Transplantation of Severed Left Foot on Right Leg
The patient, male, aged 31, was admitted on March 4, 1971 following crushing injuries of both legs in a train accident one hour before admission. On examination, his right foot from the ankle was crushed to a pulp, the whole left leg was severely injured, and 4 fingers of the left hand sustained open fractures. The patient was in a slate of severe shock, pale and semiconscious, pulseless, and his blood pressure was undetectable.
After measures to combat shock, the patient was operated upon under ether anesthesia. In order to save time, 2 teams of surgeons simultaneously carried out debridement and suture of the fractured fingers of the left hand and the amputation stump of the left thigh, while another 2 teams worked on the preparation of the stump of the right lower leg and of the left foot at the ankle for transplantation.
The first step after debridement and perfusion was introduction of a V-shaped steel pin through the talus and tibia thus fixing the talotibial joint in a position of function, after which the lower end of the fibula was shortened about 5 6 cm. The problems arising from the reversion of joints were solved as follows: the fascia propria of the right lower leg was slit open and dissected free of the anterior and posterior tibial vessels upwards for about 7-8 cm. The vessels were re-arranged in the required position for anastomosis; they were passed under the tendons, finally assuming a curved or S-shaped course without kinking. The vascular anastomosis was then carried out in the following order: the posterior tibial artery and vein and the great saphenous vein of the right leg were anastomosed to the anterior tibial artery and vein and the lesser saphenous vein of the severed left foot; the anterior tibial artery and vein and the lesser saphenous vein of the leg were anastomosed to the posterior tibial artery and vein and the great saphenous vein of the foot stump. The total ischemic time from injury to resumption of circulation in the severed foot was 10 hours. As soon as the clamps were released, the skin assumed a fresh color and the transplanted foot became warm. The posterior tibial nerve was taken round the posterior aspect of the tibia and joined to the posterior tibial nerve of the severed foot. The tendons at the ankle and the extensor tendons of the toes were selectively sutured. Finally the skin was sutured employing Z-flaps in two places to avoid tension from a circular scar.
The postoperative course was smooth. The slight swelling of the foot subsided after 5 days; the sutures were removed in 2 weeks and the wound healed by first intention. After 3 months the V-shaped pin was removed and the patient was helped to move about on his one leg.
The patient is now in excellent health. Reversion of the foot is of course apparent. Circulation and temperature of the transplanted fool are normal. No swelling occurs after walking. There are signs that the posterior tibial nerve is recovering its function; deep sensation can be elicited in the toes. The patient can walk more than 2 hours with a crutch.
*This English abstract from the Journal reprinted with the kind permission of the publisher, Chinese Medical Association, Peking, Peoples Republic of China.