Yes, it is possible for severed legs to be reattached through surgical reattachment. With advances in microsurgery, surgeons are able to reconnect blood vessels, nerves, muscles, tendons, and bone in order to restore circulation and function to the amputated limb. Success rates for leg reattachment vary depending on the location and extent of the injury, the time between amputation and reattachment, and the expertise of the surgical team.
Overview of Leg Reattachment
Leg amputation refers to the traumatic or surgical removal of all or part of a leg. Causes include motor vehicle accidents, industrial accidents, acts of violence, medical complications like severe infection or cancer, and military combat injuries. When a leg is abruptly severed, the blood vessels constrict to prevent major blood loss. However, this also cuts off circulation to the distal portion of the limb. Without oxygenated blood, tissues quickly become ischemic and start to die.
The goal of leg reattachment surgery is to restore blood flow as soon as possible before irreversible damage occurs. This requires delicately reconnecting the complex network of arteries, veins, nerves, muscles, tendons, lymphatics, and skin. The procedure may involve bone stabilization with plates, screws, or an external fixator. The surgery typically takes many hours and is followed by extensive recovery and rehabilitation.
Requirements for Successful Reattachment
Several factors influence the viability of leg reattachment:
– Level of amputation – More distal amputations (below the knee) have higher success rates than amputations close to the hip. There is more muscle mass distal to mobilize for coverage.
– Mechanism of injury – Crush or avulsion injuries often cause severe tissue damage compared to clean, sharp amputations. This makes reattachment more difficult.
– Time to reattachment – The best outcomes occur when the limb is reattached within 6-12 hours of amputation. After 12-24 hours, muscle and nerve death progresses rapidly.
– Transport conditions – Keeping the amputated part cool (but not frozen) and wrapped in moist saline gauze helps preserve tissues until reattachment.
– Surgical expertise – Replantation requires an experienced surgical team, ideally plastic and orthopedic surgeons working together. Not all hospitals offer replantation services.
The Reattachment Procedure
The sequence of leg reattachment may include:
– Prepping the amputated part – This involves removing contaminated or dead tissue and irrigating blood vessels.
– Exposing healthy vessel ends – This is done on both the proximal (thigh) and distal (lower leg/foot) ends to prepare for reconnection.
– Realigning and stabilizing bones – Fractured bones are reduced and fixed with plates, screws, or external fixation.
– Reconnecting arteries and veins – Arteries carry oxygenated blood to the limb and are joined first using microsurgical techniques. Veins drain blood back to the heart.
– Repairing nerves – Motor and sensory nerves must be meticulously matched and stitched together. This is critical for restoring function.
– Reattaching muscles and tendons – These tissues facilitate movement and are carefully rejoined.
– Restoring skin – The incisions are closed with sutures, skin grafts, or flaps. Additional tissue may be mobilized to cover any defects.
– Monitoring circulation – Blood flow is continually evaluated using clinical exams, Doppler, and other testing. Any issues are immediately revised.
Recovery After Leg Reattachment
The postoperative recovery period lasts several months to over a year given the scale of injury. Strict elevation, frequent monitoring, medications, and second look operations are needed to support healing and prevent complications like thrombosis or flap failure. Extensive rehabilitation helps the patient regain strength and function in the reattached limb. Physical and occupational therapy focus on restoring range of motion, rebuilding muscles, retraining balance and coordination, and facilitating the use of orthotics or prosthetics if needed. With commitment to rehabilitation, many patients can ambulate independently and participate in sports/activities after leg reattachment.
Outcomes and Success Rates
Rates of leg salvage after replantation generally range from 70-90%, with success loosely defined as regaining a functional limb. However, the level of function varies. Younger patients with distal, sharp amputations and timely reattachment surgery tend to have the best outcomes. Delayed reattachment, proximal amputations near the hip, and crush mechanisms reduce the chances of a full recovery.
According to studies, 50-84% of patients regain ambulatory status after leg replantation. However, many continue to have some degree of disability. Common long term issues include muscle atrophy, loss of sensation, chronic pain or phantom limb pain, stiff joints, arthritis, and poor balance/coordination. Secondary procedures may be required, including nerve revisions, tendon transfers, bone grafts, and additional soft tissue coverage. Even with limitations, most patients prefer salvaging their own limb versus amputation and prosthetics.
Success Rates by Amputation Level
– Hip disarticulation – 50% survival rate
– Transfemoral (above knee) – 70% survival
– Knee disarticulation – 80% survival
– Transtibial (below knee) – 90% survival
– Ankle disarticulation – 95% survival
– Partial foot – 95% survival
Distal amputations have higher success since more joints, muscles, and nerves are left intact. Outcomes also depend on which structures are repaired and the degree of damage.
Controversies and Ethical Considerations
While replantation can restore form and function for many amputees, several controversies exist:
– Cost – Leg reattachment averages $20,000-$50,000 in hospital costs alone, not including rehabilitation. This expenses may not be justified for limited benefit.
– Tissue viability – Timely restoration of circulation is key. At what point is ischemia so advanced that tissues are unsalvageable?
– Adequate function – Will reattachment result in a stable, sensate, ambulant limb? Or will disability be so severe that prosthetics would provide superior function? It is difficult to predict final outcomes.
– Quality of life – Factors like chronic pain may impair well-being, despite limb preservation. Patients may regret reattachment.
– Informed consent – Do patients fully understand prognosis, required commitment, and potential complications before agreeing to replantation? Setting realistic expectations is important.
– Resource utilization – Is it appropriate to devote significant healthcare resources to a single patient when replantation services are limited? Alternatives like prosthetics may be more cost-effective.
These issues have fueled debate around patient selection criteria for replantation. However, excluding patients based on age, mechanism of injury, or level of amputation remains controversial. Ultimately, decisions to attempt limb salvage must be made on a case by case basis considering both ethics and expected total function.
Status of Leg Reattachment Globally
While replantation is an established practice in many developed nations, significant global disparities exist. Access is extremely limited in low and middle income countries. Challenges include:
– Shortage of trained surgeons – Microsurgery is a specialized skill requiring years of training. This expertise is concentrated in high resource settings.
– Cost of care – Resource-poor healthcare systems cannot absorb the substantial costs of replantation surgery and rehabilitation. Most patients pay out-of-pocket.
– Lack of infrastructure/equipment – Replantation relies on specialized instruments for microsurgery and stable postoperative intensive care. This is often not available.
– Variable healthcare coverage – Even in wealthier nations, insurers may deny reimbursement for replantation, leaving patients with massive medical bills.
– Cultural stigma – In certain regions, disability is highly stigmatized. Patients may feel pressure to decline available replantation.
– Delayed presentation – Long transit times from injury to care make replantation unfeasible in many cases. Lack of public knowledge also contributes.
– Alternative prosthetics – For patients unable to access replantation, quality rehabilitative services and well-fitted prosthetics can still provide mobility.
While geographic, economic, and cultural barriers persist worldwide, advocacy efforts continue to improve access to limb salvaging procedures. Partnerships between high and low resource care settings also aim to spread expertise in reconstructive surgery.
Future Directions in Replantation
Ongoing research strives to make reattachment more successful, including:
– Tissue preservation – New solutions show promise for prolonging viability of amputated parts. This may expand the window for replantation.
– Nerve regeneration – Techniques to bridge long nerve gaps could improve restoration of sensation and function.
– Muscle/bone stimulation – Methods to prevent atrophy and strengthen repaired tissues are being investigated.
– Robotics – Microsurgery robots may enable more precise vessel and nerve repairs.
– Stem cell therapies -Injecting cells could limit ischemia-reperfusion injury and enhance healing.
– 3D printing – Customized bone scaffolds and skin grafts created through 3D printing may improve structural reconstruction.
– Immunomodulation – Manipulating immune pathways may reduce risk of thrombosis and rejection after replantation.
– Rehabilitation – Advances in prosthetics, neuromodulation, and physiotherapy will further maximize function.
With a multidisciplinary approach, the field of extremity replantation will continue to evolve rapidly. This offers hope for improving care and outcomes among the population of limb amputees worldwide.
The decision to attempt limb salvage through replantation surgery is highly complex. While success is possible with microsurgical reattachment of arteries, veins, nerves and other tissues, optimal functional recovery requires careful patient selection, timely intervention, high surgical skill, multidisciplinary inpatient care, extensive rehabilitation, and realistic expectations. However, despite limitations, replantation provides the greatest chance for restoration of form and function after traumatic leg amputation for appropriate candidates. Ongoing research strives to make reattachment more feasible and effective so that this life changing option is available to more limb loss patients across the globe. With dedication and support, many can indeed regain the ability to stand and walk again after losing a leg.