Crossover replantation after bilateral traumatic lower limb amputations: a case report
© Fang et al.; licensee BioMed Central Ltd. 2012
Received: 10 November 2011
Accepted: 29 February 2012
Published: 24 July 2012
Replantation of a limb to the contralateral stump after bilateral traumatic amputations is rare. To the best of our knowledge, there are only a few reports of crossover lower limb replantation in the literature.
We treated a 37-year-old Chinese woman with bilateral lower limb crush injuries sustained in a traffic accident. Her lower limb injuries were at different anatomic levels. We performed emergency bilateral amputations followed by crossover replantation. Five years later, the woman had recovered well, and had perfect movement and stability in her replanted leg. After reviewing the literature, we thought that presentation of our patient’s case might provide useful information for clinicians.
Crossover replantation should be considered when evaluating a patient with bilateral lower limb injuries, thus allowing the patient to touch the ground and stand using their own foot.
Microsurgical techniques have enabled the replantation of traumatically amputated limbs. Crossover replantation or ectopic implantation should be considered in cases of bilateral amputations, to salvage at least one limb . Replantation of a limb to the contralateral stump after bilateral traumatic amputations is rare, and may incur criticism due to the prolonged hospital stay and complications. To the best of our knowledge, there are only a few reports of crossover replantation of the lower limb in the literature [2–5].
After rapid infusion of intravenous fluids, our patient rapidly recovered from shock and did not develop acute renal failure or acute respiratory distress syndrome. Emergency surgery was performed. Bilateral lower limb amputations were necessary. Her lower left leg was unsalvageable, but her lower right leg was suitable for replantation to the left leg stump after debridement. We decided to perform crossover replantation of her right lower leg to the left leg stump to provide our patient with a sensate weight-bearing extremity. Her amputated right lower leg was wrapped in sterile dressings, placed on a sterile tray and stored in the refrigerator at 4°C during fixation of the left leg fracture.
After amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia (Figure 1D). The fibula was not fixed. The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures. The anterior tibial artery and posterior tibial artery were anastomosed crosswise, and the ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover. The sural nerve and saphenous nerve were anastomosed crosswise, and the anterior and posterior tibial nerves were anastomosed without crossover. Heterotopic replantation of her right lower leg to the left leg stump was thus completed. A stump was created on the right side at her hip joint. Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively. In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap. The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days; aspirin (100mg) orally three times a day for three days; narceine (30mg) four times a day for seven days; and tolazoline (25mg) three times a day for seven days. Routine post-operative blood tests, including coagulation tests, were performed for seven days.
The indications for replantation depend on many factors, including the general condition of the patient. Although lower leg replantation prolongs hospital stay, delays mobilization and increases the required secondary procedures compared to simple amputation, the functional outcome is much better after replantation than with a prosthetic limb, especially when there is successful restoration of sensation to the weight-bearing area. Function including movement and stability, as well as quality of life, are greatly improved by lower limb replantation.
The possibility of crossover replantation should be considered when evaluating a patient with bilateral lower limb injuries, thus allowing the patient to touch the ground and stand using their own foot.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Kayikcioglu A, Agaoglu G, Nasir S, Kecik A: Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation. Plast Reconstr Surg. 2000, 106: 868-873. 10.1097/00006534-200009040-00019.View ArticlePubMedGoogle Scholar
- Betz AM, Stock W, Hierner R, Schweiberer L: Crossover replantation after bilateral traumatic lower-leg amputation: a case-report with a six-year follow-up. J Reconstr Microsurg. 1996, 12: 247-255. 10.1055/s-2007-1006484.View ArticlePubMedGoogle Scholar
- Chang WG, Tang YQ, Liu SZ: A case of heterotopic transplantation after bilateral traumatic above-knee amputations. J Trauma. 1990, 30: 496-502.View ArticlePubMedGoogle Scholar
- Girot J, Marin-Braun F, Merle M, Xenard J: Cross replantation in a case of bilateral amputation of the legs. Rev Chir Orthop Reparatrice Appar Mot. 1988, 74: 259-261.PubMedGoogle Scholar
- Wang D, Yin YS, Gao FG, Lu Z, Hu SB: Cross-replantation of lower extremities in multilimbed amputation: case report and literature review in China. J Trauma. 1995, 38: 947-951. 10.1097/00005373-199506000-00024.View ArticlePubMedGoogle Scholar
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