Replantation of a crush amputation of distal tibia followed by lengthening with Ilizarov circular external fixator: Two‐year follow‐up

Abstract

A 20-year-old male sustained a severe crush injury to his left leg, resulting in amputation of the foot at the level of the distal tibia. Despite 12-h warm ischemia, replantation was attempted after radical debridement, bone shortening, and proximal fasciotomies. The replanted part survived totally. Four months later, a 13-cm shortness of the extremity was managed by 10-cm lengthening with distraction osteogenesis, using Ilizarov's circular external fixator and by means of a special shoe. Two-year follow-up of the patient revealed acceptable functional and sensorial recovery. Success of replantation despite the excessive warm-ischemia time was attributed to the sparse muscle content of the distal tibia and foot. Fasciotomies performed on the proximal segment of the leg ensured the patency of anastomoses by maintaining adequate blood flow distally despite increasing edema after the crush injury. Debridement and bone shortening at the proximal stump eliminated the vein and nerve grafts to bridge the gap. In conclusion, considering the functional outcome of our case, replantation of distal parts of a lower extremity should be attempted first, even if the nature of the injury is unfavorable and the ischemia time is longer than the documented ischemia-tolerance.

Can Indications for Lower Limb Replantation and Revascularization be Expanded with Simultaneous Free-Flap Transfer for Limb Salvage?

“…In recently reported papers, severe soft-tissue injury and bone damage requiring shortening of less than 8 to 10 cm have not been accepted as contraindications for lower limb replantation or revascularization, because these problems may be solved successfully with primary shorthening and secondary lengthening. 7,8,14 Although functional lower limbs may be obtained with distraction osteogenesis after replantation, there are some disadvantages of this approach such as the required additional surgical procedures, a longer time needed for ambulation because distraction may be initiated after bone healing, and possible complications of the distraction osteogenesis procedure such as nonunion, pin infection, joint problems, and nerve damage.…”

“…Although many functionally successful lower limb re-plantation cases have been reported, extensive soft tissue damage is still accepted as a limiting factor for limb salvage. [5][6][7][8][9][10] We believe that free-flap transfer simultaneously with replantation not only increases the success rate, but also expands the indications for lower limb replantation in appropriately selected patients. We here present our results and limited experience in simultaneous reconstruction of soft-tissue defects with free flaps in the replanted lower extremities in a five-patient series.…”

Distraction Lengthening of the Thumb Following Replantation

“…It has been performed following replantation of a crush amputation of the lower extremity. 8 In this case, the distraction was initiated approximately 4 months following replantation, resulting in an overall 10-cm increase in length. 8 Distraction lengthening has also been performed following a toe-to-thumb transplant in which the patient required a mobile, sensate thumb, capable of precision pinch, and therefore distraction of the metacarpal alone was not an option.…”

Reconstruction of a Severely Crushed Leg with Interpositional Vessel Grafts and Latissimus Dorsi Flap

“…These procedures are followed by limb lengthening procedures with an llizarov apparatus, which aids the bone lengthening over a 1-2 month period [1,2,4,5]. In this case, no shortening was performed even though there were significant defects of the vessels and soft tissue combined with a severely comminuted fracture.…”