Amputation Alternatives in the Lower Limb, Stressing Combined Management of the Traumatized Extremity

Salvage of a lower extremity by microsurgical transfer of tibial bone from the contralateral extremity traumatically amputated at the ankle level

The authors present a case of free vascularized transfer of the tibial bone as an osteomyocutaneous flap based on the posterior tibial vessels. A 42-year-old man presented with severe crush injury to bilateral legs. The left tibial bone and soft tissue defect required reconstruction with an osteomyocutaneous free flap. Since the contralateral leg was traumatically amputated at the level of the ankle, a decision was made to harvest a free tibial osteomyocutaneous flap with below-knee-amputation completed. The transfer was achieved successfully with complete survival of the flap and bony union. This report describes the technical and healing aspects of such a unique transfer which may rarely be indicated.

[Reconstructive surgery of knee para-articular amputation stumps]

Reconstructive plastic procedures in primary care and in postprimary/secondary treatment following below knee and above knee amputation are discussed. Short amputation stumps and stumps suffering from insufficient soft tissue coverage should be primarily avoided employing salvage replantation techniques. Secondarily conventional flaps and grafts, tissue expansion and/or microsurgical free tissue transfer all serve for achieving stable skin conditions and preserve adequate stump lengths. Interdisciplinary treatment racionale will lead to improvement of functional and social rehabilitation.

Salvage of a through-knee amputation level using a free fillet of sole flap

A young adult male sustained a compound crural fracture with a 15 cm defect of tibia and fibula, and an extensive soft-tissue loss of the lower leg and knee joint. A free fillet of sole flap was raised on the amputated foot and transferred to the soft-tissue defect around the femoral condyles in order to prevent an above-knee amputation. Intact vascularisation and sensation of the flap were secured by microsurgical anastomoses of the popliteal and posterior tibial vessels and the sciatic and tibial nerves. The patient was rehabilitated rapidly with a prosthesis. At the 12-month follow-up, he demonstrated excellent "foot" sensibility, stable soft-tissue coverage of the stump, and an optimal functional result.

Team approach to tibial fracture. 37 consecutive type III cases reviewed after 2-10 years

During a 10-year period, we managed 35 patients with 37 cases of Type III open tibial fractures, 15 cases within 1 week and 22 as late referrals. In all cases, simultaneous assessment and management by a microvascular and an orthopedic surgeon were mandatory throughout the treatment period. 6 of the 15 acute cases had a primary amputation. Of the remaining 31 cases, limb salvage was possible in 27. 31 flaps, pedicle and microvascular free flaps were used. Major complications occurred in 6 cases, but in 27 cases infection-free solid union was obtained. At long-term follow-up, average 5 years, the function was good or acceptable in 23 cases. We conclude that: (1) patients with Type III tibial injuries should preferably be transferred within a week after injury to a hospital where major reconstructive procedures are commonly performed, (2) early soft tissue coverage is essential in the management of these injuries, (3) unilateral external fixation should be the preferred technique of stabilization, and, finally, (4) plastic surgery expertise is important in management of severe tibial fractures.