Wang Kuan-Chih, Hung Kuo-Shu, Chang Tzu-Yen, Wu Po-Ting, Lee Yao-Chou
From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and.
Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Ann Plast Surg. 2019 Jan;82(1):71-75. doi: 10.1097/SAP.0000000000001630.
Infrapopliteal replantation is indicated in selected patients. When the patient is hemodynamically unstable or the amputation site is severely contaminated, temporary ectopic implantation of the amputated limb is an option. To the best of our knowledge, this is the first case report using the distal runoff vessel of the anterolateral thigh flap for temporary ectopic implantation of an amputated leg followed by replantation with the prefabricated anterolateral thigh flap.
A 28-year-old male driver had left leg avulsion amputation after a car accident. Because of concerns about the high-energy trauma mechanism and extensive trauma zone, temporary ectopic implantation was planned to avoid a lengthy replantation procedure and to enable future replantation. The amputated leg was implanted to the thigh using the distal runoff vessel of the descending branch of the lateral circumflex femoral system in the preservation of proximal cutaneous perforator. When the patient became hemodynamically stable and the amputated stump was relatively clean and healthy, we replanted the amputated leg with the prefabricated anterolateral thigh flap on day 7.
The replanted leg and anterolateral thigh flap survived well after the procedure. At the 15-month follow-up, the patient could walk independently. There was no need for custom-made shoes because there was no obvious leg length discrepancy and the flap was not bulky.
We believe that the distal runoff vessel of the descending branch of the lateral circumflex femoral system can not only serve as a recipient site for temporary ectopic implantation but also enable the harvest of a prefabricated anterolateral thigh flap with the amputated part at the replantation stage. This prefabricated tissue containing the anterolateral thigh flap and the amputated part needs only 1 set of vascular anastomosis to accomplish replantation and simultaneous revascularization of the anterolateral thigh flap. Most importantly, this ectopically prefabricated chimeric tissue minimizes the need for extensive bone shortening after radial debridement by providing sufficient soft tissue coverage at the replantation stage.
在特定患者中可行腘下再植术。当患者血流动力学不稳定或截肢部位严重污染时，截肢肢体的临时异位植入是一种选择。据我们所知，这是首例使用股前外侧皮瓣的远端流出血管进行截肢腿临时异位植入，随后用预制股前外侧皮瓣进行再植的病例报告。
一名28岁男性司机在车祸后左腿撕脱性截肢。由于担心高能创伤机制和广泛的创伤区域，计划进行临时异位植入以避免冗长的再植手术，并为未来的再植创造条件。在保留近端皮穿支的情况下，利用旋股外侧动脉降支的远端流出血管将截肢腿植入大腿。当患者血流动力学稳定且截肢残端相对清洁健康时，于第7天用预制股前外侧皮瓣对截肢腿进行再植。
术后再植腿和股前外侧皮瓣存活良好。在15个月的随访中，患者能够独立行走。由于没有明显的腿长差异且皮瓣不臃肿，无需定制鞋子。
我们认为，旋股外侧动脉降支的远端流出血管不仅可作为临时异位植入的受区部位，还能在再植阶段获取带有截肢部分的预制股前外侧皮瓣。这种包含股前外侧皮瓣和截肢部分的预制组织仅需一组血管吻合即可完成再植及股前外侧皮瓣的同期血运重建。最重要的是，这种异位预制的嵌合组织通过在再植阶段提供足够的软组织覆盖，最大限度地减少了清创后广泛缩短骨骼的需求。
