C. Braun and A. Olinger
STAGED MAJOR LIMB REPLANTATION: A CONCEPT TO MINIMIZE THE RISK REPLANTATION OF Downloaded by: Universite Laval. Copyrighted material.
THE LOWER EXTREMITY ABSTRACT The replantation of large limb segments presents two major problems: first, a general danger to survival because of major accompanying injuries and additional ischemia-reperfusion injury; second, local softtissue damage at the amputation site. Successful replantation can be compromised by infection, vessel thrombosis, and disturbed bone healing. Possible risk reduction may be accomplished by the concept of a two-staged replantation. A brief primary emergency procedure involving bone resection, osteosynthesis, and revascularization (with the goal of limb survival) is followed by a second procedure within 72 hr after trauma, for final debridement, completing the osteosynthesis, nerve and tendon suturing, and soft-tissue coverage by free flaps. The advantages of the double procedure are demonstrated in 27 patients by comparison of two treatment groups. Group 1 comprised 15 patients with definitive primary care. In Group 2 (n = 12), the two-stage operation was performed. The second group showed a shorter duration of overall treatment, reduction of blood loss, and fewer infections.
In contrast to the upper extremity, indications for replantation of the lower extremity are controversial. The expense, risks, and functional results of lowerextremity replantation have to be compared with the relative simplicity of prosthetic use and care, and generally acceptable results. In the majority of cases, therefore, amputation has been proposed, even for below-knee compound fractures with vascular injury. The criteria for amputation are still under discussion.1-6 Replantation statistics in the literature cover only a small number of cases.7-10 In the present study, the authors propose a concept to minimize the risks of systemic and local complications after replantation of the lower extremity, with the possibility of widening the spectrum of indications. Patients between 1976 and 1990 included 27 major
limb replantations at the lower extremity, i.e., with separation above the ankle joint. Near total amputations were characterized as those with no more than one-quarter of the cross section of soft-tissue cover maintained by a major blood vessel—11 cases in this study. These cases involved mostly blunt trauma, including five who were run over by a train. Sixty percent of the patients suffered several other major injuries at the time of the accident, and were regarded as multiply injured. Group 1 patients comprised 15 limb replantations between 1976 and 1985. During the primary operation, a definitive management was attempted. This required operations of longer duration with prolonged blood loss. Routine secondary procedures were not performed. In 12 patients operated on between 1986 and 185
Department of Trauma Surgery, The University of Saarland Medical School, Homburg/Saar, Germany Reprint requests: Drs. Braun or Olinger, Chirurgische Universitaetsklinik, Abteilung Unfallchirurgie, Oskar-Orth-Strasse, D-6650 Homburg/Saar, Germany Accepted for publication January 2, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
MAY 1992
after major limb replantation, especially when there are substantial accompanying injuries. After an amputation at the lower extremity, 60 percent of the patients had considerable additional injuries, in contrast to 20 percent of upper extremity amputations (Fig. 2). In addition, tissue damage and a reperfused ischemic extremity are both major sources for the initiation of traumatic shock. These are triggers for generalized vascular endothelial damage, with possible consequences of ARDS and multiple organ failure.1'-13 Ischemia time of over 4 to 6 hr, except in very distal amputations should not be exceeded. The more proximal the level of amputation, the greater the systemic effect of reperfuRESULTS (Fig, 1) sion. Replantation of separations proximal to the knee For the patients in Group I, replantations lasted joint are therefore to be viewed very critically. Among an average of 5.6 hr and required 6.5 units of preserved four above-knee replantations not included in the preblood. There were seven reoperations necessary due to sented series, we had one mortality. Since our early complications or for secondary soft-tissue transfer. experience, above-knee replantations are no longer Chronic deep infections complicated the course in performed in our clinic. nine of the 15 patients. In Group 2, the operation time By restricting the primary operative procedure, for replantations averaged 3.5 hr, and required about 4 the danger of generalized risk for the multiply injured units of preserved blood. There were four reoperations patient with amputation of large lower-limb segments per patient on average, which included a planned sec- can be reduced (Fig. 3). Osteosynthesis and soft-tissue ond procedure in all the cases and elongation osteo- debridement should be limited to whatever is absotomy in five cases. Significant complications occurred lutely necessary and appropriate to the situation. in only two cases: a single reamputation in this group Large-scale bone shortening solves the first problem became necessary on the first postoperative day for a of soft-tissue coverage and facilitates vascular anastocontinuing ischemia of a badly damaged amputated mosis. A relatively short primary operation should lead part. The only infection occurred at the site of a plate the patient as soon as possible to optimal treatment in for osteosynthesis, and was managed by debridement an intensive care unit. The principle of reduced primary operative care results in a significantly shorter during removal of the plate. operation in our series. The aim of the primary operation is the preservation of the extremity. DISCUSSION Following stabilization of the patient's general condition and after 24 to 72 hr, a routine second proceIn replantations of large limb segments, two prob- dure is due. Under elective conditions, with stable lems must be considered: 1) a general systemic risk circulation and intact blood clotting, extensive softthreatening survival; and 2) local soft-tissue damage tissue debridement can now be performed. At this at the site of amputation. A patient is at general risk time also, a final decision about tissue viability can be made. After extensive debridement, there are exten-
186
Duration prim.op. (hours)
Units of pres.blood at prim.op.
Second look
Re-op.
1976 - 85 n= 15
5.6
6.5
0
6.9
4
9
1986 - 90 n = 12
3.5
4
11
4.5
1
1
Reamputation
Infection
Figure 1. Treated populations and results using two different regimens after major replantation at the lower extremity.
Downloaded by: Universite Laval. Copyrighted material.
1990 (Group 2), the concept of a "restricted" primary operation was followed, i.e., osteosynthesis after largescale bone shortening (in one case of 11 cm), debridement, and vascular anastomoses done as a relatively brief procedure. In all these patients, a second operation followed within 24 to 72 hr, with more extensive debridement, nerve suturing, eventual completion of the osteosynthesis with external fixation and, in eight cases, with transfer of a muscle flap for soft-tissue reconstruction.
Downloaded by: Universite Laval. Copyrighted material.
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
Figure 2. Case 1: G.V., a 45-year-old male, run over by a train. A, Near total amputation of the right lower leg. Accompanying injuries included a femur fracture on the opposite side and pelvic fracture. B, Before second operation. C, After secondary tissue transfer. D, E, F, With 7-cm limb shortening. (Figure continued on next page)
187
MAY 1992
Downloaded by: Universite Laval. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
Figure 2, cont. callus distraction.
188
G, After 6-cm bone lengthening by
sive defects, with bone, vessels, and nerves exposed (Fig. 4). The debridement of necrotic tissue and sufficient coverage of injured bone, vessels, and nerves aid in a positive prognosis. 21415 In our management, indications for microsurgical soft-tissue transfer are wide. Bone stabilization is now completed with external fixators, used primarily in eight of 12 cases, in addition to
plates. Necessary nerve reconstruction also can be performed at this point. Debridement of the nerves during the second procedure is safer than when done primarily. Contused segments and possibly damaged fascicles can be identified by swelling and hematoma between the fascicles. We have found that perceptible nerve damage is much more extensive in the ampu-
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
bone shortening reduced primary operation
soft tissue debridement osteosynthesis
limb survival
revascularisation
final debridement routine second look
=
soft tissue transfer repair of functional structures
functional recovery
tated part than in the stump, and at the primary operation, the amount of damage is not always readily visible. In all cases, due to bone shortening, nerve suturing without nerve transfer was possible. The aim of the secondary operation is soft-tissue coverage and reconstruction of important functional structures. The problem of local tissue damage is also minimized through the two-stage operation. Obviously necrotic tissues are first excised to reduce local contam-
Figure 4. Case 2: M.K., a 32-year-old male with belowknee amputation. A, Large defect after secondary debridement. B, Lengthening procedure by callus distraction; osteotomy in the replanted part.
Downloaded by: Universite Laval. Copyrighted material.
Figure 3. Schematic of staged replantation procedure.
ination and the release of mediators for activation of granulocytes." Secondary necrosis should be expected, especially in lower-extremity amputations with blunt amputation causes.7 For this reason alone, a second operation for final debridement is indicated.15 After extensive secondary debridement, a wide set of indications for free-flap transfer should be considered. A further solution to sufficient soft-tissue coverage is sufficient bone shortening: vascular anastomo-
B 189
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
of replantation at the lower extremity can be calculated. So with the two-stage replantation—a restricted primary operation for extremity preservation and a second procedure for soft-tissue and functional reconstruction under elective conditions—operative stress and danger to the frequently multiply injured patient is reduced. Through replantation of the lower extremity, a functional gain can be achieved, compared to a prosthesis. Apart from problems with seating a prosthesis, the energy cost to a patient with a below-knee prosthesis is considerable.19 An estimate of the reduction in
Downloaded by: Universite Laval. Copyrighted material.
sis will be easier, and interposition grafts shorter or unnecessary. Furthermore, even severely shortened extremities can be functionally useful. With the possibility of secondary elongation, e.g., using the method of callus distraction, significant shortening is not really a contraindication to replantation (Fig. 5).1617 The current maximal 5-cm limit of shortening 71018 for obtaining a meaningful function can certainly be substantially exceeded. To elongate without problems, however, good soft-tissue coverage is of foremost importance. By critical selection and consequent management, the risk
MAY 1992
Figure 5. Case 3: B.H., a 36year-old male, with clean cut by rotary saw. A, Lower leg amputation. (Figure continued on next page) 190
Downloaded by: Universite Laval. Copyrighted material.
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
Figure 5, cont. B, Before second operation; 8-cm bone shortening. C, After secondary tissue transfer. (Figure continued on next page)
191
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
MAY 1992
gainful employment after a below-knee replantation, compared to a below-knee amputation, is on average 10 percent less.
Figure 5, cont.
192
D, After 6-cm lengthening.
1. Bondurant FJ, Cotler HB, Buckle R, et al: The medical and economic impact of severely injured lower extremities: Primary vs. delayed lower extremity amputation. ) Trauma 28:1270, 1988 2. Caudle RJ, Stern PJ: Severe open fractures of the tibia. ) Bone Joint Surg69A:801, 1987 3. Hansen ST Jr: Editorial: The type III-C tibial fracture: Salvage or amputation? J Bone Joint Surg 69A:799, 1987 4. Heatley FW: Severe open fractures of the tibia: The courage to amputate. Br Med J 296:229, 1988 5. Herve C, Gaillard M, Anrivet P, et al: Treatment in serious lower limb injuries: Amputation versus preservation. Injury 18:21, 1987 6 Lange RH, Bach AW, Hansen ST Jr, Johansen KH: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage J Trauma 25:203, 1985 7. Biemer E, Stock W, Duspiva W: Replantationen an der unteren Extremitaet. Chirurgie 54:361, 1983 8. Colen SR, Somita MC: Salvage replantation. Clin Plast Surg 10:125, 1983 9. Jupiter JB, Tsai TM, Kleinert H: Salvage replantation of lower limb. Plast Reconstr Surg 69:1, 1982 10. Tamai S, Horii Y, Tatzumi Y, et al.: Major limb, hand, and digital replantation. World J Surg 3:17, 1979 11 Morganroth ML, Till GO, Kunkel RG, Ward AP: Complement and neutrophil-mediated injury of perfused rat lungs. Lab Invest 54:507, 1986 12 Parks DA, Bulkley GB, Granger DN: Role of oxygen free radicals in shock, ischemia and organ preservation. Surgery 94:428, 1983 13 Warren JS, Ward PA: Review: Oxidative injury to the vascular endothelium. Am J Med Sci 2:97, 1986 14 Byrd HS, Spicer TE, Cierney G: Management of open tibial fractures. Plast Reconstr Surg 76:719, 1985 15. Urbaniak JR: Replantation. In Green DP (ed): Operative Hand Surgery. New York: Churchill Livingstone, 1982 16 Giebel G: Extremitaeten-Verlaengerung und die Behandlung von Segmentdefekten durch Callusdistraktion. Chirurgie 58:601, 1987 17. Peyran PL: The Ilizarov procedure: Revolution or evolution in treatment by external fixation. Chirurgie 112:73, 1986 18 Seiler H, Braun C, Op den Winkel R, Zwank L: Makro- und Mikroreplantationen an Unterschenkel und Fuss. Langenbecks Arch Chir 369:625, 1986 19. Waters RL, Perry J, Antonelli D, Hislop H: Energy cost of walking on amputees: The influence of level of amputation. J Bone Joint Surg 58A:46, 1976
Downloaded by: Universite Laval. Copyrighted material.
REFERENCES
STAGED MAJOR LIMB REPLANTATION: A CONCEPT TO MINIMIZE THE RISK REPLANTATION OF Downloaded by: Universite Laval. Copyrighted material.
THE LOWER EXTREMITY ABSTRACT The replantation of large limb segments presents two major problems: first, a general danger to survival because of major accompanying injuries and additional ischemia-reperfusion injury; second, local softtissue damage at the amputation site. Successful replantation can be compromised by infection, vessel thrombosis, and disturbed bone healing. Possible risk reduction may be accomplished by the concept of a two-staged replantation. A brief primary emergency procedure involving bone resection, osteosynthesis, and revascularization (with the goal of limb survival) is followed by a second procedure within 72 hr after trauma, for final debridement, completing the osteosynthesis, nerve and tendon suturing, and soft-tissue coverage by free flaps. The advantages of the double procedure are demonstrated in 27 patients by comparison of two treatment groups. Group 1 comprised 15 patients with definitive primary care. In Group 2 (n = 12), the two-stage operation was performed. The second group showed a shorter duration of overall treatment, reduction of blood loss, and fewer infections.
In contrast to the upper extremity, indications for replantation of the lower extremity are controversial. The expense, risks, and functional results of lowerextremity replantation have to be compared with the relative simplicity of prosthetic use and care, and generally acceptable results. In the majority of cases, therefore, amputation has been proposed, even for below-knee compound fractures with vascular injury. The criteria for amputation are still under discussion.1-6 Replantation statistics in the literature cover only a small number of cases.7-10 In the present study, the authors propose a concept to minimize the risks of systemic and local complications after replantation of the lower extremity, with the possibility of widening the spectrum of indications. Patients between 1976 and 1990 included 27 major
limb replantations at the lower extremity, i.e., with separation above the ankle joint. Near total amputations were characterized as those with no more than one-quarter of the cross section of soft-tissue cover maintained by a major blood vessel—11 cases in this study. These cases involved mostly blunt trauma, including five who were run over by a train. Sixty percent of the patients suffered several other major injuries at the time of the accident, and were regarded as multiply injured. Group 1 patients comprised 15 limb replantations between 1976 and 1985. During the primary operation, a definitive management was attempted. This required operations of longer duration with prolonged blood loss. Routine secondary procedures were not performed. In 12 patients operated on between 1986 and 185
Department of Trauma Surgery, The University of Saarland Medical School, Homburg/Saar, Germany Reprint requests: Drs. Braun or Olinger, Chirurgische Universitaetsklinik, Abteilung Unfallchirurgie, Oskar-Orth-Strasse, D-6650 Homburg/Saar, Germany Accepted for publication January 2, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
MAY 1992
after major limb replantation, especially when there are substantial accompanying injuries. After an amputation at the lower extremity, 60 percent of the patients had considerable additional injuries, in contrast to 20 percent of upper extremity amputations (Fig. 2). In addition, tissue damage and a reperfused ischemic extremity are both major sources for the initiation of traumatic shock. These are triggers for generalized vascular endothelial damage, with possible consequences of ARDS and multiple organ failure.1'-13 Ischemia time of over 4 to 6 hr, except in very distal amputations should not be exceeded. The more proximal the level of amputation, the greater the systemic effect of reperfuRESULTS (Fig, 1) sion. Replantation of separations proximal to the knee For the patients in Group I, replantations lasted joint are therefore to be viewed very critically. Among an average of 5.6 hr and required 6.5 units of preserved four above-knee replantations not included in the preblood. There were seven reoperations necessary due to sented series, we had one mortality. Since our early complications or for secondary soft-tissue transfer. experience, above-knee replantations are no longer Chronic deep infections complicated the course in performed in our clinic. nine of the 15 patients. In Group 2, the operation time By restricting the primary operative procedure, for replantations averaged 3.5 hr, and required about 4 the danger of generalized risk for the multiply injured units of preserved blood. There were four reoperations patient with amputation of large lower-limb segments per patient on average, which included a planned sec- can be reduced (Fig. 3). Osteosynthesis and soft-tissue ond procedure in all the cases and elongation osteo- debridement should be limited to whatever is absotomy in five cases. Significant complications occurred lutely necessary and appropriate to the situation. in only two cases: a single reamputation in this group Large-scale bone shortening solves the first problem became necessary on the first postoperative day for a of soft-tissue coverage and facilitates vascular anastocontinuing ischemia of a badly damaged amputated mosis. A relatively short primary operation should lead part. The only infection occurred at the site of a plate the patient as soon as possible to optimal treatment in for osteosynthesis, and was managed by debridement an intensive care unit. The principle of reduced primary operative care results in a significantly shorter during removal of the plate. operation in our series. The aim of the primary operation is the preservation of the extremity. DISCUSSION Following stabilization of the patient's general condition and after 24 to 72 hr, a routine second proceIn replantations of large limb segments, two prob- dure is due. Under elective conditions, with stable lems must be considered: 1) a general systemic risk circulation and intact blood clotting, extensive softthreatening survival; and 2) local soft-tissue damage tissue debridement can now be performed. At this at the site of amputation. A patient is at general risk time also, a final decision about tissue viability can be made. After extensive debridement, there are exten-
186
Duration prim.op. (hours)
Units of pres.blood at prim.op.
Second look
Re-op.
1976 - 85 n= 15
5.6
6.5
0
6.9
4
9
1986 - 90 n = 12
3.5
4
11
4.5
1
1
Reamputation
Infection
Figure 1. Treated populations and results using two different regimens after major replantation at the lower extremity.
Downloaded by: Universite Laval. Copyrighted material.
1990 (Group 2), the concept of a "restricted" primary operation was followed, i.e., osteosynthesis after largescale bone shortening (in one case of 11 cm), debridement, and vascular anastomoses done as a relatively brief procedure. In all these patients, a second operation followed within 24 to 72 hr, with more extensive debridement, nerve suturing, eventual completion of the osteosynthesis with external fixation and, in eight cases, with transfer of a muscle flap for soft-tissue reconstruction.
Downloaded by: Universite Laval. Copyrighted material.
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
Figure 2. Case 1: G.V., a 45-year-old male, run over by a train. A, Near total amputation of the right lower leg. Accompanying injuries included a femur fracture on the opposite side and pelvic fracture. B, Before second operation. C, After secondary tissue transfer. D, E, F, With 7-cm limb shortening. (Figure continued on next page)
187
MAY 1992
Downloaded by: Universite Laval. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
Figure 2, cont. callus distraction.
188
G, After 6-cm bone lengthening by
sive defects, with bone, vessels, and nerves exposed (Fig. 4). The debridement of necrotic tissue and sufficient coverage of injured bone, vessels, and nerves aid in a positive prognosis. 21415 In our management, indications for microsurgical soft-tissue transfer are wide. Bone stabilization is now completed with external fixators, used primarily in eight of 12 cases, in addition to
plates. Necessary nerve reconstruction also can be performed at this point. Debridement of the nerves during the second procedure is safer than when done primarily. Contused segments and possibly damaged fascicles can be identified by swelling and hematoma between the fascicles. We have found that perceptible nerve damage is much more extensive in the ampu-
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
bone shortening reduced primary operation
soft tissue debridement osteosynthesis
limb survival
revascularisation
final debridement routine second look
=
soft tissue transfer repair of functional structures
functional recovery
tated part than in the stump, and at the primary operation, the amount of damage is not always readily visible. In all cases, due to bone shortening, nerve suturing without nerve transfer was possible. The aim of the secondary operation is soft-tissue coverage and reconstruction of important functional structures. The problem of local tissue damage is also minimized through the two-stage operation. Obviously necrotic tissues are first excised to reduce local contam-
Figure 4. Case 2: M.K., a 32-year-old male with belowknee amputation. A, Large defect after secondary debridement. B, Lengthening procedure by callus distraction; osteotomy in the replanted part.
Downloaded by: Universite Laval. Copyrighted material.
Figure 3. Schematic of staged replantation procedure.
ination and the release of mediators for activation of granulocytes." Secondary necrosis should be expected, especially in lower-extremity amputations with blunt amputation causes.7 For this reason alone, a second operation for final debridement is indicated.15 After extensive secondary debridement, a wide set of indications for free-flap transfer should be considered. A further solution to sufficient soft-tissue coverage is sufficient bone shortening: vascular anastomo-
B 189
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
of replantation at the lower extremity can be calculated. So with the two-stage replantation—a restricted primary operation for extremity preservation and a second procedure for soft-tissue and functional reconstruction under elective conditions—operative stress and danger to the frequently multiply injured patient is reduced. Through replantation of the lower extremity, a functional gain can be achieved, compared to a prosthesis. Apart from problems with seating a prosthesis, the energy cost to a patient with a below-knee prosthesis is considerable.19 An estimate of the reduction in
Downloaded by: Universite Laval. Copyrighted material.
sis will be easier, and interposition grafts shorter or unnecessary. Furthermore, even severely shortened extremities can be functionally useful. With the possibility of secondary elongation, e.g., using the method of callus distraction, significant shortening is not really a contraindication to replantation (Fig. 5).1617 The current maximal 5-cm limit of shortening 71018 for obtaining a meaningful function can certainly be substantially exceeded. To elongate without problems, however, good soft-tissue coverage is of foremost importance. By critical selection and consequent management, the risk
MAY 1992
Figure 5. Case 3: B.H., a 36year-old male, with clean cut by rotary saw. A, Lower leg amputation. (Figure continued on next page) 190
Downloaded by: Universite Laval. Copyrighted material.
STAGED MAJOR LIMB REPLANTATION/BRAUN, OLINGER
Figure 5, cont. B, Before second operation; 8-cm bone shortening. C, After secondary tissue transfer. (Figure continued on next page)
191
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
MAY 1992
gainful employment after a below-knee replantation, compared to a below-knee amputation, is on average 10 percent less.
Figure 5, cont.
192
D, After 6-cm lengthening.
1. Bondurant FJ, Cotler HB, Buckle R, et al: The medical and economic impact of severely injured lower extremities: Primary vs. delayed lower extremity amputation. ) Trauma 28:1270, 1988 2. Caudle RJ, Stern PJ: Severe open fractures of the tibia. ) Bone Joint Surg69A:801, 1987 3. Hansen ST Jr: Editorial: The type III-C tibial fracture: Salvage or amputation? J Bone Joint Surg 69A:799, 1987 4. Heatley FW: Severe open fractures of the tibia: The courage to amputate. Br Med J 296:229, 1988 5. Herve C, Gaillard M, Anrivet P, et al: Treatment in serious lower limb injuries: Amputation versus preservation. Injury 18:21, 1987 6 Lange RH, Bach AW, Hansen ST Jr, Johansen KH: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage J Trauma 25:203, 1985 7. Biemer E, Stock W, Duspiva W: Replantationen an der unteren Extremitaet. Chirurgie 54:361, 1983 8. Colen SR, Somita MC: Salvage replantation. Clin Plast Surg 10:125, 1983 9. Jupiter JB, Tsai TM, Kleinert H: Salvage replantation of lower limb. Plast Reconstr Surg 69:1, 1982 10. Tamai S, Horii Y, Tatzumi Y, et al.: Major limb, hand, and digital replantation. World J Surg 3:17, 1979 11 Morganroth ML, Till GO, Kunkel RG, Ward AP: Complement and neutrophil-mediated injury of perfused rat lungs. Lab Invest 54:507, 1986 12 Parks DA, Bulkley GB, Granger DN: Role of oxygen free radicals in shock, ischemia and organ preservation. Surgery 94:428, 1983 13 Warren JS, Ward PA: Review: Oxidative injury to the vascular endothelium. Am J Med Sci 2:97, 1986 14 Byrd HS, Spicer TE, Cierney G: Management of open tibial fractures. Plast Reconstr Surg 76:719, 1985 15. Urbaniak JR: Replantation. In Green DP (ed): Operative Hand Surgery. New York: Churchill Livingstone, 1982 16 Giebel G: Extremitaeten-Verlaengerung und die Behandlung von Segmentdefekten durch Callusdistraktion. Chirurgie 58:601, 1987 17. Peyran PL: The Ilizarov procedure: Revolution or evolution in treatment by external fixation. Chirurgie 112:73, 1986 18 Seiler H, Braun C, Op den Winkel R, Zwank L: Makro- und Mikroreplantationen an Unterschenkel und Fuss. Langenbecks Arch Chir 369:625, 1986 19. Waters RL, Perry J, Antonelli D, Hislop H: Energy cost of walking on amputees: The influence of level of amputation. J Bone Joint Surg 58A:46, 1976
Downloaded by: Universite Laval. Copyrighted material.
REFERENCES
