Simultaneous replantation of both lower legs in a child: a long-term result

Nerve Regeneration and Functional Recovery With Neurorrhaphy Performed at the Early Distraction Osteogenesis: An Experimental Study

Distraction osteogenesis is widely used in many clinical situations, but distraction in cases accompanying nerve injury has been avoided due to concern of unfavorable effect on nerve regeneration by traction. This study evaluated the feasibility of early distraction lengthening after neurorrhaphy. Thirty-six rats were evenly distributed into 3 groups (12 rats in each group); neurorrhaphy and distraction (group I), neurorrhaphy and osteotomy without distraction (group II), and only distraction without neurorrhaphy (group III), respectively. After osteotomy on the right tibia, distraction started after 1 week and was continued for 40 days with 0.25 mm per day. Histological evaluation was carried out to identify nerve regeneration at 4, 8, and 12 weeks after surgery. Walking tract analysis was performed to assess the functional recovery preoperatively and 1, 4, 8, and 12 weeks postoperatively. Histologically, axon number ratio was significantly impaired in group I (0.48 ± 0.14) and group II (0.53 ± 0.13) compared with group III (0.88 ± 0.04) at 4 weeks (P = 0.020). There was no significant difference at both 8 and 12 weeks. Walking tract analysis showed significant differences between groups I and III (-40.5 ± 4.3), and groups II and III (-35.5 ± 5.0) at 1 week (P = 0.001), but no difference was observed at 8 and 12 weeks. Distraction osteogenesis in early stage after nerve repair is safe and effective, when performed at a rate of 0.25 mm per day in rats.

Bilateral Leg Replantation in a 3-Month-Old Baby After a Knee Level Crush Amputation-A 2-Year Follow-up

We present a case of a successful bilateral leg replantation in a 3-month-old baby after a knee-level crush amputation with the loss of both knee joints. The legs were replanted after 4 hours of warm and an additional 2.5 and 3.5 hours of cold ischemia time. Both legs show motor and sensory reinnervation, without additional procedures performed on the right leg, and after a nerve reconstruction with cadaveric allografts on the left leg. Both replanted legs exhibit excellent bony and soft tissue growth. Two years after the injury, the patient is progressing well with rehabilitation, with favourable odds of having knee reconstructions performed at a later age. This is the youngest patient reported to have had successful replantation of both legs.

Above-the-knee replantation in a child: a case report with a 24-year follow-up

Replantation of an amputated limb is generally contraindicated in crushing and traction injuries. Injury to muscle tissue and skin also creates difficulties in coverage, and bony fractures may shorten limb length which can impede lower extremity function. Numerous cases have been reported on the successful replantation of the lower limb in children; however, review of previous English literature has documented only very few replantation at the thigh level, and those with severe crushing injury resulted in subsequent amputation. We report a case of successful thigh-level replantation in a 3-year-old child who sustained a crushing–traction type of injury with a follow-up of 24 years. After the replantation, early and late complications developed but these were successfully managed. On her last visit, the patient had pain-free ambulation without assistance, had intact protective sensation distal to the injury, and was very satisfied with the outcome. Replantation of the lower limb in children with crushing or avulsion type of injuries is still a worthwhile procedure. However, both the patient and the family should be aware that multiple surgeries may be needed to accommodate to long-term complications such as joint stiffness, scar contractures, and limb length discrepancies.

Crossover Replantation of the Foot After Bilateral Traumatic Lower Extremity Amputation

BACKGROUND

Bilateral traumatic amputation and limb-threatening injury of the lower extremities is more challenging than the unilateral amputation. Successful replantation of both lower extremities has been reported previously. However, orthotopic implantations may not be possible when amputation of both lower limbs with different levels of section and degrees of damage to surrounding tissues occurs. It was reported that the crossover replanted foot in combination with prosthetic limb is better than 2 artificial limbs. Hence, crossover replantation should be considered when anatomic replantation of both lower extremities is not possible as a result of bilateral total or subtotal amputation. To our knowledge, there are few reports about the crossover replantation of the lower extremity in the literature.

CASE REPORT

A 30-year-old engineer being run over by the train had crushed the bilateral lower limbs in different anatomic levels. We decided to perform the crossover replantation of the right foot to the stump of the left leg to provide the patient with at least 1 weight-bearing sensate extremity. At the latest follow-up examination, 30 months after the operation, he had mild pain, especially in toes of the replanted foot. There was no ulceration in both the replanted extremity and the right amputation stump. The sole has maintained complete protective sensation. The patient described the functional result of the reimplanted leg as satisfying and better than the prosthesis that has caused much more problems than the replanted extremity. He had no complaint about the cosmetic result. He stated that he would have the crossover replantation again under the same condition. He was able to return to his previous job. Moreover, he affirmed that he is able to carry on his all social activities as he had done before the accident except for playing football. In conclusion, the possibility of the crossover replantation should be considered while evaluating the patient with bilateral lower limb injuries to allow the patient to stand on their own foot and still touch ground.

Above-Knee Replantation Following Traumatic Bilateral Amputation: Sciatic Nerve Transplantation

A 12-year-old boy who was overrun by a train, sustained traumatic bilateral above-knee amputation and a rupture of the symphysis. The left leg had multiple fractures and soft tissue injuries and amputation was necessary. The right one, although severely crushed, at the amputation site and with a MESS of 9, was replanted accepting some shortening and a soft tissue defect at the amputation site, employing saphenic vein grafts from the amputate (left leg) and an early free latissimus dorsi-flap. Septic complications at the amputation site were managed, and an autologous sciatic nerve graft was performed 8 months after the accident, employing the contralateral above-knee stump as the donor. Protective foot sole sensitivity was noticed after 2 years and 4 months and continued to improve. Further reconstructive procedures included ORIF of a femoral fracture in the contra-lateral stump. On the replanted leg proximal tibia corrective osteotomy and lateral collateral knee ligament reconstruction were performed. A follow-up of 7 years and 9 months demonstrates now a leg capable of full weight bearing and recovery of overall protective sensitivity. The boy made good psycho-social progress after difficulties and feels that the replanted leg is of significantly greater use to him than the hi-tech prosthesis on the other leg.

Rehabilitation after the replantation on a 2-year-old girl with both amputated legs

We had an opportunity to perform replantation of both legs on a 2-year-old girl, and our decision to perform replantation rather than amputation surgery was carefully made taking her age, degree of crushing injury, ischaemic time and level of the amputation into consideration. Painstakingly designed rehabilitation treatments were continuously performed on this girl from the early stage after the operation, and the treatments were comprised of four parts; that is, flexion and extension exercise for the ankle in order to prevent it from stiffness or contracture, functional electrical stimulation (FES) in order to prevent muscular atrophy on the lower extremities, muscle strengthening exercise for the lower extremities, and electrical stimulation to regenerate the damaged nerves and to prevent muscular atrophy from occurring. For an objective assessment of the postoperative conditions, total active motion angles of the ankle joint were measured, and also EMG and NCV were conducted at the end of the first month as well as at the end of the 6th month. Total active motion angles of the ankle joint were increased progressively as time went on, from 15 to 60 degrees on the right and from 10 to 45 degrees on the left. NCV did not show any sensation or response from motor nerves, or amplitude decreased considerably 1 month after the operation; however, at the end of the 6th month conditions improved a great deal with both amplitude and latency. And most muscles that did not show any signals on EMG or showed less than normal at the end of the first month after the operation eventually recovered at the end of the 6th month. The patient had no particular difficulties in walking after 6 months or rather she started running in small steps showing her legs functioning superbly. An infant with both of lower extremities amputated is quite a rare case. We believe that the replantation surgery was successful due to the fact that carefully selected preoperative factors were taken into consideration and well designed postoperative rehabilitation program consisted of four parts was carried out continuously.

Bilateral Lower Leg Replantation Versus Prosthetic Replacement: Long-Term Outcome of Amputation After an Occupational Railroad Accident

BACKGROUND

This retrospective study investigated three very similar cases of bilateral lower leg amputation. The aim was to determine which of two therapeutical procedures is associated with better long-term outcome: replantation or primary treatment of the stumps and subsequent prosthetic replacement.

METHODS

Evaluation included clinical examination, gait analysis, and a workup of the psychosocial background. Health problems were documented using the Nottingham Health Profile. Follow-up assessments were performed 6, 7, and 18 years after the trauma.

RESULTS

One patient underwent successful bilateral lower leg replantation and continued to work for the same employer. Two patients underwent prosthetic replacement. One became a social outcast confined to a wheelchair. The other patient had a good psychosocial background, similar to that of the patient who underwent replantation. He showed a better gait analysis on even ground than the replantation patient, but the findings were vice versa for uneven ground.

CONCLUSIONS

The decision between replantation and prosthetic replacement after bilateral lower leg amputation is case related and cannot be generalized. Patients who have undergone these procedures require long-term psychological and physiotherapeutic care to achieve a good long-term surgical outcome.

Digital replantation in children

Digital amputations in children can frequently be reconstructed using microvascular replantation techniques. An adequate preoperative assessment of the patient and amputated part is important to define associated trauma and to determine the candidacy for replantation. Preoperative care of the injured extremity and patient, as well as optimal perioperative medical and surgical management, increases the success of these microsurgical procedures.

Replantation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the indications and contraindications for extremity replantation. 2. Outline the sequence and technique of replantation. 3. Identify potential complications of replantation and recognize treatment options. 4. Assess the results of replantation in terms of function and costs versus benefits.