Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.     

Thumb replantation after cardiac transplantation

Generally, severe medical illnesses, including chronic immunosuppression and heavy steroid use, have been deemed relative contraindications for replantation surgery. We report the successful replantation of an amputated thumb in a patient who had previously undergone heart transplantation and was on therapeutic immunosuppression. Despite extensive soft-tissue damage and joint involvement, thumb function and sensibility returned to acceptable levels. This case demonstrates that digital bony union, tendon repair healing, and nerve regeneration are not significantly altered by the standard immunosuppressive regimen following major organ transplant. The implications raised by this case for possible transplantation of allograft digits or limbs are discussed in detail.     

Alternatives to thumb replantation

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Have a variety of options for thumb reconstruction. 2. Know the advantages and disadvantages of the nonmicrosurgical and microsurgical techniques for thumb reconstruction. 3. Understand the decision making from the variety of thumb reconstruction techniques based on patient needs. 4. Have a basic understanding of the various thumb reconstruction techniques discussed. The traumatic amputation of the thumb is an absolute indication for attempted replantation. The profound disability of the hand resulting from absence of the thumb, with loss of pinch and grasp, obliges the surgeon to make every attempt to replant the amputated thumb and preserve hand function. However, not all attempts at replantation result in survival of the amputated portion, and unreconstructable damage to or complete loss of the amputated part may preclude attempted replantation. In such situations, the surgeon must have alternative methods of dealing with the sequelae of thumb loss. This article will discuss nonmicrosurgical and microsurgical techniques for thumb reconstruction.     

A new strategy of fingertip reattachment: sequential use of microsurgical technique and pocketing of composite graft

Many methods have been used to reattach amputated fingertips. Of these methods, microsurgery has been accepted as the procedure of choice because the defining characteristic of a microsurgically replanted finger is that its surival in the recipient bed is predicated on functioning intravascular circulation. Although considerable progress has been made in the techniques for microvascular replantation of amputated fingers, the replantation of an amputated fingertip is difficult because digital arteries branch into small arteries. This is in addition to digital veins that run from both sides of the nail bed to the median dorsal sides, which are difficult to separate from the immobile soft tissue. Furthermore, even with the most technically skilled microsurgeon, replantation failure often occurs, especially in severe injury cases. Therefore, the technique is not the only protection against failure, and a new strategy of fingertip reattachment is needed. From March of 1997 to December of 1999, 12 fingers of 11 patients with zone 1 or zone 2 fingertip amputations that were reattached microsurgically but were compromised were deepithelialized, reattached, and then inserted into the abdominal pocket. All had been complete amputations with crushing injuries. Approximately 3 weeks later, the fingers were depocketed and covered with a skin graft. Of the 12 fingers, 7 survived completely and 3 had partial necrosis on less than one-third the volume of the amputated part. The complete survival rate was approximately 58 percent. The results of the above 10 fingers were satisfactory from both functional and cosmetic aspects. The authors believe that this high success rate was achieved because the deepithelialized finger pulp was placed in direct contact with the deep abdominal fascia, which was equipped with plentiful vascularity, not subcutaneous fat. In addition, the pocketing was performed promptly before necrosis of the compromised fingertip occurred. From the results of this study, it is clear that this new method is useful and can raise the survival rate of an amputated fingertip.     

Microsurgical replantation of the amputated nose

A case of successful replantation of the nose is presented. Two arteries and one vein were anastomosed, providing a stable framework for direct revascularization of the amputated nasal segment. This resulted in complete survival of the nose, with an excellent aesthetic result. However, despite successful microsurgical arterial and venous repair, significant postoperative blood loss still occurred as a result of anticoagulation. In cases of the amputation of specialized structures, the improved functional and cosmetic result obtained with replantation must be weighed against the risk of blood-borne disease transmission when postoperative transfusion is required. Recognizing the potential need for postoperative transfusion in these cases is important in allowing the surgeon to exercise appropriate judgment in deciding whether replantation should be performed.     

Replantation of fingertip amputation by using the pocket principle in adults

There are several treatment modalities for zone 1 or zone 2 fingertip amputations that cannot be replanted by using microsurgical techniques, such as delayed secondary healing, stump revision, skin graft, local flaps, distant flaps, and composite graft. Among these, composite graft of the amputated digit tip is the only possible means of achieving a full-length digit with a normal nail complex. The pocket principle can provide an extra blood supply for survival of the composite graft of the amputated finger by enlarging the area of vascular contact. The surgery was performed in two stages. The amputated digit was debrided, deepithelialized, and reattached to the proximal stump. The reattached finger was inserted into the abdominal pocket. About 3 weeks later, the finger was removed from the pocket and covered with a skin graft. We have consecutively replanted 29 fingers in 25 adult patients with fingertip amputations by using the pocket principle. All were complete amputations with crushing or avulsion injuries. Average age was 33.64 years, and men were predominant. The right hand, the dominant one, was more frequently injured, with the middle finger being the most commonly injured. Of the 29 fingers, 16 (55.2 percent) survived completely and 10 (34.5 percent) had partial necrosis less than one-quarter of the length of the amputated part. The results of the above 26 fingers were satisfactory from both functional and cosmetic aspects. Twenty of the 29 fingers, which had been followed up for more than 6 months (an average of 16 months), were included in a sensory evaluation. Fifteen of these 20 fingers (75 percent) were classified as "good" (static two-point discrimination of less than 8 mm and normal use). From the overall results and our experience, we suggest that the pocket principle is a safe and valuable method in replantation of zone 1 or zone 2 fingertip amputation, an alternative to microvascular replantation, even in adults.     

Microvascular surgery in young children.

We present a series of 8 children, all less than 6 years of age, which demonstrates the feasibility of primary microvascular replantation or reconstruction of amputated or devascularized parts in children. The function and the appearance obtained were excellent, and the potential for growth was maintained. Fortunately, the vessels were larger in these young children than one would expect. It is apparent that in a healthy, stable child, the careful application of microsurgical principles is an excellent method for salvaging devascularized or amputated parts that are vital for function or appearance.     

CONSERVATIVE AMPUTATION IN ARTERIOSCLEROSIS OBLITERANS

Sixty-three toe and leg amputations in patients with arteriosclerosis obliterans were reviewed in an attempt to determine how often and under what conditions a toe or leg amputation gave satisfactory results, and when transmetatarsal amputation might better have been considered. In many cases in which toes were amputated, it was necessary later to amputate the leg or the thigh because of improper healing or spread of infection. Transmetatarsal amputations apparently heal frequently in carefully selected cases and permit better function in the foot than do toe amputations. Successful use of a prosthesis is not obtained in many cases after leg amputation. When this difficulty is anticipated transmetatarsal rather than leg amputation should be attempted, if other conditions warrant, since prosthesis is not necessary after transmetatarsal amputation.     

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.     

Replantation of the testis by microsurgical technique

Microsurgical replantation of amputated testes were performed in two patients. Both were caused by trauma to the genitoperineal regions. These reconstructed testes are viable and not atrophic grossly. The patients are satisfied with these operations.     

Running-specific prostheses reduce lower-limb muscle activity compared to daily-use prostheses in people with unilateral transtibial amputations

People with unilateral transtibial amputation (TTA) have biomechanical differences between the amputated and intact legs and compared to people without TTA during running. Additional biomechanical differences emerge between running with running-specific (RSPs) and daily-use prostheses (DUPs), but the associated underlying muscle activity is unclear. We collected surface electromyography from the biceps femoris long head, rectus femoris, vastus lateralis, and gastrocnemius as well as body kinematics and ground reaction forces in six people with and six people without TTA. We compared stance phase muscle activity and peak activation timing in people with and without TTA and between people using RSPs compared to DUPs during running at 3.5 m/s. Peak amputated leg hamstring activity occurred 34% (RSP) and 31% (DUP) earlier in stance phase compared to the intact leg. Peak amputated leg rectus femoris activity of people wearing DUPs occurred 8% and 9% later in stance phase than the intact leg of people wearing DUPs and amputated leg of people wearing RSPs, respectively. People with TTA had 45% (DUP) and 61% (RSP) smaller peak amputated leg knee extension moments compared to people without TTA, consistent with observations of quadriceps muscle activity. Using RSPs decreased overall muscle activity compared to DUPs.     

低分子肝素钙对小血管损伤术后血液流变学影响的临床研究

目的：观察应用低分子肝素钙如何提高断指再植成活率的作用机制,为临床更好的应用低分子肝素钙提供理论基础。方法：通过临床随机对照试验设计,以30例断指再植患者为研究对象,30例健康成人为参照对象。观察30例断指再植患者术前术后不同时段血液流变学指标的变化。结果：断指患者受伤至术后72h血液流变学指标均明显升高,与对照组比较有显著差异（P〈0.01）。低分子肝素钙可以显著降低断指再植患者的血液粘度,改善血液不利于断指成活状态,提高断指成活率,降低其坏死率、致残率。结论：低分子肝素钙,毒副作用小,为防治断指再植术后并发症的一种良药,为临床断指成功再植提供了一种较为理想的治疗方法。     

Seven-digit replantation: digit survival after 39 hours of cold ischemia

A patient who has undergone successful replantation of seven of eight amputated digits is presented. Survival in the last viable digit was seen 39 hours after amputation with cold ischemia preservation. No graded ischemia-related changes in the digits have been appreciated over 35 months of follow-up.     

Successful replantation of lower leg and foot, with good sensibility and function.

The successful replantation of the lower part of a leg with the foot is reported in a 17-year-old boy. Adequate protective sensibility was obtained, and he walks well with a 3-inch lift on that shoe. He is also able to hike, climb, swim, dive, and engage in most normal activities. The pros and cons of leg replantation are considered.     

中华真地鳖的断足再生

报道了中华真地鳖Eupolyphaga sinensis Walker的断足再生特征。研究结果表明,不同虫龄期的若虫都有断足再生能力;足的不同部位断足后均能再生;断掉不同数量的足后,只要能成活均可再生。断足再生后,继续断掉再生足的原位或其他部位也可以再生。再生足的跗节均比正常的少一节,具有再生不完整性。断足后,只要经1～2次蜕皮,均可再生。断掉一对足的腿节后,再生足出现大小不一的现象,小的一般发育不全,断足数量多容易出现再生足发育不全。再生足比正常足要小,但生长速度要快,断掉足的腿节或跗节后的再生足经过2次蜕皮后基本可恢复到正常足大小。     

Dynamic balance during running using running-specific prostheses

Running is beneficial for physical, social, and emotional health, and participating in physical activity, including running, is becoming more popular for people with an amputation. However, this population has a greater risk of falling relative to people without an amputation, which may be a barrier to running. Understanding how dynamic balance is maintained during running is important for removing this barrier. To investigate dynamic balance, we quantified whole-body angular momentum in eight people with a unilateral transtibial amputation (TTA) using running-specific prostheses (RSPs) compared to eight people without TTA during running at 2.5, 3.0, and 3.5 m/s. People with TTA had greater ranges of whole-body angular momentum compared to people without TTA in the frontal and sagittal planes (p < 0.01). These greater ranges resulted from smaller peak medial, lateral, and braking ground reaction forces from the amputated leg compared to the intact leg and people without TTA. Reduced RSP mass relative to the biological leg also influenced whole-body angular momentum as evidenced by smaller ranges of amputated leg angular momentum compared to the intact leg in the frontal and sagittal planes. Smaller amputated leg angular momentum corresponded with smaller contralateral arm angular momentum in the sagittal plane (p < 0.01). People with TTA maintain balance during running with altered muscle coordination and prosthesis characteristics. Restoring mediolateral force generation through prosthetic design advances may help in regulating the frontal plane component of whole-body angular momentum for people with TTA, with potential to improve their ability to maintain balance during running.     

Lymphatic drainage in patients after replantation of extremities

Lymph drainage was studied by means of lymph scintigraphy in eight patients in whom successful replantation of a totally or subtotally amputated extremity had been performed. Scintigrams were made after subcutaneous injection of technetium-99m in the replanted part of the patient and the contralateral, normal extremity. In all scintigrams, axillary or inguinal lymph node activity is seen, implying drainage of lymph by means of the lymph vessels. Retention of colloid in the replanted part (79 to 94 percent) shows no significant difference with the contralateral, normal side (86 to 94 percent). Unquestionable evidence of regeneration of lymphatics in humans is delivered in the three patients, in whom lymph node activity and normal retention percentages are seen on the scintigrams after total amputation of an extremity followed by replantation without anastomosing of interrupted lymph vessels.     

Involvement of canonical Wnt/Wingless signaling in the determination of the positional values within the leg segment of the cricket Gryllus bimaculatus

The cricket Gryllus bimaculatus is a hemimetabolous insect whose nymphs possess the ability to regenerate amputated legs. Previously, we showed that Gryllus orthologues of Drosophila hedgehog (Gb'hh), wingless (Gb'wg) and decapentaplegic (Gb'dpp) are expressed during leg regeneration and play essential roles in the establishment of the proximal-distal axis. Here, we examined their roles during intercalary regeneration: when a distally amputated tibia with disparate positional values is placed next to a proximally amputated host, intercalary growth occurs in order to regenerate the missing part. In this process, we examined expression patterns of Gb'hh and Gb'wg. We found that expressions of Gb'hh and Gb'wg were induced in a regenerate and the host proximal to the amputated region, but not in the grafted donor distal to the regenerate. This directional induction occurs even in the reversed intercalation. Because these results are consistent with a distal-to-proximal respecification of the regenerate, Gb'wg may be involved in the re-establishment of the positional values in the regenerate. Furthermore, we found that no regeneration occurs when Gb'armadillo (the orthologue of beta-catenin) was knocked down by RNA interference. These results indicate that the canonical Wnt/Wingless signaling pathway is involved in the process of leg regeneration and determination of positional information in the leg segment.     

中华真地鳖断足再生对发育的影响

研究中华真地鳖EupolyphagasinensisWalker的断足时间及数量对发育历期的影响,以及不同龄期断足处理后发育历期间的差异。以8龄若虫为研究对象,发现其再生临界期为20~26日龄。不同日龄的8龄若虫断去1条后足,蜕1次皮后能再生的若虫从断足至蜕皮的平均时间与8龄的正常历期相近,整个8龄若虫的发育历期均比正常历期长,并随断足处理日龄的增加而逐渐增加。蜕1次皮后断足没有再生的绝大部分个体,8龄若虫的历期均比正常历期短。以3日龄的4龄若虫为处理对象,发现断去不同数量的足后(蜕1次皮后均能再生),从断足至蜕皮的历期及4龄的历期,均随虫体断足数量的增加而增加,但断去1条或2条后足处理,从断足至蜕皮的历期间及断足处理后4龄历期与正常历期间的差异不显著。不同虫龄的若虫断去1条后足的腿节后1次蜕皮后能再生的大部分个体,从断足至蜕皮的时间比同龄若虫的正常历期稍长,所延长的时间相当于从龄初至断足处理的时间,而断足后1次蜕皮未再生的其余个体从断足到蜕皮的时间均很短。     

Contribution of each leg to the control of unperturbed bipedal stance in lower limb amputees: new insights using entropy

The present study was designed to assess the relative contribution of each leg to unperturbed bipedal posture in lower limb amputees. To achieve this goal, eight unilateral traumatic trans-femoral amputees (TFA) were asked to stand as still as possible on a plantar pressure data acquisition system with their eyes closed. Four dependent variables were computed to describe the subject's postural behavior: (1) body weight distribution, (2) amplitude, (3) velocity and (4) regularity of centre of foot pressure (CoP) trajectories under the amputated (A) leg and the non-amputated (NA) leg. Results showed a larger body weight distribution applied to the NA leg than to the A leg and a more regular CoP profiles (lower sample entropy values) with greater amplitude and velocity under the NA leg than under the A leg. Taken together, these findings suggest that the NA leg and the A leg do not equally contribute to the control of unperturbed bipedal posture in TFA. The observation that TFA do actively control unperturbed bipedal posture with their NA leg could be viewed as an adaptive process to the loss of the lower leg afferents and efferents because of the unilateral lower-limb amputation. From a methodological point of view, these results demonstrate the suitability of computing bilateral CoP trajectories regularity for the assessment of lateralized postural control under pathological conditions.