ABSTRACT
Replantation in the lower leg, although technically feasible, still remains a complicated
clinical issue in terms of the decision-making process. In children, a limb salvage
or replant procedure would seem preferable; however, in crush amputations from railroad
injury, a very severe trauma, difficulties in treatment should be thoroughly weighed
against prosthetic possibilities; for example, only a fair or good functional outcome
would justify an attempt to replant a severed shin. Unfortunately, the outcome in
most cases is unpredictable at the time of initial evaluation, and even during the
replantation procedure itself.
To facilitate prognosis, the authors determine four typical variants of replantation
course and outcome, based on local patient conditions, although they stress that no
clear indications for replantation vs. prosthesis can be derived from the variants
listed. Rather, general guidelines for the surgeon's decision at a very early stage
of treatment are presented. Choice of procedure and tactics cannot be determined once
and for all, because the prognosis for functional outcome can change during the course
of treatment.
Among a few well-defined situations are clean amputations (replantation is indicated)
and traumas with very extensive crushing of the whole lower leg (replantation is contraindicated).
In the majority of cases, replantation is a worthwhile attempt, but this does not
imply that a replanted extremity must be preserved at any cost. The surgeon must consider
the possibility of re-amputation, in case of an unfavorable variant in the postoperative
course.
A successful case of replantation, involving two lower leg railroad amputations in
a child, is presented.
