1
Lower limb replantation:27 years follow up
Bumbaširević Marko a,b,c, Lešić Aleksandar a,b, Palibrk Tomislav a,b, Georgescu Alexandru Valentin d,e, Matei Ileana Rodica d,e, Tabaković Dejan a, Matić Slađana a,b, Glišović Jovanović Ivana a, Petrović Aleksandra a, Manojlović Radovan a,b a. Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia b. Faculty of Medicine, University of Belgrade, Belgrade, Serbia c. SANU - Serbian Academy of Sciences and Arts d. Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania e. Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
Funding: No funding was received for this study. Conflict of interest: The authors have no conflicts of interest to disclose.
Corresponding author: Marko Bumbaširević Address: Stojana Novakovića 25 11000 Belgrade, Serbia e-mail: [email protected] Key words: replantation, lower limb amputation, functional results
2
Abstract 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.
3
Introduction There are limited reports in literature regarding lower limb replantations. There are papers reporting an 11, 17, 23 and even 25 year follow-up1-4. Reports mostly regard children, whereas replantations in elderly patients are much less common. This type of surgery still continues to be controversial and technically challenging. It is considered that the tibial nerve lesion results in significant morbidity and those bad results after replantation can only bring difficulties for patients. It is thought that a prosthetic device with excellent functional and cosmetic appearance is better than a poorly functional replanted limb5. Indications for replantation are generally based on ischemia time; the severity of soft tissue damage, patient’s age and prediction of functional result. If we decide to do a replantation, the goal is a painless, functional extremity/limb with adequate sensibility and sufficient length6.
Case Report A 41-year-old patient sustained a traumatic below-knee amputation of his left leg in April, 1989. He was injured in the woods working as a logger. He arrived at a hospital 2.5 hours after the injury. The amputated part was draped in saline soaked gauze, placed in a bag and brought in a bucket of water and ice. Surgery began 3.5 hours after the injury, in a two-team approach, where one worked on the amputated part and the other on the leg stump. Initially, the leg was thoroughly cleaned and a debridement of the severely damaged soft and bone tissue was performed. The tibia was shortened about 3 cm and fibula about 4 cm in order to approximate soft tissue. After a rigid osteosynthesis of the tibia with a plate and six screws, the posterior tibial artery was sutured. After tourniquet deflation, good arterial flow was gained. Ischemia time from the moment of injury to successful revascularization was 5.5 hours. We sutured the Achilles tendon, tibialis anterior and posterior muscle, extensor digitorum longus, extensor hallucis longus 4
and peroneal muscles. We also sutured the tibial nerve, superficial sensitive branch of femoral and peroneal nerve, concomitant vein of posterior tibial artery, two superficial veins and great saphenous vein. After skin closure, a 3x4 cm defect, which remained over the sutured muscles was covered with a split thickness skin graft. Total operating time was 5 hours. (Figure 1). Continuous monitoring of the patient’s vital functions and replanted part was carried out. The acid-base balance and urine analysis were constantly controlled. His leg was kept warm with lamps, elevated just above the heart level, and a continuous Heparin infusion was administered. We treated the patient with three antibiotics and pain medications. Physical therapy was started on the 10th postoperative day. 40 days after the surgery partial weight bearing was allowed and after 82 days, the patient put away his crutches and started walking without support. We had no major complications and there were no clinical and laboratory signs of infection in the postoperative period (Figure 2). The plate was removed 18 months after the operation. Now, 27 years after the replantation, the patient is satisfied with his leg. He is able to perform his everyday activities as a farmer and he had no problem with performing normal daily activities. He can perform stair climbing, moderate running, jumping and squatting. His leg is 3.5 cm shorter, but he is compensating the difference with high heel orthopedic shoes. Circulation of the foot is good, without cyanosis, but mild intolerance to cold was noticed. Claw toe deformity is present and on the plantar side of the first and second toe he has a small clavus. At the knee joint he has a full range of motion. At the ankle joint his active and passive plantar flexion, measured with goniometer is 30°, and compared to his right leg, that is about 10° less. Passive dorsal flexion is about 15°, but he can’t actively dorsiflex his foot. As a result, during the walk he had a slightly noticeable peroneal walk. Ankle joint is stable with limited eversion and inversion and he can stand on his toes (Figure 3). We were quite surprised when we marked and sketched sensibility impairment. He regained full sensibility, without zones of 5
paresthesia. He has two-point discrimination of 4 mm on his entire foot and he can tell the difference between cold and warm. Assessment of functional result is done using Clinical Rating System for the Ankle-Hind foot, by American Orthopedic Foot and Ankle Society, Olerud and Molander score and the MOS (Measures of Quality of Life Core Survey) 36-item short-form health survey (SF-36).7-9 We decided to use these tests because of the close proximity of the amputation level to the ankle joint and because all functional deficiencies in our case are linked to anatomical structures around the ankle. Clinical Rating System for the Ankle-Hind foot was 74 points, which is a fair result by the grading scale. Olerud and Molander score was 65 points, which is a good result. The MOS 36item short-form health survey (SF-36) results are shown in Table 1.
Discussion 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 our decision, but the conclusion is that statistics cannot replace clinical judgment. 10, 13, 14
Systemic and local complications, technical difficulties and possible poor functional results
discourage surgeons from performing this complex procedure. 10 We must consider the patient’s general health, his habits (smoking, alcohol abuse, hygiene), financial, social and occupational implications and the difficulty when it comes to reintegrating to society. 11, 12 But mostly we consider patient’s determination and motivation to go through the difficult and demanding treatment protocol. The patient’s age is an important factor when deciding on treatment. Most successful replantations are performed with children, while patients older than 50 have a considerably greater number of complications. 10 Numerous experimental studies have shown that the maximum warm ischemia time for 6
macroreplantation is about 6 hours, although successful attempts were reported even after a much longer ischemia time.15 Muscle destruction, oxygen-derived free radicals and other catabolites can induce life threatening complications.16 Proper transportation of amputated parts play a significant role in the decision for replantation. In our case, the amputated part was adequately transported and fast revascularization resulted in a success. The tibial nerve is the most important for lower leg function. Its postoperative recovery affects thermal modulation capacities, vasodilatation and cold intolerance. Sensibility of the foot and foot sole must give adequate feedback to the patient, which is important for work and protection.17 In our case, the patient has full sensitive recovery that provides him adequate feedback, protection and functionality. Adequate length is also important for function, but moderate shortening can be compensated with an orthopedic shoe.18, 19 In our case, 3.5 cm length deficiency isn’t debilitating for the patient. In the beginning, amputation seems to be more adequate, especially if we have a good functional, prosthesis result in mind, which has been reported.1 Less hospital time, fast rehabilitation, early return to functional life and social integration are very appealing to the patient and surgeon. Financial reasons are also of a great significance. But we must consider some drawbacks. Patients with amputations often deal with amputation stump problems. Prosthesis fitting after muscle volume reduction or weight gain, skin ulcerations, and neuroma formation are just few reasons for frequent ambulatory evaluations. On the other hand, a replantation in the beginning, requires much more: a complex operation, prolonged hospitalization, functional reeducation and cost effectiveness. But if it is successful, later we don’t have to see this patient often. In this case, the patient did not have ambulatory checks for more than 25 years. Also, body integrity preservation can be of a great importance for patients, especially in some cultures. 7
We always ask is replantation worth it? Results achieved with this patient give us a hope to proceed with lower limb replantations, although a lot of controversies exists. One of the most important factors is proper patient selection. The decision of whether to do an amputation or a replantation should be made patient-related and no generalization is appropriate. Complications are high, but with motivated patients, dedicated and competent teams, results can be rewarding 20, 21, 22
Disclosure
This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM).
8
References 1. Ricketts S, De Steiger R, Breidahl A. Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation. J Reconstr Microsurg 2009;25(2):11-5. 2. Masuda K, Usui M, Ishii S. A 17-year follow-up of replantation of a completely amputated leg in a child: case report. J Reconstr Microsurg 1995;11(2):89-92. 3. Datiashvili RO. Simultaneous replantation of both lower legs in a child: 23 years later. J Reconstr Microsurg 2009;25(5):323-9. 4. Vilkki S, Mustonen P, Huopio J. Replantation of amputated leg. First case in Finland, how is the patient doing 25 years later? Duodecim 2005;121(6):617-21. 5. Muneuchi G1, Suzuki S, Ito O, Kurokawa M. Successful replantation of an amputated leg with severe crush and avulsion injury in an elderly patient: case report. J Reconstr Microsurg 2003;19(2):87-92. 6. Tukiainen E, Suominen E, Asko-Seljavara S. Replantation, revascularization, and reconstruction of both legs after amputations. J Bone Joint Surg Am 1994;76(11):1712-6. 7. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-53. 8. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473-83. 9. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg 1984;103(3):190-4. 10. Battiston B, Tos P, Pontini I, Ferrero S. Lower limb replantations: indications and a new scoring system. Microsurgery 2002;22(5):187-92. 11. Zubairi AJ, Hashmi PM. Long term follow-up of a successful lower limb replantation in a 9
3-year-old child. Case Rep Orthop 2015. 2015: 425376 doi:10.1155/2015/425376. Epub 2015 Apr 2. 12. Liverneaux P, Delattre O, Thoreux P. Long-term follow-up after leg replantation. Rev Chir Orthop Reparatrice Appar Mot 2005;91(5):482-6. 13. Jupiter JB, Tsai TM, Kleinert HE. Salvage Replantation of Lower Limb Amputations. Plast Reconstr Surg 1982;69(1):1-8 14. Russell WL, Sailors DM, Whittle TB, Fisher DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213(5):473–481. 15. Datiashvili RO, Chichkin VG. Successful Replantation of the Lower Leg after 42-Hour Ischemia: Case Report. J reconstr Microsurg 1992;8(6):447-453 16. Ferrari RP, Battiston B, Brunelli G, Cassela A, Caimi L. The role of allopurinol in preventing oxygen free radical injury to skeletal muscle and endothelial cells after ischemia-reperfusion. J Reconstr Microsurg 1996;12:447-50. 17. Tudosie A, Popescu S, Cinteza D, Romanescu S, Popa R, Sandu A, et al. Rehabilitation in a patient with replantation of amputated distal leg. Maedica (Buchar) 2011;6(1):36-44. 18. Hierner R, Berger AK, Frederix PR. Lower leg replantation-decision-making, treatment, and long-term results. Microsurgery 2007;27(5):398-410. 19. Chen ZW, Qian YQ, Yu ZJ. Extremity replantation. J World Surg 1978;2:513. 20. Cavadas PC, Landín L, Ibáñez J, Roger I, Nthumba P. Infrapopliteal lower extremity replantation. Plast Reconstr Surg 2009;124(2):532-9. 21. Schmidhammer R, Nimmervoll R, Pelinka LE, Huber W, Schrei K, Kroepfl A, et al. Bilateral lower leg replantation versus prosthetic replacement: long-term outcome of amputation after an occupational railroad accident. J Trauma 2004;57(4):824-31. 10
22. Hierner R, Betz AM, Comtet JJ, Berger AC. Decision making and results in subtotal and total lower leg amputations: reconstruction versus amputation. Microsurgery 1995;16(12):830-9.
11
Legends
Figure 1 - a and b: Findings during operation, after osteosynthesis; c: preoperative radiography.
12
Figure 2 – a and b: Appearance 7 months after the operation. Skin graft on a medial side is completely healed. Noticeable clawing of the toe; c: Radiography, 7 months after the surgery.
13
Figure 3 – 27 years after; a: he regained full range of motion of the knee joint and good ankle function but with limited dorsiflexion; b: full weight bearing on the injured leg; c: stand on the toes with noticeable shortening of the leg.
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Table 1. The MOS (Measures of Quality of Life Core Survey) 36-item short-form health survey (SF-36).
Physical functioning (PF)
100.0
Role limitations due to physical health (RP)
50.0
Role limitations due to emotional problems (RE)
100.0
Energy/ fatigue (VT) Emotional well being (MH)
70.0 92.0
Social functioning (SF) Pain (BP)
100.0
General health (GH)
72.0
32.0
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