Purpose of the study: We reviewed traumatic distal leg amputations managed in our unit between 1990 and 1993. Reimplantation or unilateral emergency revascularization were undertaken in five cases.

Material and methods: The initial loss of length was considerable (range 8.5–12 cm) allowing direct internal fixation, protected with an external fixator bridging the ankle, and direct vasculonervous suture. Secondary lengthening was undertaken early in the proximal metaphyseal zone before sensorial recovery was complete.

Results: Healing was achieved within a normal delay in all cases. Nerve regeneration was monitored from the site of the microsuture by following the progression of the Tinel sign along the repaired nerve trunks; this defined the rate of regeneration. Our observations showed that nerve lengthening above the site of the microsurgical suture did not hinder nerve regeneration and even appear to stimulate it.

Conclusion: This strategy of extensive initial debridement compensated for by significant but well-tolerated secondary lengthening enabled us to broaden indications for unilateral leg reimplantations. The quality of the functional results at follow-up extending up to 15 years is probably one of the reasons justifying this strategy.

Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy.

Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting.

Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation.

Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.