What is the Real Time Limit for Foot Revascularization?

Even if they are not as frequent as at the upper limb level, lower limb amputations follow the same indications, restrictions, and principles for reconstruction. The maximum time limit for replantation/revascularization in the distal part of the lower limb is considered to be 6–8 hours. The authors presented a very unusual case, both on account of the time until revascularization, and the method used for reconstruction.

A patient presented with severe crush and torsion trauma, resulting in open IIIB Gustillo tibio-tarsal fracture-dislocation, with extensive soft tissue defect, severed vascular tibial anterior pedicle, severed vascular tibial posterior pedicle, severed vascular peroneal pedicle, and quasi-complete destruction of the posterior tibial nerve. The patient arrived in the authors' clinic after about 18 hr from the trauma, after having an emergency procedure in another orthopedic clinic (minimal excision, reduction,and fixation with screws).

Because the foot showed signs of complete devascularization, the patient was sent to the authors' service, were wide debridement, fasciotomy, and application of all-in-one reconstruction techniques were carried out: foot revascularization by microsurgically suturing the posterior tibial artery and one comitant vein (at 22 hr after trauma!!), and covering the extensive soft tissue defect of the foot dorsum with an emergency latissimus dorsi free flap (microsurgically sutured to the peroneal artery and a comitant vein). At 48 hr, the flap was covered with a split-thickness skin graft.

The local postoperative condition was very good, with survival of the foot and complete integration of the free flap, but was marked by an alcohol withdrawal syndrome that occurred at 48 hr post-surgery.

This foot survival was extraordinary, because all three important vascular pedicles were severed, and was probably due to the existence in the proximal part of the shank of some vascular connections that provided a limited survival for the almost completely amputated limb. It is difficult to define limits for the precise time to decide not to revascularize a limb in an act of major reconstructive surgery.