Standardized management of subtotal and total amputation injuries at the lower leg level - the "Integrated Treatment Concept"

Abstract

Because of better defined indications and operative concepts for replantation, and better postoperative management, there has been a clear improvement of results. In spite of the higher costs and the longer time of recovery after lower leg replantation compared to primary amputation and early prosthetic fitting, replantation should be carried out if possible, indicated and desired. The importance of adequate debridement of any damaged tissue is the key to better functional results, leading to the reduction of local (thrombosis, infection) and/or systemic (crush-syndromes, ischemia-reperfusion-syndromes) complications. Postoperative physiotherapy also plays a decisive role. The functional potential after replantation can only be achieved if adequate physiotherapy is applied over an extended period of time. Provided exact indication, meticulous operative technique and adequate postoperative physiotherapy, better functional results, lack of prosthesis-related problems and lack of psychological disturbances caused by missing body integrity will result. On the other hand, the lack of good replantation indicates primary amputation and early subsequent prosthetic fitting in the benefit of the patient. Contrary to the local situation at the lower leg, for which objective clinical criteria are existing which predict with a high probability the functional outcome and the duration of therapy at the time of injury, there are no objective criteria to predict systemic impairment of the patient caused by the replantation. The actual forecast based on subjective clinical experience is not sufficient for at least 11 % of the replanted patients. In those cases there will be danger of life during the postoperative period because of mono-, oligo-, or multiple organ failure requiring immediate secondary reamputation to reduce harm for the patient. The aim of future studies must be an objective predictive score in order to primarily avoid harm to such a patient.