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Amin. Plast Aesthet Res 2022;9:24 https://dx.doi.org/10.20517/2347-9264.2021.119 Page 3 of 10

Figure 1. Decision making for complex lower limb reconstruction in the future will likely be bespoke and utilize autologous
reconstructive techniques where possible. When this is unsatisfactory, transplantation, bionics and tissue engineering may offer
alternative solutions.

It can be argued, amongst other reasons, that there are two caveats to performing VCA on a routine basis.
Firstly, cell death and necrosis after procurement and reperfusion impact donor health and the allograft.
Secondly, VCA is not life-saving, and the need for life-long immunosuppression increases the risk of cancer,
infection, major causes of post-transplant morbidity and mortality [28-30] . Moreover, the prospect of revision
amputation of the lower limb must be carefully considered given one recipient ceased immunosuppression
after being diagnosed with lymphoma . Establishing which patients advance best after
[31]
salvage/replantation, modern-day prostheses, or VCA is challenging . Given the low number of VCA,
[32]
randomised clinical trials providing a meaningful comparison between alternative strategies is yet to exist.

MODERN-DAY PROSTHESES AND STATE OF THE ART
Functional outcomes from modern-day lower limb prostheses can be excellent [15,33] but must be able to
[34]
withstand considerable forces transmitted via the residuum . The goal is a healed residuum with prosthetic
[35]
fit that is painless and provides acceptable function . Socket fit is influenced by trauma, oedema, atrophy,
body habitus and changing temperature and is further complicated by pressure sores, blisters, infection and
pistoning [36,37] . Bone anchored prostheses were designed to tackle poor prosthetic fit and address many
complicating factors. The theoretical advantage is that bypassing soft tissues and transmitting force to
skeletal components reduces energy expenditure and preserves the health of residuum. This has been met
with a further improvement in gait efficiency, quality of life, range of motion and prosthetic uptake [38,39] .
Movement at the knee is controlled by mechanical (passive, impedance controlled by friction/hydraulics) or
microprocessor-controlled devices (impedance adjusted by kinematics and force via prosthetic sensors
enabling predetermined states in various phases of gait). Foot microprocessors are often non-articulated
such as the solid ankle cushion heel or energy storage and return systems (compression springs for
propulsion). However, current systems still fall short in delivering embodiment and function.

Bionic prostheses are advanced active prostheses that aim to delivery subconscious, intuitive bidirectional
control between an electronic device and the nervous system. Communication is via a human-machine
interface, and despite advancing prostheses, the interface continues to pose numerous challenges. This
technology has witnessed significant advances, primarily from the application of myoelectric systems.
Electrodes in contact with innervated muscle convey electromyographical signals to actuate prosthetic