On “Lengthening of Replanted or Revascularized Lower Limbs: Is Length Discrepancy a Contraindication for Limb Salvage?” (J Reconstr Microsurgery 2002;18:471-480)

I would like to comment on the paper by Parmaksizoglu and Beyzadeoglu, “Lengthening of Replanted or Revascularized Lower Limbs: Is Length Discrepancy a Contraindication for Limb Salvage?” (J Reconstr Microsurg 2002;18:471-480). Some of the information in this article is unclear. First, the authors state that the left leg and right foot in the first case were replanted by two different teams, and pre- and post-replantation images are shown to that effect. It is understood that the two replantations were carried out by two teams of which the authors were a part. The article does not indicate clearly that the replantation of the right foot was not, in fact, performed by the authors; I carried out this procedure, although replantation of the left leg was carried out by the senior author of the article.

Another point is that these procedures were performed at a private hospital, Kadikoy Vatan Hospital, and not at Yeditepe University.

Third, although shortening of the ankle can be done to avoid sepsis or to insure the success of the replantation, the right foot replantation that I did in this case did not involve any bone shortening, except for less than 1 cm, which was done to secure the ankle arthrodesis. The foot after replantation was of an acceptable shape, length, and size.

In my opinion, extreme bone shortening performed to insure surgical success and to prevent sepsis is too simplistic a method. As seen in this particular case, adverse expectations can be minimized by more careful wound management.

We would like to correct the misunderstanding of our colleague, Dr. Okcesiz, regarding our article in the Journal of Reconstructive Microsurgery (2002;18:471- 480). We believe that two points require clarification: participation in the case and the clinical indications.

The senior author (F.P.) managed these cases while he was working in a private hospital, but he has had an institutional affiliation with Yeditepe University since 2001 and is currently actively teaching on that faculty, and therefore does not understand any objection to this academic affiliation in the article.

In one of the cases with bilateral amputations of both lower extremities, it was clearly pointed out in the text of our article that the replantations were performed with two different surgical teams; indeed, Dr. Okcesiz did the replantation of the right foot. But the main topic of our article is not the results of major replantation; on the contrary, it is a discussion about decision-making scoring systems for severe lower extremity injuries, emphasizing avoidance of leg length discrepancy problems. Thus, the lengthened leg was the one that the senior author replanted. Our colleague did not have any role in any of the lengthening procedures, either in the lengthening of the left leg of that case, or in any stage of the other cases. The right-foot procedure had no contribution to the reconstructive phase of the leg lengthening, and is not used as any source of reference in the article.

About our colleague's critique of the clinical indication of “primary deliberate shortening,” we believe that the best answer is in the article itself. Adequate debridement and deliberate shortening are consensual golden rules, particularly in surgery of major replantations. However, comparison with replantations at the ankle and mid-calf levels would be misleading. We believe that the advantages of debridement and shortening have been argued in detail, and can easily be understood, if the article is re-read carefully.

We hope that this letter clarifies the issues raised by Dr. Okcesiz.