Case Study
European Journal of Trauma and Emergency Surgery
Above-Knee Replantation Following Traumatic Bilateral Amputation: Sciatic Nerve Transplantation Reinhard Friedel1, Ralf Schmidt1, Torsten Dönicke1, Egbert Hüttemann2, Olaf Bach3, Gunther O. Hofmann1,4
Abstract 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.
Key Words Reconstructive surgery Eur J Trauma Emerg Surg 2007;33:192–7 DOI 10.1007/s00068-006-6008-2
Summary 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 contra-lateral 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 reconstruc-
1
Department of Trauma, Hand and Reconstructive Surgery, Faculty of Medicine, University of Jena, Jena, Germany, Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine University of Jena, Jena, Germany, 3 Grampian University NHS Trust, Orthopaedic Department, Aberdeen Royal Infirmary & Woodend Hospital, Scotland, UK, 4 Department of Trauma and Reconstructive Surgery, Trauma Center Halle, Halle/Saale, Germany. 2
Received: January 16, 2006; revision accepted: June 6, 2006; Published Online: April 4, 2007
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Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 1. A 12-year old boy who was over run by a train, sustaining traumatic bilateral above-knee amputation and a ruptured symphysis.
tion 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.
Case Report A 12-year-old boy was run over by a train resulting in a bilateral proximal above-knee amputation. The rescue team arrived approximately 15 min after being alarmed on the accident side. The boy was very drowsy, not able to talk properly but could open his eyes on pain sensation (Glasgow Coma Scale of 5). Blood loss was significant. Blood pressure 80/40 but very faint, pulse rate 117. Immediate resuscitation was initiated. He received iv lines – volume substitution: 1,000 ml of colloidal and 2500 ml of cristalloidal fluids) – and was intubated and artificially respirated. External bleeding was primarily controlled by manual compression of both iliac arteries and later compression bandages were applied on both lower extremities. Transport was carried out in a rescue helicopter. On arrival the patient was brought directly into the operating theater. The vital signs and some key laboratory findings were blood pressure 80/40, pulse rate 80, temperature 32.6°C, SpO2 100%, Hb 6.5 mmol/l, Ht 0.32, pH 7.116, base excess –16.3. On the left side there was additionally destruction of the lower leg with multiple open fractures and extensive soft tissue damage (Figure 1). Apart from a symphysis rupture, there were no further injuries. Soft tissue and bone damage on the amputation site at the right leg were severe, with bone damage of at least
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
15 cm. Despite a calculated Mangled Extremity Severity Score (very high energy injury, cool and paralyzed legs, persistent hypotension) of 9 (very high energy 4, cool, paralyzed insensate, numb 3, persistent hypotension 2) according to Johansen & Daines [9], the young age of the patient and no additional injuries led our decision to replant the right leg. The operation started 2 h after the accident and was carried out simultaneously by two teams; the first one, led by a pediatric Surgeon, debrided and covered the stump on the left side and harvested vein grafts from the left leg amputate. Simultaneously, the replantation team of the Trauma Center started the replantation of the right leg. After debridement, the fracture site at the femur was cut plane and an osteosynthesis was carried out using an AO/ASIF LC-DCP1. This was followed by reconstructing the femoral artery using long vein grafts harvested from the contra-lateral amputated leg. The sciatic nerve was found to be severely damaged along a length of 20 cm, and repair was not attempted. Four hours after the accident, circulation had been reestablished. After that, soft tissue debridement was completed. Subsequently, the remaining extensor and flexor muscle stumps were approximated. The persisting large soft tissue damage was covered with an instillation vacuum seal using Coldex2 foam and Lavasept 0,2%3 for continuous irrigation. Intra-operatively the patient received 33 erythrocyte concentrates, 20 fresh frozen plasma concentrates, 2 g Hemocompletan4 and 2,000 IU anti-thrombine III. The duration of the replantation was 8 h. Postoperatively the boy was admitted to ICU for mechanical ventilation. He demonstrated cardio-vascular stability under moderate doses of catecholamines, and he was weaned off within a few days. Repeated transfusions were required. At this point, myoglobine levels were peaking extremely high, but there was no clinical manifestation of a crush syndrome. In addition to the usual intensive monitoring and treatment, the patient received medications according to our treatment protocol for replantations (Table 1). Dressings were changed daily under general anesthesia at the ICU and several additional debridements were performed in the operating theater. Such interventions always were followed by a rise of systemic inflammation markers (CRP, procalcitonin) and an increase of body temperature. The microbiologic monitoring of all 1
Low Contact Dynamic Compression Plate (Synthes). Velo Medizinprodukte GmbH. 3 Serag Wiessner/Polyhexanid. 4 Aventis, Behring GmbH Marburg. 2
193
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Table 1. Post-operative treatment protocol for replantations. Heparin
5,000 iE tds/sc
Haes steril 10% Cefuroxim
125 ml qid/iv 1.5 g tds/ i.v.
wounds revealed contamination by Enterococcus, several Bacilli and Pseudomonas aeroginosa. A septic complication became apparent at the site of the vascular femoral anastomosis. In this context the patient developed an epidimitis 10 days after the accident. Surgical exploration revealed a partial necrosis of the cremaster muscle but the testicle itself was intact. Necrectomy and orchidopexy were performed. On day 14 after replantation another debridement was required, during which the entire necrotic sciatic nerve had to be resected over a length of around 20 cm. During the same anesthesia, we covered the infected region around the femoral vascular anastomoses using a free latissmus dorsi-flap harvested from the ipsilateral shoulder (Figure 2). The thoraco-dorsal artery and the veins were connected end-to-side to the vein grafts of the femoral artery and the venous interponate of the replantation procedure. After this session, systemic inflammatory markers rose again (procalcitonin 10.9 ng/ml, CRP 85.6 mg/dl and body temperature rose to 38.8°C). Although implanted into a contaminated site, the microvascular flap healed primarily. Subsequently, local and general signs of infection disappeared. Pain management was achieved by epidural catheter block as part of our replantation protocol, in addition to systemic morphine applications. All catheters were removed and changed during the time of the septic complication at the femoral anastomosis. On day 29 following trauma, ORIF of the femoral fracture in the above-knee stump on the left-hand side was performed using a seven-hole LCDCP titanium plate. The aim was to provide sufficient stability for the application of an above-knee prosthesis as soon as possible to enforce mobilization of the boy. On the right-hand side, significant soft tissue damage lateral to the hip persisted. It was treated by dermato-traction, successive skin grafts, and the local application of somatotropins (GenotropinÒ5). A psychotherapist visited the boy at least once a day beginning with the day of extubation. During the early period after injury, the boy was struggling between successively neglecting and realizing the severity 5
Pfizer Pharma GmbH.
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Figure 2. Using a free latissimus dorsi flap to cover the region around the vascular anastomosis.
and implications of the injury. This process was later complicated by signs of psychological hospitalism, and consequently his mood kept changing between depression and resignation on the one hand and a positive and co-operative approach on the other. As soon as general conditions allowed, physiotherapy and occupational therapy were employed to improve motivation and coping. Further improvements were achieved after it became possible for his mother to stay with him all day long. Rehabilitation progressed using a provisional above-knee prosthesis on the left side and a Thomas splint with a Swiss lock on the right side. This allowed the patient to be mobilized with a walking frame. Local lymphatic drainage techniques were applied daily by a specially trained physiotherapist and compression stockings were used. Eight months after the accident, when all soft tissue damages had completely healed, the sciatic nerve defect was bridged using sciatic nerve graft from the above-knee stump on the left leg. The 20 cm long free nerve graft was divided into four fascicle groups
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 3. The 20 cm long nerve graft was divided into four fascicle groups. Table 2 Progress of sensory and motor function following free sciatic nerve graft from the above-knee-amputated contra-lateral leg.
Hip flexors Hip extensors Hip adductors Hip abductors Hip internal rotators Hip external rotators Knee flexors Knee extensors Foot elevators Foot depressors Sensibility of plantar pedis
1 year + 2 years + 3 months 4 months
4 years + 7 years + 10 months 8 months
M5 M5 M3 M4–5 M3–4 M4–5 M1 M1–2 M0 M0 S0
– M4 M5 M4 M5 M5 M2 M2 – M2–3 S3
– M2–3 M5 M3 M4 M4 M0 M2 – M0 S2
M4 M5 M4 M5 M5 M3 M3 M4 S3
(Figure 3). On the recipient site, the proximal nerve end was resected sufficiently high to reach undamaged viable nerve tissue. This was proofed by histologic examination, including acetylcholine esterase staining of motoric fibers. At the distal end of the sciatic nerve on the recipient site, motoric fibers were localised using electro-stimulation. The nerve anastomoses were performed employing microsurgical peri-neural technique. The post-operative course was unremarkable with continuously progressing Tinel’s sign. The progress of sensitivity and motor function is outlined in Table 2. At the time of our last follow-up 92 months after the accident, the boy had sufficient protective sensitivity in the distribution area of the sciatic nerve. Interestingly, phantom pain at the site of the replanted right leg decreased as the re-innervation of the sciatic nerve progressed and has now completely vanished. In contrast, on the left-hand side, the patient suffers from persistent phantom pain.
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Nine months after the accident, osseous consolidation at the right-hand side replantation site of the femur was sufficient to permit full weight bearing while still using a knee splint. As adherent scars limited the excursion of the right quadriceps muscle, three tissue expanders were implanted 4 weeks later. This allowed all scars to be resected and the damage to be covered using the skin gained. Subsequently, extension of the knee joint improved. However, an increasing varus deformity and anterio-lateral instability of the right knee required a medial subcondylar osteotomy of the right tibia and reconstruction of the right lateral collateral ligament. Two years later varus deformity was still 10° and the proximal tibial osteotomy was repeated with an open wedge technique using iliac crest grafting and internal fixation using Tomofix from a medial approach. Now 7.5 years after the accident, the patient is completely independent and able to walk with two crutches for short distances of 200–300 m (Figure 4). He uses hydraulic above-knee prosthesis on the left, and a brace on the replanted right leg. His passive range of motion is full extension and up to 110° of flexion in the knee joint. However, the active range of motion is reduced (0°/30°/90°). The initially severe osteoporosis in the right leg has completely vanished with load-bearing walking. Although the boy lost 1 year of school, he is socially well rehabilitated at home and school, and is now preparing for his A levels. The overall result of this replantation can be classified as 3 according to the criteria of Chen [4]. The patient himself feels that the replanted right leg is of more functional use to him than the left leg with the above-knee prosthesis.
Discussion Traumatic amputations of the lower extremity are severe and, not infrequently, life-threatening injuries. The decision in favor or against replantation has to be made under extreme time pressure. Any wrong decision is irreversible and will lead to fatal consequences for the patient. Because more muscle mass is involved, the duration of avascularity of the detached part is more critical. Immediate arterial inflow is necessary to prevent or diminish myonekrosis. When replanting a major amputation, arterial inflow should be established first and for a sufficient period of time to purge the amputated part of its toxic metabolites before reestablishing venous outflow. Venous outflow may produce systemic acidosis, hyperkaliemia, and myo-
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Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 4. 7 and a half years after the accident the Patient is able to walk with 2 crutches for short distances. He uses a hydraulic above -knee prosthesis on the left, and a brace on the reimplanted right leg.
globinurie. These by-products of metabolism and cell death may be lead to the Systemic inflammatory response syndrome (SIRS) and multiple organ failure. By improving the standards of polytrauma management (damage control surgery) and using massive transfusion systems, the indication for primary limb salvage under hypovolemic shock conditions is increased. The two most common causes of failure in major limb replantation are myonecrosis with subsequent infection and failure to provide adequate decompression of the restored vessels. In 1987 Krylow [10] saw an indication for replantation at the lower extremity only in the case of clearcut amputations. Extensive bruising, laceration, and severe soft tissue damage at multiple amputation levels were considered as contraindications. Hierner [8] postulated the following contraindications for replantation at the lower extremity: gross contamination, severe soft tissue and bone damage, lesion of the sciatic nerve, extended injuries at multiple levels. The time of cold ischemia should be less than 4– 6 h. Our own experience with macro-replantations at the upper extremity ascertained that the prognosis deteriorates after cold ischemia of 4 h and longer [1].
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Post-trauma leg-length discrepancy at the lower extremity is considered as a minor problem regarding the good results of extremity lengthening [3, 7]. However, in case of bilateral traumatic amputation of lower extremities, any loss of leg length after unilateral replantation can easily be compensated by adjusting the contra-lateral prosthesis. In case of subtotal amputation or complex bone and soft tissue injuries, the Mangled Extremity Severity Score (MESS) according to Johanson & Daines [9] has proven to be a versatile tool in decision making. If this score reaches 7 or higher, a significantly higher complication rate has to be expected [9]. In a series of 23 replantations of upper extremities in our own patients, we had to perform four reamputations. These had an average MESS of 8.25, while the 19 successfully replanted extremities had an MESS of only 6.7. The sequelae of traumatic amputation without replantation are stump complications and phantom pain. For many patients the definitive loss of an extremity is associated with serious psychological problems [8].
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
On the other hand, it is well accepted that the replantation of lower extremity has a certain acute mortality [10, 11]. Nevertheless, it has to be considered that most of the papers dealing with replantation of lower extremities focus on amputations at lower leg level [6, 10, 12]. Extensive interdisciplinary discussion is impossible, and the consent from patients and relatives is hardly to be gained while the patient is either in a shock situation, already anesthetised, or at least under the influence of strong analgesics, and time is very limited because of cold ischemia. The strategic goal of replantation of the lower extremity should be a painfree limb able to bear weight and having at least protective sensibility. Age of the children ranges from 3 to 8 years and follow-up varies between 2 and 17 months. All published replantations have been successful, except for two reported cases [2]. To the best of our knowledge, no case of bilateral above-knee amputation and replantation has been published up to now. In the case reported in this paper, the strategic goal of pain-free extremity, able to bear weight with protective sensibility has been achieved. This required a total of 27 operations, a total of 52 weeks in hospital, and medical and physiotherapy treatment continuing for more than 7 years so far. The function of this leg is far from normal, but we feel that the key point is the patient’s judgement. The replanted leg is still more useful to him than the artificial limb on the other side. We conclude from this case that, in children and adolescents, the high potential for regeneration and adaptation should be considered when deciding for or against replantation in cases of traumatic lower limb amputation. In particular as far as re-innervation is considered, prognostic judgements should be made very cautiously, all therapeutic options must be explored and sufficient time for nerve regeneration should be allowed [5, 13]. It should be noted that it took almost 2.5 years for protective sensibility of the foot sole to return and that there was still neurologic progress detectable between the follow-ups after 4 years + 9 months and 7 years + 8 months.
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
References 1.
Bach O, Friedel R, et al. Mikrovaskuläre Komplikationen nach Replantationen und Revaskularisationen. Handchir Mikrochir Plast Chir 2002;34:363–8. 2. Beris AE, Soucacos PN, et al. Major limb replantation in children. Microsurgery 1994;15:474–8. 3. Betz AM, Stock W, et al. Primary shortening with secondary limb lengthening in amputation or amputation like injuriesof the lower leg with extensive soft tissue loss – a 6 year experience.’’ Microsurg 1993;(14):446–53. 4. Chen ZW, YH. Current procedures in China on replantation of severed limbs and digits. Clin Orthop Relat Res 1987;215:15–23. 5. Datiashvili RO. Simultaneous replantation of both legs in a child: a long-term result. Plast Reconstr Surg 1993;91:541–7. 6. Deutinger M, Girsch W, et al. Successful replantation of the lower leg in a child. Unfallchirurgie 1990;16:302–5. 7. Giebel G, Braun C. Unterschenkelreplantation mit primärer Verkürzung und sekundärer Verlängerung durch Kallusdistraktion. Handchir Mikrochir Plast Chir 1991;(23):174–82. 8. Hierner R, Cedidi C, et al. Zur Standartisierung des therapeutischen Vorgehens bei der Versorgung von Amputations-und amputationsartigen Verletzungen im Unterschenkelbereich das ‘‘integrative Therapiekonzept. Handchir Mikrochir Plast Chir 2002;34:277–91. 9. Johansen K, Daines M, et al. Objective Criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568–73. 10. Krylow VS, Milanow NO, et al. Lower leg replantation in Children: railroad amputation. J Reconstr Microsurg 1987;3:321–26. 11. Masuda K, Usui M, et al. A 17- Year follow - up of replantation of completely amputated leg in a Child: case report. J Reconstr Microsurg 1995;11:89–92. 12. Usui M, Minami M, et al. Successful replantation of an amputated leg in a child. Plast Reconstr Surg 1979;63:613–7. 13. Yaffe B, Borenstein A, et al. Successful replantation of both legs in a child – 5 year followup: case report. J Trauma 1991;31:264– 67.
Address for Correspondence Dr. med. Reinhard Friedel Department of Trauma, Hand, and Reconstructive Surgery Faculty of Medicine University of Jena Erlanger Allee 101 07747 Jena Germany Phone (+49/3641) 9322823, Fax (+49/3643) 9322832 e-mail: [email protected]
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European Journal of Trauma and Emergency Surgery
Above-Knee Replantation Following Traumatic Bilateral Amputation: Sciatic Nerve Transplantation Reinhard Friedel1, Ralf Schmidt1, Torsten Dönicke1, Egbert Hüttemann2, Olaf Bach3, Gunther O. Hofmann1,4
Abstract 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.
Key Words Reconstructive surgery Eur J Trauma Emerg Surg 2007;33:192–7 DOI 10.1007/s00068-006-6008-2
Summary 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 contra-lateral 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 reconstruc-
1
Department of Trauma, Hand and Reconstructive Surgery, Faculty of Medicine, University of Jena, Jena, Germany, Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine University of Jena, Jena, Germany, 3 Grampian University NHS Trust, Orthopaedic Department, Aberdeen Royal Infirmary & Woodend Hospital, Scotland, UK, 4 Department of Trauma and Reconstructive Surgery, Trauma Center Halle, Halle/Saale, Germany. 2
Received: January 16, 2006; revision accepted: June 6, 2006; Published Online: April 4, 2007
192
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 1. A 12-year old boy who was over run by a train, sustaining traumatic bilateral above-knee amputation and a ruptured symphysis.
tion 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.
Case Report A 12-year-old boy was run over by a train resulting in a bilateral proximal above-knee amputation. The rescue team arrived approximately 15 min after being alarmed on the accident side. The boy was very drowsy, not able to talk properly but could open his eyes on pain sensation (Glasgow Coma Scale of 5). Blood loss was significant. Blood pressure 80/40 but very faint, pulse rate 117. Immediate resuscitation was initiated. He received iv lines – volume substitution: 1,000 ml of colloidal and 2500 ml of cristalloidal fluids) – and was intubated and artificially respirated. External bleeding was primarily controlled by manual compression of both iliac arteries and later compression bandages were applied on both lower extremities. Transport was carried out in a rescue helicopter. On arrival the patient was brought directly into the operating theater. The vital signs and some key laboratory findings were blood pressure 80/40, pulse rate 80, temperature 32.6°C, SpO2 100%, Hb 6.5 mmol/l, Ht 0.32, pH 7.116, base excess –16.3. On the left side there was additionally destruction of the lower leg with multiple open fractures and extensive soft tissue damage (Figure 1). Apart from a symphysis rupture, there were no further injuries. Soft tissue and bone damage on the amputation site at the right leg were severe, with bone damage of at least
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
15 cm. Despite a calculated Mangled Extremity Severity Score (very high energy injury, cool and paralyzed legs, persistent hypotension) of 9 (very high energy 4, cool, paralyzed insensate, numb 3, persistent hypotension 2) according to Johansen & Daines [9], the young age of the patient and no additional injuries led our decision to replant the right leg. The operation started 2 h after the accident and was carried out simultaneously by two teams; the first one, led by a pediatric Surgeon, debrided and covered the stump on the left side and harvested vein grafts from the left leg amputate. Simultaneously, the replantation team of the Trauma Center started the replantation of the right leg. After debridement, the fracture site at the femur was cut plane and an osteosynthesis was carried out using an AO/ASIF LC-DCP1. This was followed by reconstructing the femoral artery using long vein grafts harvested from the contra-lateral amputated leg. The sciatic nerve was found to be severely damaged along a length of 20 cm, and repair was not attempted. Four hours after the accident, circulation had been reestablished. After that, soft tissue debridement was completed. Subsequently, the remaining extensor and flexor muscle stumps were approximated. The persisting large soft tissue damage was covered with an instillation vacuum seal using Coldex2 foam and Lavasept 0,2%3 for continuous irrigation. Intra-operatively the patient received 33 erythrocyte concentrates, 20 fresh frozen plasma concentrates, 2 g Hemocompletan4 and 2,000 IU anti-thrombine III. The duration of the replantation was 8 h. Postoperatively the boy was admitted to ICU for mechanical ventilation. He demonstrated cardio-vascular stability under moderate doses of catecholamines, and he was weaned off within a few days. Repeated transfusions were required. At this point, myoglobine levels were peaking extremely high, but there was no clinical manifestation of a crush syndrome. In addition to the usual intensive monitoring and treatment, the patient received medications according to our treatment protocol for replantations (Table 1). Dressings were changed daily under general anesthesia at the ICU and several additional debridements were performed in the operating theater. Such interventions always were followed by a rise of systemic inflammation markers (CRP, procalcitonin) and an increase of body temperature. The microbiologic monitoring of all 1
Low Contact Dynamic Compression Plate (Synthes). Velo Medizinprodukte GmbH. 3 Serag Wiessner/Polyhexanid. 4 Aventis, Behring GmbH Marburg. 2
193
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Table 1. Post-operative treatment protocol for replantations. Heparin
5,000 iE tds/sc
Haes steril 10% Cefuroxim
125 ml qid/iv 1.5 g tds/ i.v.
wounds revealed contamination by Enterococcus, several Bacilli and Pseudomonas aeroginosa. A septic complication became apparent at the site of the vascular femoral anastomosis. In this context the patient developed an epidimitis 10 days after the accident. Surgical exploration revealed a partial necrosis of the cremaster muscle but the testicle itself was intact. Necrectomy and orchidopexy were performed. On day 14 after replantation another debridement was required, during which the entire necrotic sciatic nerve had to be resected over a length of around 20 cm. During the same anesthesia, we covered the infected region around the femoral vascular anastomoses using a free latissmus dorsi-flap harvested from the ipsilateral shoulder (Figure 2). The thoraco-dorsal artery and the veins were connected end-to-side to the vein grafts of the femoral artery and the venous interponate of the replantation procedure. After this session, systemic inflammatory markers rose again (procalcitonin 10.9 ng/ml, CRP 85.6 mg/dl and body temperature rose to 38.8°C). Although implanted into a contaminated site, the microvascular flap healed primarily. Subsequently, local and general signs of infection disappeared. Pain management was achieved by epidural catheter block as part of our replantation protocol, in addition to systemic morphine applications. All catheters were removed and changed during the time of the septic complication at the femoral anastomosis. On day 29 following trauma, ORIF of the femoral fracture in the above-knee stump on the left-hand side was performed using a seven-hole LCDCP titanium plate. The aim was to provide sufficient stability for the application of an above-knee prosthesis as soon as possible to enforce mobilization of the boy. On the right-hand side, significant soft tissue damage lateral to the hip persisted. It was treated by dermato-traction, successive skin grafts, and the local application of somatotropins (GenotropinÒ5). A psychotherapist visited the boy at least once a day beginning with the day of extubation. During the early period after injury, the boy was struggling between successively neglecting and realizing the severity 5
Pfizer Pharma GmbH.
194
Figure 2. Using a free latissimus dorsi flap to cover the region around the vascular anastomosis.
and implications of the injury. This process was later complicated by signs of psychological hospitalism, and consequently his mood kept changing between depression and resignation on the one hand and a positive and co-operative approach on the other. As soon as general conditions allowed, physiotherapy and occupational therapy were employed to improve motivation and coping. Further improvements were achieved after it became possible for his mother to stay with him all day long. Rehabilitation progressed using a provisional above-knee prosthesis on the left side and a Thomas splint with a Swiss lock on the right side. This allowed the patient to be mobilized with a walking frame. Local lymphatic drainage techniques were applied daily by a specially trained physiotherapist and compression stockings were used. Eight months after the accident, when all soft tissue damages had completely healed, the sciatic nerve defect was bridged using sciatic nerve graft from the above-knee stump on the left leg. The 20 cm long free nerve graft was divided into four fascicle groups
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 3. The 20 cm long nerve graft was divided into four fascicle groups. Table 2 Progress of sensory and motor function following free sciatic nerve graft from the above-knee-amputated contra-lateral leg.
Hip flexors Hip extensors Hip adductors Hip abductors Hip internal rotators Hip external rotators Knee flexors Knee extensors Foot elevators Foot depressors Sensibility of plantar pedis
1 year + 2 years + 3 months 4 months
4 years + 7 years + 10 months 8 months
M5 M5 M3 M4–5 M3–4 M4–5 M1 M1–2 M0 M0 S0
– M4 M5 M4 M5 M5 M2 M2 – M2–3 S3
– M2–3 M5 M3 M4 M4 M0 M2 – M0 S2
M4 M5 M4 M5 M5 M3 M3 M4 S3
(Figure 3). On the recipient site, the proximal nerve end was resected sufficiently high to reach undamaged viable nerve tissue. This was proofed by histologic examination, including acetylcholine esterase staining of motoric fibers. At the distal end of the sciatic nerve on the recipient site, motoric fibers were localised using electro-stimulation. The nerve anastomoses were performed employing microsurgical peri-neural technique. The post-operative course was unremarkable with continuously progressing Tinel’s sign. The progress of sensitivity and motor function is outlined in Table 2. At the time of our last follow-up 92 months after the accident, the boy had sufficient protective sensitivity in the distribution area of the sciatic nerve. Interestingly, phantom pain at the site of the replanted right leg decreased as the re-innervation of the sciatic nerve progressed and has now completely vanished. In contrast, on the left-hand side, the patient suffers from persistent phantom pain.
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Nine months after the accident, osseous consolidation at the right-hand side replantation site of the femur was sufficient to permit full weight bearing while still using a knee splint. As adherent scars limited the excursion of the right quadriceps muscle, three tissue expanders were implanted 4 weeks later. This allowed all scars to be resected and the damage to be covered using the skin gained. Subsequently, extension of the knee joint improved. However, an increasing varus deformity and anterio-lateral instability of the right knee required a medial subcondylar osteotomy of the right tibia and reconstruction of the right lateral collateral ligament. Two years later varus deformity was still 10° and the proximal tibial osteotomy was repeated with an open wedge technique using iliac crest grafting and internal fixation using Tomofix from a medial approach. Now 7.5 years after the accident, the patient is completely independent and able to walk with two crutches for short distances of 200–300 m (Figure 4). He uses hydraulic above-knee prosthesis on the left, and a brace on the replanted right leg. His passive range of motion is full extension and up to 110° of flexion in the knee joint. However, the active range of motion is reduced (0°/30°/90°). The initially severe osteoporosis in the right leg has completely vanished with load-bearing walking. Although the boy lost 1 year of school, he is socially well rehabilitated at home and school, and is now preparing for his A levels. The overall result of this replantation can be classified as 3 according to the criteria of Chen [4]. The patient himself feels that the replanted right leg is of more functional use to him than the left leg with the above-knee prosthesis.
Discussion Traumatic amputations of the lower extremity are severe and, not infrequently, life-threatening injuries. The decision in favor or against replantation has to be made under extreme time pressure. Any wrong decision is irreversible and will lead to fatal consequences for the patient. Because more muscle mass is involved, the duration of avascularity of the detached part is more critical. Immediate arterial inflow is necessary to prevent or diminish myonekrosis. When replanting a major amputation, arterial inflow should be established first and for a sufficient period of time to purge the amputated part of its toxic metabolites before reestablishing venous outflow. Venous outflow may produce systemic acidosis, hyperkaliemia, and myo-
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Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
Figure 4. 7 and a half years after the accident the Patient is able to walk with 2 crutches for short distances. He uses a hydraulic above -knee prosthesis on the left, and a brace on the reimplanted right leg.
globinurie. These by-products of metabolism and cell death may be lead to the Systemic inflammatory response syndrome (SIRS) and multiple organ failure. By improving the standards of polytrauma management (damage control surgery) and using massive transfusion systems, the indication for primary limb salvage under hypovolemic shock conditions is increased. The two most common causes of failure in major limb replantation are myonecrosis with subsequent infection and failure to provide adequate decompression of the restored vessels. In 1987 Krylow [10] saw an indication for replantation at the lower extremity only in the case of clearcut amputations. Extensive bruising, laceration, and severe soft tissue damage at multiple amputation levels were considered as contraindications. Hierner [8] postulated the following contraindications for replantation at the lower extremity: gross contamination, severe soft tissue and bone damage, lesion of the sciatic nerve, extended injuries at multiple levels. The time of cold ischemia should be less than 4– 6 h. Our own experience with macro-replantations at the upper extremity ascertained that the prognosis deteriorates after cold ischemia of 4 h and longer [1].
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Post-trauma leg-length discrepancy at the lower extremity is considered as a minor problem regarding the good results of extremity lengthening [3, 7]. However, in case of bilateral traumatic amputation of lower extremities, any loss of leg length after unilateral replantation can easily be compensated by adjusting the contra-lateral prosthesis. In case of subtotal amputation or complex bone and soft tissue injuries, the Mangled Extremity Severity Score (MESS) according to Johanson & Daines [9] has proven to be a versatile tool in decision making. If this score reaches 7 or higher, a significantly higher complication rate has to be expected [9]. In a series of 23 replantations of upper extremities in our own patients, we had to perform four reamputations. These had an average MESS of 8.25, while the 19 successfully replanted extremities had an MESS of only 6.7. The sequelae of traumatic amputation without replantation are stump complications and phantom pain. For many patients the definitive loss of an extremity is associated with serious psychological problems [8].
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Friedel R, et al. Above-Knee Replantation Following Traumatic Bilateral Amputation
On the other hand, it is well accepted that the replantation of lower extremity has a certain acute mortality [10, 11]. Nevertheless, it has to be considered that most of the papers dealing with replantation of lower extremities focus on amputations at lower leg level [6, 10, 12]. Extensive interdisciplinary discussion is impossible, and the consent from patients and relatives is hardly to be gained while the patient is either in a shock situation, already anesthetised, or at least under the influence of strong analgesics, and time is very limited because of cold ischemia. The strategic goal of replantation of the lower extremity should be a painfree limb able to bear weight and having at least protective sensibility. Age of the children ranges from 3 to 8 years and follow-up varies between 2 and 17 months. All published replantations have been successful, except for two reported cases [2]. To the best of our knowledge, no case of bilateral above-knee amputation and replantation has been published up to now. In the case reported in this paper, the strategic goal of pain-free extremity, able to bear weight with protective sensibility has been achieved. This required a total of 27 operations, a total of 52 weeks in hospital, and medical and physiotherapy treatment continuing for more than 7 years so far. The function of this leg is far from normal, but we feel that the key point is the patient’s judgement. The replanted leg is still more useful to him than the artificial limb on the other side. We conclude from this case that, in children and adolescents, the high potential for regeneration and adaptation should be considered when deciding for or against replantation in cases of traumatic lower limb amputation. In particular as far as re-innervation is considered, prognostic judgements should be made very cautiously, all therapeutic options must be explored and sufficient time for nerve regeneration should be allowed [5, 13]. It should be noted that it took almost 2.5 years for protective sensibility of the foot sole to return and that there was still neurologic progress detectable between the follow-ups after 4 years + 9 months and 7 years + 8 months.
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References 1.
Bach O, Friedel R, et al. Mikrovaskuläre Komplikationen nach Replantationen und Revaskularisationen. Handchir Mikrochir Plast Chir 2002;34:363–8. 2. Beris AE, Soucacos PN, et al. Major limb replantation in children. Microsurgery 1994;15:474–8. 3. Betz AM, Stock W, et al. Primary shortening with secondary limb lengthening in amputation or amputation like injuriesof the lower leg with extensive soft tissue loss – a 6 year experience.’’ Microsurg 1993;(14):446–53. 4. Chen ZW, YH. Current procedures in China on replantation of severed limbs and digits. Clin Orthop Relat Res 1987;215:15–23. 5. Datiashvili RO. Simultaneous replantation of both legs in a child: a long-term result. Plast Reconstr Surg 1993;91:541–7. 6. Deutinger M, Girsch W, et al. Successful replantation of the lower leg in a child. Unfallchirurgie 1990;16:302–5. 7. Giebel G, Braun C. Unterschenkelreplantation mit primärer Verkürzung und sekundärer Verlängerung durch Kallusdistraktion. Handchir Mikrochir Plast Chir 1991;(23):174–82. 8. Hierner R, Cedidi C, et al. Zur Standartisierung des therapeutischen Vorgehens bei der Versorgung von Amputations-und amputationsartigen Verletzungen im Unterschenkelbereich das ‘‘integrative Therapiekonzept. Handchir Mikrochir Plast Chir 2002;34:277–91. 9. Johansen K, Daines M, et al. Objective Criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568–73. 10. Krylow VS, Milanow NO, et al. Lower leg replantation in Children: railroad amputation. J Reconstr Microsurg 1987;3:321–26. 11. Masuda K, Usui M, et al. A 17- Year follow - up of replantation of completely amputated leg in a Child: case report. J Reconstr Microsurg 1995;11:89–92. 12. Usui M, Minami M, et al. Successful replantation of an amputated leg in a child. Plast Reconstr Surg 1979;63:613–7. 13. Yaffe B, Borenstein A, et al. Successful replantation of both legs in a child – 5 year followup: case report. J Trauma 1991;31:264– 67.
Address for Correspondence Dr. med. Reinhard Friedel Department of Trauma, Hand, and Reconstructive Surgery Faculty of Medicine University of Jena Erlanger Allee 101 07747 Jena Germany Phone (+49/3641) 9322823, Fax (+49/3643) 9322832 e-mail: [email protected]
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