REPLANTATION OF A CRUSH AMPUTATION OF DISTAL TIBIA FOLLOWED BY LENGTHENING WITH ILIZAROV CIRCULAR EXTERNAL FIXATOR: TWO-YEAR FOLLOW-UP MUSTAFA N _ IS Ë ANCI, M.D., 1 ERGIN ER, M.D., 1* CEMIL YILDIZ, M.D., 2 MURAT TU È REGU È N, M.D., 1 SABRI ATEALP, M.D., 2 AND MUSTAFA S Ë ENGEZER, M.D. 1 A 20-year-old male sustained a severe crush injury to his left leg, resulting in amputation of the foot at the level of the distal tibia. Despite 12-h warm ischemia, replantation was at- tempted after radical debridement, bone shortening, and proximal fasciotomies. The replanted part survived totally. Four months later, a 13-cm shortness of the extremity was managed by 10-cm lengthening with distraction osteogene- sis, using Ilizarov's circular external fixator and by means of a special shoe. Two-year follow-up of the patient revealed acceptable functional and sensorial recovery. Success of replantation despite the excessive warm-ischemia time was attributed to the sparse muscle content of the distal tibia and foot. Fasciotomies performed on the proximal segment of the leg ensured the patency of anastomoses by maintaining adequate blood flow distally despite increasing edema after the crush injury. Debridement and bone shortening at the proximal stump eliminated the vein and nerve grafts to bridge the gap. In conclusion, considering the functional outcome of our case, replantation of distal parts of a lower extremity should be attempted first, even if the nature of the injury is unfavorable and the ischemia time is longer than the docu- mented ischemia-tolerance. ã 2002 Wiley-Liss, Inc. MICROSURGERY 22:295±299 2002 Although replantation of upper extremity elements is a common procedure, reports concerning leg replantation are quite rare. 1À4 Replantation of the leg is rarely indi- cated, because in traumatic amputations, crushing and/or avulsion of the involved parts make the proce- dure difficult to perform. 5 Even for amputations due to a moderately clear-cut injury, the indication for re- plantation is uncertain because of the disadvantages of skeletal shortening and poor nerve regeneration. 1 Fur- thermore, another reason for the reluctance to perform this procedure is the availability of efficient prosthetic devices, which may function quite well in comparison to a replanted leg with poor functional recovery. 6 Hence, the replantation of lower extremity elements should be justified only for carefully indicated cases. Here, we report on the successful replantation of a severelycrushedlegafter12hofwarmischemia.Theleg length discrepancy due to the shortening procedure was correctedwithdistractionosteogenesis,usinganIlizarov circular external fixator (CEF). CASE REPORT A 20-year-old man became the victim of a collapsed aircraft-shelter door while he was doing his military service. He sustained a severe crush injury to his left leg due to the fall of a concrete block, resulting in ampu- tationofthefootatthelevelofthedistaltibiaaswellas extensive destruction of the leg. Following emergency procedures accomplished at a local hospital immediately after injury, he was referred to our department for a possible replantation attempt. Hesitation in decision- making and the transport of the patient via highways over a long distance caused excessive delay in the pa- tient's arrival. When the patient was admitted to our department,10hhadelapsedsincetheoccurrenceofthe injury. Physical examination revealed a severely crushed leg, with the amputation of the foot at the level of the distal 1/3 of the tibia (Fig. 1). A tendon piece stripped off the stump was the only attachment of the amputated part to the stump. The amputated part had not been transported properly, leading to prolonged warm isch- emia. 1 Department of Plastic and Reconstructive Surgery, Gu Èlhane Military Medical Academy, Ankara, Turkey 2 Department of Orthopaedic Surgery, Gu Èlhane Military Medical Academy, Ankara, Turkey 1 *Correspondence to: Mustafa Nis Ë anci, M.D., Division of Plastic Surgery, University of Kentucky, Kentucky Clinic, K454, Lexington, KY 40536-0284. E-mail: drnisanci@yahoo.com Received 18 April 2002; Accepted 10 July 2002 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/micr.10057 ã 2002 Wiley-Liss, Inc.