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Page 2 of 10 Amin. Plast Aesthet Res 2022;9:24 https://dx.doi.org/10.20517/2347-9264.2021.119

of injury, patient condition, and available expertise. Depression, anxiety, substance abuse, and suicidal
ideation can be significant months after injury, emphasising the importance of delivering a holistic
[1]
approach .

Further reconstructive surgery using autologous tissues (nerve, muscle, soft tissue flaps, bone) provide a
platform to replace and rebuild missing parts when available. When the desired outcome is unachievable,
amputation with or without the incorporation of prostheses remains an acceptable treatment option. A
healed and anatomically well-shaped residuum is crucial if not compromised by obesity, diabetes,
[2,3]
cardiovascular disease and phantom limb pain (PLP) . Corrective surgery at the residuum to address PLP
(affects the quality of life in 65%-80% of lower limb amputees ), complex regional pain syndrome, bone
[4]
[5]
spurs and delayed healing equally prohibit the use of prostheses increasing the rate of revision . A
[6]
proportion of lower limb amputees with the aid of a prosthesis return to work (50%). Few are able enough
to return to their premorbid occupations [3 in 9 below-knee amputees (BKA) ]. During ambulation, mean
[7]
oxygen consumption rises (9% increase after BKA, 49% unilateral above knee and 280% bilateral above
knee) . This review briefly addresses the limitations that can be encountered using the conventional
[8]
reconstructive armamentarium. Competing technologies continue to evolve, and bionic solutions may offer
widespread functional benefit as a limb replacement strategy in the absence or presence of severely
compromised tissues [Figure 1].

LOWER LIMB RECONSTRUCTION
Complex lower limb injury after open fracture results in considerable loss of function and is primarily
accounted for by road traffic accidents in 65% of cases [9-11] . The last two decades have seen significant
advances in surgical approach and service-led management, such that limbs previously deemed non-
salvageable forego amputation. In spite of this, after salvage, infection, thrombosis, impaired bone healing,
and revision surgery are not uncommon . The Lower Extremity Assessment Project found that the
[12]
[11]
likelihood of amputation increases in the presence of complex fractures, muscle injury, vascular injury and
large skin defects with mass contamination and absent plantar sensation . It has been argued that limb
[13]
salvage outcomes are not dissimilar from amputation, but formal comparisons do not always address the
wider complexities after lower limb injury .
[14]
The current reconstructive armamentarium often satisfies the common goal of limb length preservation,
adequate stable soft tissue cover for weight bearing and sensory recovery . Recognising the zone of injury
[15]
can be challenging, and the failure rate of fasciocutaneous and muscle flaps are reportedly 8%-9% [16,17] . Limb
shortening after segmental tissue loss can lead to a discrepancy that, when significant, gives rise to
unfavourable function . Bone transport/distraction osteogenesis often require prolonged recovery and
[18]
rehabilitation, and in some instances, patients request a voluntary amputation [19,20] . Isolated bone defects can
be addressed by grafts (vascularised/non-vascularised) [21-24] or more advanced techniques
(Masquelet et al. , Capanna ). Collectively, this comes at the expense of a donor site and, in complex
[26]
[25]
cases, delays rehabilitation.

TRANSPLANTATION
The most achievable yet realistic strategy to replace “like with like” is transplantation. Vascularised
composite allotransplantation (VCA) enables the transfer of multiple tissues (skin, muscle, bone, nerve,
vessel). The enthusiasm for lower limb transplantation has yet to mirror that of the upper extremity. This is
despite United States estimates suggesting the pool of lower limb amputees exceeds the upper limb by three
times . Though rare, lower limb transplantation has witnessed active knee flexion, extension, ankle motion
[27]
and sensory recovery.