Management of total and subtotal amputation injuries at the lower leg

Although subtotal and total lower leg amputation have been successfully replanted in the past, nowadays there is a common opinion that these operations do not justify their efforts, and therefore most of those patients are amputated. In order to clarify this hypothesis we carried out a retrospective clinical study of our personal cases operated on between 1981-1998 and an extensive literatur research. The following criteria were evaluated 1) survival rate, 2) individual motor and sensory functions and global lower extremity function juged according to the classification of CHEN, 3) socioeconomic aspects (operation time, number of operations per patient, time of hospitalization, return to normal life), 4) number and nature of local and/or systemic complications and 5) subjective judgment by the patient. All replanted lower legs in our series survived. Using CHEN`s classification the functional results can be given as follows: Stage I 66.6%, Stage II 25% (thus a "functional extremity" could be reconstructed in 91.6%), stage III 8.4% and stage IV 0%. Social reintegration was achieved within 8 to 10 months after replantation. 4 to 7 secondary operations were carried out in every patient in order to improve the result. Total duration of therapy took 28 to 48 months. There were no secondary re-amputation. Using our personal algorithm, on the one hand there is a significant decrease in replantation frequency (30% of all tranferred cases in our replantation center). However, on the other hand those cases replanted show better functional and aesthetic results and a significant lower replantation risk. Our results as well as those of other large series show that low er leg replantation is still worthwhile in a well selected patient group, contrary to what is believed by an increasing number of orthopaedic and trauma surgerons.