Re-implantation of foot and ankle following crush injury of the distal leg with 22 cm bone deficit: A case report

Abstract

Introduction/importance

Crush injury with extensive soft tissue damage to an extremity is generally considered a contraindication to re-implantation and the extremity best managed by prosthesis. However good prosthesis is not easily available especially in resource constrained environment, the overall long term quality of life is also considered better with re-implantation.

Case presentation

We report a 24 year old tourist patient who presented with post-traumatic amputation of the left leg following a road traffic accident. The patient had no other injuries. Clinical examination revealed extensive soft tissue damage to the involved leg. Radiograph done demonstrated segmental fracture of the distal tibia. The foot was successfully re-implanted after a lengthy surgery of 10 h. The patient was then subjected to an Illizarov bony lengthening procedure to correct the limb discrepancy length of about 20 cm.

Clinical discussion

Our patient through multidisciplinary approach and after a combination of many procedures had his foot salvaged with good functional outcome. Though the injury had both bony and soft tissue loss, limb shortening necessitated by the segmental fracture followed by Illizarov technique were able to ensure adequate length.

Conclusion

Post-traumatic crush amputation of the foot previously considered a contraindication for re-implantation could be salvaged by re-implantation in combination with bone lengthening procedure with good functional outcome.

Highlights

• •Crush injury of the foot is rarely considered for reimplantation.
• •Reimplantation should however be considered if the patient is stable and necessary expertise is available.
• •Bone lengthening procedure should be considered for the bone loss that would otherwise lead to limb length discrepancies.

1. Introduction

Re-implantation of the limbs has been practiced for more than fifty years in selected centers globally [1]^, [2]. With improvements in microsurgical techniques, an increasing number of cases have been reported [3]^, [4]^, [5]^, [6]. Majority of the cases have however been of the upper limb with few done on the lower limbs. Crush injuries with multiple fractures especially of the lower limbs are considered contraindication for re-implantation and offered prosthesis. This is due to the extensive zone of injury that makes it hard to get vessels suitable for vascular anastomosis. Good prosthesis on the other hand is not readily available in many centers. They are also associated with low quality of life compared to re-implantation [7]. We report our experience of a successful re-implantation of a crushed foot followed by a bone lengthening procedure.

2. Patient information

This study has been reported in line with the SCARE criteria [8]. A twenty-four-year-old patient was referred to our facility at Coptic Hospital Nairobi, Kenya after sustaining a crush amputation to the left foot in a road traffic accident.

On examination at the point of entry, we found a young patient in fair general condition with early signs of hypovolemic shock. Local examination revealed a foot that was amputated at the level of the ankle joint and a crushed distal stump (Fig. 1, Fig. 2). Investigations revealed a hemoglobin level of 9.5 g/dl. Urea, electrolytes and creatinine levels were all normal. Radiological investigations revealed a segmental fracture of the distal tibia with extensive soft tissue edema. The patient was prepared for surgery, and blood was obtained for grouping and cross matching. A team comprising orthopedic and plastic surgeons was urgently formed, and surgery commenced.

Fig. 1.

Post-traumatic amputated foot of a 24-year-old patient.

Fig. 2.

Proximal stump of the amputated limb after surgical debridement and removal of the segment.

The surgery was performed under epidural anesthesia with the aid of a tourniquet. After a thorough surgical toilet, all important anatomical structures were identified. The segmental distal part of the tibia was removed. Fusion of the ankle joint was performed with a five whole dynamic compression plate (Fig. 3). Due to extensive soft tissue damage, approximately 7 cm of the blood vessels were involved in the zone of injury and thus were not fit for anastomosis. Contralateral small and greater saphenous vein grafts were harvested and utilized to bridge the gap for both the anterior and posterior tibia arteries. Three veins, one dorsal vein and two venae were repaired with the aid of a venous graft. Local tissue was then mobilized and utilized to cover the repaired vascular structures, and the plate. The ischemic time was approximately 12 h. Post-surgery, the patient was transferred to the High Dependency Unit (HDU) for close monitoring that lasted 48 h after which he was transferred to the general ward. Laboratory investigations done while in the HDU including urea electrolytes and creatinine levels were not deranged. The foot was monitored every 4 h for venous or arterial incompetency. The dressing was changed every third to fourth day.

Fig. 3.

Fixation of the amputated foot to the tibia with a five-hole plate.

The second surgical procedure was performed four weeks after the first surgery. The sural nerve and the tibial nerve were identified on both the leg and the foot. Using a sural nerve graft and the saphenous nerve from the opposite leg, they were co-opted, ensuring tension-free repair (Fig. 4). The patient was discharged 35 days after injury and referred for further management in his home country Egypt for a bone lengthening procedure (Fig. 5). Follow-up after five and half months in the patient's native country revealed 20 cm of shortening and non union with a 25-degree varies deformity of the ankle (Fig. 6). Operative interference using the corticotomy as the first technique was employed to manage the nonunion, deformity and bone shortening [9]. An Illizarov external fixator was applied to the upper part of the tibia, and corticotomy was performed (Fig. 7). The plate was then removed, followed by debridement of the nonunion site and correction of the varus deformity. Acute compression of the fracture site was then performed. An extra-calcaneal 5/8th ring was applied to increase the stability. After a waiting period of two weeks; bone distraction at a rate of 1 mm per day was commenced. The distraction rate was modified according to the regenerated bone formation until a length of 22 cm was attained (Fig. 8A–C). The frame was then removed in the outpatient clinic 18 months after the operation after the formation of three cortices, as evidenced in the radiographs (Fig. 9). The surgical procedures were all uneventful. There was no incidence of vascular compromise or thrombus formation during recovery. No wound sepsis was reported. Sensory recovery was near normal for the plantar surface of the foot with some paresthesia on the dorsal aspect. The patient was able to ambulate on the limb approximately two years after the accident with the aid of crutches.

Fig. 4.

Nerve grafts harvested and utilized for the repair of the sural nerve and tibial nerve. The wound was grafted with skin at the same time.

Fig. 5.

Patient ready for discharge 35 days after re-implantation. Note the limb length discrepancy of approximately 20 cm.

Fig. 6.

Follow-up radiographs at five and half months of the injury show nonunion and 20-degree varus deformity.

Fig. 7.

Ilizarov external fixator fixed to the limb prior to commencement of the bone lengthening procedure.

Fig. 8.

A: Bone lengthening after approximately one month of distraction osteogenesis; the arrow indicates new bone formation.

B: Bone lengthening after 8 months of distraction osteogenesis. Note the newly formed bone.

C: Completion of bone lengthening prior to the removal of the external fixator in the outpatient clinic.

Fig. 9.

Completion of bone lengthening; note the well-formed cortices of the tibia and complete bone union.

3. Discussion

Re-implantation of the extremities has been practiced globally for the last sixty years since the first case was described by Malt et al. in 1962 [1]. The practice has, however, been limited mainly to re-implantation centers, which are largely found in developed countries, and fewer cases if any have been reported in the rest of the world. Ironically, majority of trauma necessitating re-implantation occurs in resource-constrained countries, as evidenced by the high numbers of trauma cases [10]^, [11]. Most of the reported re-implantation has involved the upper limbs, with cases involving fingers comprising the majority [12]^, [13]^, [14]. Re-implantation of the foot and the lower limb in general has been performed less frequently, with an increase in the tendency towards fashioning an amputation stump and installing a prosthesis [15]. However, good prosthesis may not be accessible in many countries, and thus, there is a need to salvage severely injured extremities.

Our patient had a crushed, mangled extremity that was considered a contraindication for re-implantation. However, the patient after counseling regarding the possibility of re-implantation not succeeding, still expressed a strong desire to have the foot re-implanted. Factors that made us strongly consider re-implantation were his relatively young age, his lack of co-morbidities and access to the well-stored extremity obtained from the site of the accident and the referral facility. The re-implantation team was also readily available, and the hospital was willing to provide all the necessary support, including blood and intensive care setup.

Technical challenges anticipated included the extensive zone of the injury and soft tissue loss and bone loss caused by the segmental fracture of the tibia. The extensive zone of injury was primarily due to the nature of the accident, which resulted in the patient's foot being stuck on the floor of the vehicle while the vehicle rolled during the accident. This resulted in massive tissue damage around the amputation site. As a result, the primary repair of the blood vessels was not possible. To achieve the vascular repair of both the veins and arteries, both contralateral small and greater saphenous vein grafts had to be used, resulting in a total of ten anastomoses. Both the anterior and posterior tibial arteries with at least three veins were repaired. All anastomoses performed well with no re-explorations.

An alternative treatment could have been ectopic re-implantation of the limb with planning for definitive attachment at a later date once the inflammation lessened [16]. Adequate soft tissue coverage of the neurovascular structures and the bone would have been a challenge had bone shortening not been performed. The use of available soft tissue was prioritized for covering vascular grafts to prevent desiccation, and the remaining raw areas of skin were grafted at a later date. Bone loss in this patient occurred primarily at the accident site as well as during surgery due to the removal of the distal segment of the tibia. The resultant bone defect was in excess of 20 cm. To solve the limb length discrepancy, the most logical option we had in this case, although it was time consuming and demanding for the patient, was the bone lengthening technique. This technique has been reported to have been used before re-implantation, but only for defects with shorter lengths and mostly in children [17]^, [18]. Currently, there is no consensus on when it is best to carry out this procedure after re-implantation. Factors to consider include the willingness of the patient to have a protracted interruption of activities of daily living as well as the length of the defect. Other factors to consider are the possible harmful effect of distraction on the nerves and blood vessels. Distraction osteogenesis has, however, been shown to have a beneficial effect by increasing vascularity of the limb, in this case, it probably assisted in combating nonunion [19].

The functional outcome in this patient at two years of follow-up was satisfactory. The patient was able to return to his daily activities and lived unaided. He attained full length of the limb with no limb discrepancy. Sensory recovery was satisfactory, with protective sensory returning to both the sole and most of the dorsum of the foot. However, the patient had a fixed ankle joint and thus no plantar or dorsiflexion of the foot.

4. Conclusion

A crushed lower limb with extensive soft tissue and bone loss can still be salvaged through multiple surgical procedures; although this is initially demanding and costly due to prolonged operation times and the multiple hospital visits needed by patients, it probably provides the best chance for the patient to have a viable extremity with a good functional outcome. This procedure should thus be considered, especially in young and motivated patients. Massive bone lengthening after re-implantation is a valid option for treatment with no serious complications.

Consent

Consent to publish this study was sought from the patient.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethical approval was sought from the local institutional research board.

Funding

N/A.

Guarantor

DR Ferdinand W Nangole.

Research registration number

None.

CRediT authorship contribution statement

• Nangole F W, study concept, carried out the surgery, follow up of the case, summary of the clinical information, writing of Manuscript.

• Gamal Josny, study concept, carried out the surgery, follow up of the case, summary of the clinical information, writing of Manuscript.

• Khainga Stanley, study concept, carried out the surgery, follow up of the case, summary of the clinical information, writing of Manuscript.

• Reuben Kamundi, study concept, carried out the surgery, follow up of the case, summary of the clinical information, writing of Manuscript.

• Michael Alfonse, study concept, carried out the surgery, follow up of the case, summary of the clinical information, writing of Manuscript.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.