Invited Discussion

Our capabilities for limb revascularization, microneurovascular surgery, osteosynthesis, and critical-care medicine are technological marvels but, paradoxically, their application in heroic attempts at limb salvage can sometimes have extraordinarily expensive economic, physiological, or even lethal costs.[1] Prior to initiating the requisite lengthy course with the multiple operative interventions required to salvage most complex lower-extremity injuries, a multidisciplinary assessment on a case-by-case basis by at least trauma, orthopaedic, vascular, and plastic surgeons is imperative, to determine if primary amputation would be the preferable mode of treatment. It is important to recognize that this should not be considered a treatment failure, but rather a valid reconstructive alternative. A lower-limb prosthesis may be a superior option to meet the demands of ambulation,[2] to which Parmaksizoglu and Beyzadeoglu have alluded, as they would not consider replantation of any level of amputation above the knee. For that matter, their criteria before embarking on even revascularization, also require that a stable knee joint and at least the potential for foot sensibility exist.

The controversial point to which these authors have objected is that the potential for lower-limb length discrepancy has previously been a relative contraindication for replantation, according to numerous predictive indices. MESS (Mangled Extremity Severity Score), AIS (Amputation Index Score), MESI (Mangled Extremity Syndrome Index), PSI (Predictive Salvage Index), and LSI (Limb Salvage Index) were formulated with the intent to provide objective criteria based on associated injuries, to justify the ultimate surgical decision.[3] The personality, motivation, socioeconomic status, degree of family support, and level of education of the individual are perhaps characteristics of more paramount importance in determining the ultimate outcome-and all are virtually impossible to evaluate initially.[4]

Thus, the instincts, skill, and experience of the surgical team appropriately remain important factors, when deciding if an attempt at limb salvage is warranted. Parmaksizoglu and Beyzadeoglu have provided additional evidence that sometimes ``primary shortening with secondary limb lengthening''[5] can be a valuable approach, especially for replantation, as primary skin closure, primary nerve coaptation, and stable osteosynthesis are major advantages. Just as with the more conventional treatment of any similar injury, adequate tissue debridement, but now restricted to a single sitting, must be performed, or else wound sepsis with potential limb loss will occur. Just how much limb shortening is tolerable, is not stated by these authors, but Betz et al.[5] avoided this approach if the segmental bone loss was greater than 15 cm.

Others have found this ``compression-distraction'' technique to have some disadvantages, including eventual restricted joint mobility, contractures, subluxation, shortening of the Achilles tendon, and exposure of bone through thin, scarred tissues.[6] The subset of patients with subtotal amputations may represent a different population, especially if nerve injury involves no more than one major nerve trunk.[5] Many have stated that, in this category, limb length should instead be maintained, but usually a free flap is required to restore soft-tissue coverage. Transfer of this free flap at the time of revascularization may be essential to cover vital structures,[7] [8] and thus should not necessarily be avoided. Intercalary bone segment transport can then be performed beneath healthy tissues, either immediately[9] or in a delayed fashion.[6] [10]

While lower-limb replantation, especially after severe crush or multi-level injuries with extreme contamination and extensive tissue loss, is normally avoided,[4] [7] Parmaksizoglu and Beyzadeoglu have demonstrated some beautiful and enviable results in selected patients. They have again shown that strict protocols, which might have precluded their attempt at salvage, may not be justifiable in general, and that these criteria should serve no greater role than as appropriate guidelines. Each case requiring such heroic efforts for limb salvage must continue to be evaluated on its individual merits (or liabilities), to provide that specific patient with the best potential outcome.

REFERENCES

• 1 Hallock G G. Reconstruction for lower extremity trauma. In: Goldwyn RM, Cohen, MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed Philadelphia: Lippincott Williams & Wilkins 2001 0: 833-842
• 2 Jupiter J B, Tsai T M, Kleinert H E. Salvage replantation of lower limb amputations.  Plast Reconstr Surg . 1982;  69 1-8
• 3 Bonanni F, Rhodes M, Lucke J F. The futility of predictive scoring of mangled lower extremities.  J Trauma . 1993;  34 99-104
• 4 Walton R L, Rothkopf D M. Judgment and approach for management of severe lower extremity injuries.  Clin Plast Surg . 1991;  18 525-543
• 5 Betz A M, Stock W, Hierner R, Baumbart R. Primary shortening with secondary limb lengthening in severe injuries of the lower leg: a six-year experience.  Microsurgery . 1993;  14 446-453
• 6 Musharafieh R S, Saghieh S S, Nassar H. Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage.  Microsurgery . 1996;  17 666-673
• 7 Gayle L B, Lineaweaver W C, Buncke G M. Lower extremity replantation.  Clin Plast Surg . 1991;  18 437-447
• 8 Hallock G G. Truly emergent free flaps.  Contemp Surg . 1997;  51 24-28
• 9 Feibel R J, Oliva A, Jackson R L. Simultaneous free-tissue transfer and Ilizarov distraction osteosynthesis in lower extremity salvage: case report and review of the literature.  J Trauma . 1994;  37 322-327
• 10 Jupiter J B, Kour A K, Palumbo M D, Yaremchuk M J. Limb reconstruction by free-tissue transfer combined with the Ilizarov method.  Plast Reconstr Surg . 1991;  88 943-951