Mangled extremity- Modern concepts in treatment

      Highlights

      • A mangled extremity is the most devastating limb injury and presents a challenge
      • Two main treatment options, reconstruction or amputation
      • Early extremity reconstruction should be the treatment of choice where possible
      • In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity

      Abstract

      A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

      Keywords

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Bumbasirevic M
        • Stevanovic M
        • Lesic A
        • Atkinson HD.
        Current management of the mangled upper extremity.
        Int Orthop. 2012; 36: 2189-2195
        • Gregory RT
        • Gould RJ
        • Peclet M
        • Wagner JS
        • Gilbert DA
        • Wheeler JR
        The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity.
        J Trauma. 1985; 25: 1147-1150
        • Prasarn ML
        • Helfet DL
        • Kloen P.
        Management of the mangled extremity.
        Strategies Trauma Limb Reconstr. 2012; 7: 57-66
        • Wolinsky PR
        • Webb LX
        • Harvey EJ
        • Tejwani NC.
        The mangled limb: salvage versus amputation.
        Instr Course Lect. 2011; 60: 27-34
        • McKinley TO
        • D Alleyrand SC
        • Valerio I
        • Tetsworth K
        • Elster EA
        Management of the mangled extremities and orthopaedic war injuries.
        J Orth Trauma. 2018; 32: S37-S42
        • Covey DC.
        Blast and fragment injuries of the musculoskeletal system.
        J Bone Joint Surg [Am]. 2002; 84A: 1221-1234
        • Okike K
        • Bhattacharyya T.
        Trend in the management of the open fractures, a critical analysis.
        J Bone Joint Surg [Am]. 2006; 88: 2739-2748
        • Tindle S.
        • Baechler M
        • Nanos PG
        • Forsberg JA
        • Potter BK.
        Traumatic and trauma-related amputations.
        J Bone Joint Surg. 2010; 92: 2934-2945
        • Miller EA
        • Iannuzzi NP
        • Kennedy SA.
        Management of the mangled upper extremity.
        J Bone Joint Surg. 2018; 6: 1-12
        • Fisher MT
        • Riehl JT.
        Orthopaedic tips: the mangled extremity.
        J Bone Joint Surg. 2017; 5: 1-4
        • Muderis MA
        • Tetsworth K
        • Khemka A.
        The osteointegration Group of Australian Accelerated Protocol (OGAAP-1) for two-stage osteointegrated reconstruction of amputated limbs.
        J Bone Joint Surg. 2016; 98-B: 952-960
        • Muderis MA
        • Khemka A
        • Lord SJ
        • et al.
        Safety of osteointegrated implants for transfemoral amputees: a two-center prospective cohort study.
        J Bone Joint Surg Am. 2016; 98: 900-909
        • Bumbasirevic M
        • Lesic A
        • Palibrk T
        • Georgescu A
        • Matei IR
        • Vucetic C
        What microsurgeon, orthopedic and plastic surgeon should know about bionic hand.
        Injury. 2019; 50: 137-140
        • Petrini FM
        • Valle G
        • Bumbasirevic M
        • Barberi F
        • Bortolotti D
        • Čvančara P
        • et al.
        Enhancing functional abilities and cognitive integration of the lower limb prosthesis.
        Sciencia Translational Medicine. 2019; 11: eaav 8939
        • Petrini FM
        • Bumbasirevic M
        • Valle G
        • Ilić V
        • Mijović P
        • Čvančara P
        • et al.
        Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain.
        Nature Med. 2019; 25: 1356-1363
        • Bumbaširević M
        • Lesic A
        • Palibrk T
        • Milovanovic D
        • Zoka M
        • Kravić-Stevović T
        The current state of bionic limbs from the surgeon's viewpoint.
        EFORT Open Rev. 2020; 5: 65-72
        • Kuiken TA
        • Miller LA
        • Lipschutz RD
        • et al.
        Targeted reinnervation for enhanced prosthetic arm function in a woman with a proximal amputation: a case study.
        Lancet. 2007; 369: 371-380
        • Hargrove LJ
        • Simon AM
        • Young AJ
        • et al.
        Robotic leg control with EMG decoding in an amputee with nerve transfers.
        N Engl J Med. 2013; 369: 1237-1242
        • Pasquina PF
        • Evaangelista M
        • Carvalho AJ
        • et al.
        Firts in-in-man demonstration of fully implanted myoelectric sensor systems to control an advanced electromechanical prosthetic hand.
        J Neurosci Methods. 2015; 244: 85-93
        • Weber DJ
        • Friesen R
        • Miller LE.
        Interfacing the somatosensory system to restore touch and proprioception: essential considerations.
        J Mot Behav. 2012; 44: 403-418
        • Navarro X
        • Krueger TB
        • Lago N
        • Micera S
        • Stieglitz T
        • Dario P.
        A critical review of interfaces with the peripheral nervous system for the control of neuroprostheses and hybrid bionic systems.
        J Peripher Nerv Syst. 2005; 10: 229-258
        • Rossini PM
        • Micera S
        • Benvenuto A
        • et al.
        Double nerve intraneuralinterface implant on a human amputee for robotic hand control.
        Clin Neurophysiol. 2010; 121: 777-783
        • Bosse MJ
        • MacKenzie EJ
        • Kellam JF
        • Burgess AR
        • Webb LX
        • Swiontkowski MF
        An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.
        N Engl J Med. 2002; 347: 1924-1931
        • Rickard RF
        • Hudson DA.
        A history of vascular and microvascular surgery.
        Ann Plast Surg. 2014; 73: 465-472
        • Chen ZW
        • Zeng BF.
        Replantation of the lower extremity.
        Clinics Plastic Surg. 1983; 10: 103-113
        • Bumbaširević M
        • Lešić A
        • Palibk T
        • Georgescu AV
        • Matei IR
        • Tabaković D
        Lower limb replantation: 27 years follow up.
        Injury. 2020; 51: S77-S80
        • Peacock K
        • Tsai TM.
        Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation.
        Clin Orthop Relat Res. 1987; 214: 153-159
        • Bueno Jr, RA
        • Neumeister MW.
        Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment.
        Hand Clin. 2003; 19: 193-204
        • Stevanovic M
        • Gutow AP
        • Sharpe F.
        The management of bone defects of the forearm after trauma.
        Hand Clin. 1999; 15: 299-318
        • Brown JB
        • Cannon B
        • Graham B
        • Davis WB.
        Restoration of major defects of the arm by combination of plastic, orthopedic and neurologic surgical procedures.
        Plast Reconstr Surg. 1949; 4: 337-340
        • Bumbasirevic M
        • Lesic A
        • Mitkovic M
        • Bumbasirevic V.
        Treatment of blast injuries of the extremity.
        J Am Acad Orthop Surg. 2006; 14: 77-81
        • Malt RA
        • Mc Khann C
        Replantation of severe arms.
        JAMA. 1964; 189: 716-722
        • Hansen Jr., ST
        The type IIIc tibial fracture. Salvage or amputation.
        J Bone Joint Surg Am. 1987; 69: 799-800
        • Korompilias AV
        • Beris AE
        • Lykissas MG
        • Vekris MD
        • Kontogeorgakos VA
        • Soucacos PN.
        The mangled extremity and attempt for limb salvage.
        J Orthop Surg Res. 2009; 13: 4
        • Langer V.
        Management of major limb injuries.
        Sci World J. 2014; 2014640430
        • Probe RA.
        Orthopaedic trauma mythbusters: is limb salvage the preferred method of treatment for the mangled lower extremity?.
        Instr Course Lect. 2013; 62: 35-40
        • Chung KC
        • Saddawi-Konefka D
        • Haase SC
        • Kaul G.
        Cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures.
        Plast Reconstr Surg. 2009; 124: 1965-1973
        • Bondurant FJ
        • Cotler HB
        • Buckle R
        • Miller-Crotchett P
        • Browner BD.
        The medical and economic impact of severely injured lower extremities.
        J Trauma. 1988; 28: 1270-1273
        • Slauterbeck JR
        • Britton C
        • Moneim MS
        • Clevenger FW.
        Mangled extremity severity score: an accurate guide to treatment of the severity injured upper extremity.
        J Orthop Trauma. 1994; 8: 282-285
        • Johansen K
        • Daines M
        • Howey T
        • Helfet D
        • Hansen Jr., ST
        Objective criteria accurately predict amputation following lower extremity trauma.
        J Trauma. 1990; 30: 568-573
        • Helfet DL
        • Howey T
        • Sanders R
        • Johansen K.
        Limb salvage versus amputation. preliminary results of the Mangled Extremity Severity Score.
        Clin Orthop Relat Res. 1990; 256: 80-86
        • Kiran Kumar M
        • Badole CM
        • Patond KR
        Salvage versus amputation: utility of mangled extremity severity score in severely injured lower limbs.
        Indian J Orthop. 2007; 41: 183-187
        • Loja MN
        • Sammann A
        • DuBose J
        • Li CS
        • Liu Y
        • Savage S
        The mangled extremity score and amputation: time for revision.
        J Trauma Acute Care Surg. 2017; 82: 518-523
        • Fochtmann A
        • Binder H
        • Rettl G
        • Starlinger J
        • Asymann O
        • Sarahrudi K
        Third degree open fractures and traumatic sub-/total amputations of the upper extremity: outcome and relevance of the mangled extremity severity score.
        Orthop Trumatol Surg Res. 2016; 102: 785-790
        • Russell WL
        • Sailors DM
        • Whittle TB
        • et al.
        Limb salvage versus traumatic amputation: a decision based on a seven-part predictive index.
        Ann Surg. 1991; 213: 473-480
        • McNamara MG
        • Heckman JD
        • Corley FG.
        Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS).
        J Orthop Trauma. 1994; 8: 81-87
        • Howe HR
        • Poole GV
        • Hansen KJ
        • Clark T
        • Plonk GW
        • LA Koman
        Salvage of lower extremities following combined orthopedic and vascular trauma. a predictive salvage index.
        Am Surg. 1987; 53 (JrJr): 205-208
        • Rajasekaran S
        • Sabapathy SR
        • Dheenadhayalan J
        • Sundararajan SR
        • Venkatramani H
        • Devendra A
        Ganga hospital open injury score in management of open injuries.
        Eur J Trauma Emerg Surg. 2015; 41: 3-15
        • Rajasekaran S
        • Giannoudis PV.
        Open injuries of the lower extremity.
        Injury. 2012; 43: 1783-1784
        • Rüedi TP
        • Buckley RE
        • Moran CG.
        AO principles of fracture management.
        Fracture reduction (p 166). 2nd ed. Georg Thieme Verlag, Stuttgart New York2007: 164-186
        • Scalea TM
        • DuBose J
        • Moore EE
        • West M
        • Moore FA
        • McIntyre R
        Western Trauma Association critical decisions in trauma: management of mangled extremity.
        J Trauma Acute Care Surg. 2012; 72: 86-93
        • Schirò GR
        • Sessa S
        • Piccioli A
        • Maccauro G.
        Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system.
        BMC Musculoskelet Disord. 2015; 16: 372
        • Durham RM
        • Mistry BM
        • Mazuski JE
        • Shapiro M
        • Jacobs D.
        Outcome and utility of scoring systems in the management of the mangled extremity.
        Am J Surg. 1996; 172: 569-574
        • Dirschl DR.
        • Dahners LE.
        The mangled extremity: when should it be amputated?.
        J Am Acad Orthop Surg. 1996; 4: 182-190
        • Lange RH
        • Bach AW
        • Hansen Jr, ST
        • Johansen KH.
        Open tibial fractures with associated vascular injuries: prognosis for limb salvage.
        J Trauma. 1985; 25: 203-208
        • Barla M
        • Gavanier B
        • Mangin M
        • Parot J
        • Bauer C
        • Mainard D.
        Is amputation a viable treatment option in lower extremity trauma?.
        Orthop Traumatol Surg Res. 2017; 103: 971-975
        • Fodor L
        • Sobec R
        • Sita-Alb L
        • Fodor M
        • Ciuce C.
        Mangled lower extremity: can we trust the amputation scores?.
        Int J Burns Trauma. 2012; 2: 51-58
        • Hertel R
        • Strebel N
        • Ganz R.
        Amputation versus reconstruction in traumatic defects of the leg outcome and costs.
        J Orthop Trauma. 1996; 10: 223-229
        • Neumeister MW
        • Brown RE.
        Mutilating hand injuries: principles and management.
        Hand Clin. 2003; 19: 1-15
        • Graham B
        • Adkins P
        • Tsai TM
        • Firrel J
        • Breidenbach WC.
        Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study.
        J Hand Surg [Am]. 1998; 23: 783-791
        • Gorche TS
        • Wood MB.
        Mutilating corn-picker injuries of the hand.
        J Hand Surg Am. 1988; 13: 423-427
        • Ring D
        • Jupiter JB.
        Mangling upper limb injuries in industry.
        Injury. 1999; 30: B5-13
        • Green DP
        • Rowland SA.
        Fractures and dislocations of the hand. In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green's Fractures in Adults.
        Philadelphia: JB Lippincott Co. 1991; : 441-561
        • Bernstein ML
        • Chung KC.
        Early management of the mangled upper extremity.
        Injury. 2007; 38: S3-S7
        • Wei FC
        • Chang YL
        • Chen HC
        • Chuang CC.
        Three successful digital replantations in a patient after 84, 86 and 94h of cold ischemia time.
        Plast Reconstr Surg. 1988; 82: 346-350
        • McGee DL
        • Dalsey WC.
        The mangled extremity. compartment syndrome and amputations.
        Emerg Med Clin North Am. 1992; 10: 783-800
        • Burkhalter W.
        Mutilating injuries of the hand.
        Hand Clin. 1986; 2: 45-68
        • Brown PW.
        The fate of exposed bone.
        Am J Surg. 1979; 137: 464-469
        • 3rd Boyd JI
        • MD Wong Wongworawat
        High-pressure pulsatile lavage causes soft tissue damage.
        Clin Orthop Relat Res. 2004; 427: 13-17
        • Hassinger SM
        • Harding G
        • Wong Wongworawat MD
        High-pressure pulsatile lavage propagates bacteria in to soft tissue.
        Clin Orthop Relat Res. 2005; 439: 27-31
        • Byrd HS.
        Discussion of microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results.
        Plast Reconstrct Surg. 1992; 89: 488-489
        • Bumbasirevic M
        • Palibrk T
        • Georgescu AV
        • Soucacos P
        • Matei IR
        • Vucetic M
        Close-open-close free flap technique” for the cover of severely injured limbs.
        Injury. 2019; Suppl 50: S29-S31
        • Penn-Barwell JG
        • Murray CK
        Venke JC early anitbiotics and the debridement independently reduce infection in an open fracture model.
        J Bone Joint Surg [Br]. 2012; 94: 107-112
        • Wd Lack
        • Karanukan MA
        • Angerame MR
        • Seymour RB
        • Sims S
        • Kellam JF
        Type III open tibial fracture: immediate antibiotic prophylaxis minimize infection.
        J Orthop Trauma. 2015; 29: 1-6
        • Hoffman RD
        • Adams BD.
        Antimicrobial management of mutilating hand injuries.
        Hand Clin. 2003; 19: 33-39
        • Hildebrand F
        • Giannoudis P
        • Kretteck C
        • Pape HC
        Damage control: extremities.
        Injury. 2004; 35: 678-689
        • Shea KG
        • Fernandez DL
        • Casillas M.
        Fixation methods in contaminated wound and massive crush injuries of the forearm.
        Hand Clin. 1997; 13: 737-743
        • Bumbasirevic M
        • Stevanovic M
        • Bumbasirevic V
        • Lesic A
        • Atkinson HD.
        Free vascularised fibular grafts in orthopaedics.
        Int Orthop. 2014; 38: 1277-1282
        • Beris AE
        • Lykissas MG
        • Korompilias AV
        • Vekris MD
        • Mitsionis GI
        • Malizos KN
        Vascularized fibula transfer for lower limb reconstruction.
        Microsurgery. 2011; 31: 205-211
        • Soucacos PN
        • Korompilias AV
        • Vekris MD
        • Zoubos A
        Beris AE The free vascularized fibular graft for bridging large skeletal defects of the upper extremity.
        Microsurgery. 2011; 31: 190-197
        • Papakostidis C
        • Bhandari M
        • Giannoudis PV.
        Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis.
        Bone Joint J. 2013; 95-B: 1673-1680
        • Gulsen M
        • Ozkan C.
        Angular shortening and delayed gradual distraction of the treatment of asymmetrical bone and soft tissue defects of tibia: a case series.
        J Trauma. 2009; 66: E61-E66
        • Masquelet AC
        • Bégué T.
        The concept of induced membrane for reconstruction of long bone defects.
        Orthop Clin N Am. 2010; 41: 27-37
        • Giannoudis PV
        • Faour O
        • Goff T
        • Kanakaris N
        • Dimitriou R.
        Masquelet technique for the treatment of bone defects: tips-tricks and future directions.
        Injury. 2011; 42: 591-598
        • Pountos I
        • Giannoudis PV.
        Is there a role of coral bone substitutes in bone repair?.
        Injury. 2016; 47: 2606-2613
        • Alt V
        • Borgman B
        • Eicher A
        • Heiss C
        • Kanakaris NK
        • Giannoudis PV
        Effects of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III open tibia fractures treated with unreamed nails - A clinical and health-economic analysis.
        Injury. 2015; 46: 2267-2272
        • Giannoudis PV
        • medicine Einhorn TA Bone morphogenetic proteins in musculoskeletal
        Injury. 2009; 40: S1-S3
      1. Giannoudis PV . fracture healing and bone regeneration: autologous bone grafting or BMPs? Injury. 2009; 40(12): 1243–4.

        • Giannoudis PV
        • Dinopoulos H
        • Tsiridis E
        Bone substitutes: an update.
        Injury. 2005; 36: S20-S27
      2. Dimitriou R, Giannoudis PV . Discovery and development of BMPs. Injury. 2005; 36 Suppl 3: S28–33.

        • Winkler T
        • Sass FA
        • Duda GN
        • Schmidt-Bleek K.
        A review of biomaterials in bone defect healing, remaining shortcomings and future opportunities for bone tissue engineering: the unsolved challenge.
        Bone Joint Res. 2018; 7: 232-243
        • Bilic R
        • Simic P
        • Jelic M
        • Stern-Padovan R
        • Dodig D
        • Pompe van Meerdervoort H
        Osteogenic protein-1 (BMP-7) accelerates healing of scaphoid non-union with proximal pole sclerosis.
        Int Orthop. 2006; 30: 128-134
      3. Heller L, Levin S. In: Bucholz RW, Heckman JD, Court-Brown C (eds). Bone and soft tissue reconstruction in Rockwood and Green's fractures in adults, 6th ed. Lippincott Co, Philadelphia, pp. 497–547.

        • Plecha EJ
        • Seabrook GR
        • Bandyk DF
        • Towne JB.
        Determinants of successful peroneal artery bypass.
        J Vasc Surg. 1993; 17: 97-105
        • Brown Re WTY.
        Use of “spare parts” in mutilated upper extremity injuries.
        Hand Clin. 2003; 19: 73-87
        • Brown HC
        • Williams HB
        • Woolhoise FM.
        Principles of salvage in mutilating hand injuries.
        J Trauma. 1968; 8: 319-332
        • Garcia RM
        • Ruch DS.
        Free flap functional muscle transfers.
        Hand Clin. 2016; 32: 397-405
        • Lundborg G
        • Dahlin L
        • Danielsen N
        • Zhao Q.
        Trophism, tropism, and specificity in nerve regeneration.
        J Reconstr Microsurg. 1994; 10: 345-354
        • Weber RA
        • Breidenbach WC
        • Brown RE
        • Jabaley ME
        • Mass DP.
        A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans.
        Plast Reconstr Surg. 2000; 106: 1036-1045
        • Stanec S
        • Stanec Z.
        Reconstruction of upper-extremity peripheral-nerve injuries with ePTFE conduits.
        J Reconstr Microsurg. 1998; 14: 227-232
        • Mackinnon SE
        • Dellon AL.
        Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube.
        Plast Reconstr Surg. 1990; 85: 419-424
        • Moucharafieh RC
        • Badra MI
        • Boulos KA
        • Mansour JI
        • Daher JC
        • Wardani HM
        Nerve transfers in the upper extremity: a review.
        Injury. 2020; 51: 2804-2810
        • Ozcelik IB
        • Yildiran G
        • Mersa B
        • Sutcu M
        • Celik ZE
        • Ozalp T.
        A novel nerve transfer: the first palmar interosseous motor branch of the ulnar nerve to the recurrent motor branch of the median nerve.
        Injury. 2020; 51: S81-S83
        • Stancic MF
        • Eskinja N
        • Bellinzona M
        • Nicovic V
        • Stosic A
        • Tomljanovic Z.
        The role of interfascicular nerve grafting after gunshot wounds. a report of 44 cases.
        Int Orthop. 1996; 20: 87-91
        • Godina M.
        Early microvascular reconstruction of complex trauma of extremities.
        Plast Reconstrct Surg. 1986; 78: 285-292
        • Francel TJ
        • Ca Vander Kolk
        • Hoopes JE
        • Manson PN
        • Yaremchuk MJ
        Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results.
        Plast Reconstr Surg. 1992; 89: 478-487
        • Faibisoff B
        • Daniel RK.
        Management of severe forearm injuries.
        Surg Clin North Am. 1981; 61: 287-301
        • Levin LS.
        The reconstructive ladder. an orthoplastic approach.
        Orthop Clin North Am. 1993; 24: 393-409
        • Lenarz CJ
        • Watson JT
        • Moed BR
        • Israel H
        • Mullen JD
        • MacDonald JB.
        Timing of wound closure in open fractures based on cultures obtained after debridement.
        J Bone Joint Surg. 2010; 92A: 1921-1926
        • Liu DS
        • Sofiadellis F
        • Ashton M
        • MacGill K
        • Webb A.
        Early soft tissue coverage and negative pressure wound therapy optimizes patient outcomes in lower limb trauma.
        Injury. 2012; 43: 772-778
        • Crowley DJ
        • Kanakaris NK
        • Giannoudis PV
        Debridement and wound closure of open fractures: the impact of the time factor on infection rates.
        Injury. 2007; 38: 879-889
        • Pu LL.
        Soft-tissue coverage of extensive mid-tibial wound with the combined medial gastrocnemius and medial hemisoleus muscle flaps: the role of local muscle flaps revisited.
        Plast Reconstr Aesthet Surg. 2010; 63: 605-610
        • Bhatti A
        • Adeshola A
        • Ismael T
        • Harris N.
        Lower leg flaps comparison between free versus local flaps.
        Internet J Plast Surg (ISPUB.COM). 2006; 3: 1-8
        • Jordan DJ
        • Malahias M
        • Hindocha S
        • Juma A.
        Flap decision and options in soft tissue coverage of the lower limb.
        Open Orthop J. 2014; 8: 423-432
        • Tu YK
        • Yen CY
        • Ch Ma
        • Yu SW
        • Chou YC
        • al Lee MSand
        Soft-tissue injury management and flap reconstruction for mangled lower extremities.
        Injury. 2008; 39: 75-95
        • Grunert BK
        • Smith CJ
        • Devine CA
        • Fehring BA
        • Matloub HS
        • al Sanger JRand
        Early psychological aspects of severe hand injury.
        J Hand Surg Br. 1988; 13: 177-180
        • Freitas D
        • Warnack E
        • DiMaggio C
        • Frangos S
        • Klein M
        • Berry C
        Embolism but not deep venous thrombosis: results from the trauma quality improvement program database.
        J Surg Res. 2020; 248: 7-13
        • Granchi T
        • Schmittling Z
        • Vaszquez J
        • Schreiber M
        • Wall M.
        Prolonged use of intraluminal arterial shunts without systemic anticoagulation.
        Am J Surg. 2000; 180: 493-496
        • Harris AM
        • Althausen PL
        • Kellam J
        • Bosse MJ
        • Castillo R
        Lower Extremity Assessment Project (LEAP) study group complications following limb-threatening lower extremity trauma.
        J Orthop Trauma. 2009; 23: 1-6
        • Lutz BS
        • Klauke T
        • Dietrich FE
        Late results after microvascular reconstruction of severe crush and avulsion injuries of the upper extremity.
        J Reconstr Micosurg. 1997; 13: 43-49
        • Jupiter JB
        • Pess GM
        • Bour CJ.
        Results of flexor tendon tenolysis after replantation in the hand.
        J Hand Surg Am. 1989; 14: 35-44
        • Russel RC
        • Bueno Jr, RA
        • Wu TY.
        Secondary procedures following mutilating hand injuries.
        Hand Clin. 2003; 19: 149-163
        • Morrison WA
        • Macleod AM
        • O'Brien BM.
        Digital reconstruction in the mutilated hand.
        Ann Plast Surg. 1982; 9: 392-399
        • Shores JT
        • Imbriglia JE
        • Lee WP.
        The current state of hand transplantation.
        J Hand Surg Am. 2011; 36: 1862-1867
        • Siemionow M
        • Ozer K.
        Advances in composite tissue allograft transplantation as related to the hand and upper extremity.
        J Hand Surg Am. 2002; 27: 565-580
        • Foroohar A
        • Elliot RM
        • Kim TW
        • Breidenbach W
        • Shaked A
        • Levin LS.
        The history and evolution of hand transplant.
        Hand Clin. 2011; 27: 405-409