Download Lower Limb Replants

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 halfyear 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.