Successful ankle replantation in two cases with different presentations


Case 1

A 32-year-old man was assaulted with a sharp sword, resulting in total amputation of the lower extremity at the level of the tibiotalar joint, with clean-cut wound (Fig. 1A). He presented 4 hours after the injury, in a stable hemodynamic condition with no other associated injuries. The patient was immediately transferred to the operating theatre and put under general anaesthesia. Surgery commenced. A two-team approach was taken; one team prepared the stump, and the other, the amputated part. Stabilization of the ankle joint was performed first, using a rush rod inserted from the calcaneum to the tibia bone (Fig. 1B). The blood vessels were then explored, and end-to-end anastomoses were done for the posterior tibial artery, dorsalis pedis artery and its venae comitantes, and the great saphenous vein. Revascularization was completed 6 hours after the injury. The wound edges were approximated, except for the lateral part, which was under some tension and was therefore left to heal secondarily. The patient’s intraoperative course was uneventful. He was managed in the intensive care unit for 4 days following replantation. The wound edges healed well, with a dressing only. No complications occurred, and no secondary procedures were needed; as such, the patient showed a good short-term outcome. The replanted foot was viable when the patient was discharged at day 35 postoperatively (Fig. 1C and ​D). However, this patient was lost to further follow-up, preventing us from assessing his mid- to long-term outcomes.

Successful ankle replantation in two cases with different presentations
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Fig. 1.
Sword-inflicted amputation of the left ankle(A) Preoperative view of amputation at the level of the tibiotalar joint. (B) Immediate postoperative X-rays showing good alignment of the bones with rush rods in situ. (C, D) At 30 days postoperatively, the medial aspect had healed primarily. The lateral aspect had healed secondarily.

Case 2

A 17-year-old boy was involved in a high-impact motor vehicle accident. His right foot was amputated at the level of the tibiotalar joint. The emergency dispatch team wrapped the amputated part of the foot in saline-soaked gauze and kept it in a cooled ice box. A plain radiograph also revealed a distal-third tibia/fibula fracture. The patient was referred to our hospital due to the availability of microsurgery and reconstructive surgery services.

The patient arrived at Hospital Universiti Sains Malaysia 8 hours after the trauma due to the time taken by interstate travel. the time from arrival at the casualty department to the start of surgery was 35 minutes. A similar two-team approach was taken. The wound edge for each respective part was cleaned and debrided. The bone was shortened by a total of 3 cm, and explored for viable vessels. For stabilisation, two rush rods were inserted from the calcaneum to the tibia. Microsurgery commenced, with the posterior tibial artery anastomosed first, followed by its vena comitans. Next, the anterior tibial artery (Fig. 2A and B), with its accompanying vena comitans, and the great saphenous vein were repaired. The tibial nerve (Fig. 2A and B) was then coapted. The ischemic time was 10 hours, ending at the time of the first artery repair.

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Fig. 2.
Traumatic amputation of right leg(A, B) Amputation at the level of the tibiotalar joint. Markings showing the tibial nerve and anterior tibial artery. (C) After bone shortening, replantation and microsurgical neurovascular repair were completed. Additional stabilization was performed with an external fixator.

Group repair of the extensor halluces longus and digitorum of the tendon was done to maintain clearance of the toes, and the flexor halluces longus and digitorum also were repaired for functional purposes. The skin was then closed with minimal tension. An external fixator was finally applied to reinforce the strength and rigidity of the bone (Fig. 2C).

Ten days postoperatively, the skin edges became necrotic and broke down (Fig. 3A). Wound debridement was carried out, followed by wound coverage with a free anterolateral thigh flap using the vastus lateralis muscle (Fig. 3B). The flap vessels (descending branch of the lateral circumflex femoral artery and vena comitans) were anastomosed to the anterior tibial artery with its venae comitantes via end-to-side anastomosis. The flap healed well, and the patient recovered (Fig. 3C). Three months postoperatively, the patient started partial weight-bearing. A plain radiograph revealed bone union. Six months later, full plantar sensation returned.

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Fig. 3.
Wound edge necrosis at 10 days post-replantation(A) Wound necrosis demarcation. (B) The wound was debrided and covered with a free anterolateral thigh flap. (C) Good viability at 6 weeks after free flap wound coverage.