Factors contributing to delayed extremity amputation in burn patients

Transcutaneous osseointegration for amputees with burn trauma

OBJECTIVE

Transcutaneous osseointegration for amputees (TOFA) surgically implants a prosthetic anchor into the residual limb's bone, enabling direct skeletal connection to a prosthetic limb and eliminating the socket. TOFA has demonstrated significant mobility and quality of life benefits for most amputees, but concerns regarding its safety for patients with burned skin have limited its use. This is the first report of the use of TOFA for burned amputees.

METHODS

Retrospective chart review was performed of five patients (eight limbs) with a history of burn trauma and subsequent osseointegration. The primary outcome was adverse events such as infection and additional surgery. Secondary outcomes included mobility and quality of life changes.

RESULTS

The five patients (eight limbs) had an average follow-up time of 3.8 ± 1.7 (range 2.1-6.6) years. We found no issues of skin compatibility or pain associated with the TOFA implant. Three patients underwent subsequent surgical debridement, one of whom had both implants removed and eventually reimplanted. K-level mobility improved (K2 +, 0/5 vs 4/5). Other mobility and quality of life outcomes comparisons are limited by available data.

CONCLUSION

TOFA is safe and compatible for amputees with a history of burn trauma. Rehabilitation capacity is influenced more by the patient's overall medical and physical capacity than their specific burn injury. Judicious use of TOFA for appropriately selected burn amputees seems safe and merited.

Burn Center Patients at Risk for Upper Extremity Amputations

Introduction Burn center patients present not only with burn injuries but also necrotizing infections, purpura fulminans, frostbite, toxic epidermal necrolysis, chronic wounds, and trauma. Burn surgeons are often faced with the need to amputate when limb salvage is no longer a viable option. The purpose of this study was to determine factors which predispose patients to extremity amputations. Methods: This retrospective registry review (2000-2019) compared patients who required upper extremity amputations with those who did not. Cases were pair-matched by age, sex, percent total body surface area (%TBSA), and type/location of injury to control for possible confounding variables. Results: There were 77 upper extremity amputee patients (APs) and 77 pair-matched non-amputees (NAPs) with the median age 45- and 43-years, %TBSA 21 and 10, respectively; second and third degree burn injuries were similar in the 2 groups. The AP group had longer hospitalizations (median 40 vs 15 days) P < .0001, with more intensive care unit days (median 28 vs 18 days). APs presented with significantly more cardiac, renal, and pulmonary comorbidities, acquired infections (61 [64%] vs 35 [36%]), escharotomies, and fasciotomies than the NAP, P < .0001. Mortality was similar (AP 14 [18.2%] vs NAP 9 [11.7%]), P = .26. Conclusions: Escharotomies, fasciotomies, sepsis, pneumonia, wound, and urinary tract infections contributed to prolonged hospitalizations and increased risk for upper extremity amputations in the AP group.

Revision Surgery Following Severe Frostbite Injury Compared to Similar Hand and Foot Burns

Severe frostbite is associated with loss of digits or limbs and high levels of morbidity. The current practice is to salvage as much of the limb/digit as possible with the use of thrombolytic and adjuvant therapies. Sequelae from amputation can include severe nerve pain and poor wound healing requiring revision surgery. The aim of this study was to examine the rate of revision surgery after primary amputation and compare this to revision surgery in isolated hand/foot burns. Frostbite and burn patients from 2014 to 2019 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with primary amputations related to isolated hand/foot burns or frostbite were included in the study. Descriptive statistics included Student's t-test and Fisher's exact test. A total of 63 patients, 54 frostbite injuries and 9 isolated hand or foot burns, met inclusion criteria for the study. The rate of revision surgery was similar following frostbite and burn injury (24% vs 33%, P = .681). There were no significant differences in age, sex, or length of stay on the primary hospitalization between those that required revision surgery and those that did not. Neither the impacted limb nor the presence of infection or cellulitis on primary amputation was associated with future need for revision surgery. Of the 16 patients requiring revision surgery, 5 (31%) required additional debridement alone, 6 (38%) required reamputation alone, and 5 required both. A total of 6 patients (38%) had cellulitis or infection at the time of revision surgery. Time from primary surgery to revision ranged from 4 days to 3 years. Planned, delayed primary amputation is a mainstay of frostbite management. To our knowledge, this is the first assessment of revision surgery in the setting of severe frostbite injury. Our observed rate of revision surgery following frostbite injury did not differ significantly from revision surgery in the setting of isolated hand or foot burns. This study brings up important questions of timing and surgical planning in these complex patients that will require a multicenter collaborative study.

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P = .009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P = .012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P = .010), electric (OR: 13.54; 95% CI: 6.23-29.45; P < .001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P < .001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study.

Review of Adult Electrical Burn Injury Outcomes Worldwide: An Analysis of Low-Voltage vs High-Voltage Electrical Injury

The aims of this article are to review low-voltage vs high-voltage electrical burn complications in adults and to identify novel areas that are not recognized to improve outcomes. An extensive literature search on electrical burn injuries was performed using OVID MEDLINE, PubMed, and EMBASE databases from 1946 to 2015. Studies relating to outcomes of electrical injury in the adult population (≥18 years of age) were included in the study. Forty-one single-institution publications with a total of 5485 electrical injury patients were identified and included in the present study. Fourty-four percent of these patients were low-voltage injuries (LVIs), 38.3% high-voltage injuries (HVIs), and 43.7% with voltage not otherwise specified. Forty-four percentage of studies did not characterize outcomes according to LHIs vs HVIs. Reported outcomes include surgical, medical, posttraumatic, and others (long-term/psychological/rehabilitative), all of which report greater incidence rates in HVI than in LVI. Only two studies report on psychological outcomes such as posttraumatic stress disorder. Mortality rates from electrical injuries are 2.6% in LVI, 5.2% in HVI, and 3.7% in not otherwise specified. Coroner's reports revealed a ratio of 2.4:1 for deaths caused by LVI compared with HVI. HVIs lead to greater morbidity and mortality than LVIs. However, the results of the coroner's reports suggest that immediate mortality from LVI may be underestimated. Furthermore, on the basis of this analysis, we conclude that the majority of studies report electrical injury outcomes; however, the majority of them do not analyze complications by low vs high voltage and often lack long-term psychological and rehabilitation outcomes after electrical injury indicating that a variety of central aspects are not being evaluated or assessed.

Should early amputation impact initial fluid therapy algorithms in burns resuscitation? A retrospective analysis using 3D modelling

AIMS

While the epidemiology of amputations in patients with burns has been investigated previously, the effect of an amputation on burn size and its impact on fluid management have not been considered in the literature. Fluid resuscitation volumes are based on the percentage of the total body surface area (%TBSA) burned calculated during the primary survey. There is currently no consensus as to whether the fluid volumes should be recalculated after an amputation to compensate for the new body surface area. The aim of this study was to model the impact of an amputation on burn size and predicted fluid requirement.

METHODS

A retrospective search was performed of the database at the Queen Elizabeth Hospital Birmingham Regional Burns Centre to identify all patients who had required an early amputation as a result of their burn injury. The search identified 10 patients over a 3-year period. Burn injuries were then mapped using 3D modelling software. BurnCase3D is a computer program that allows accurate plotting of burn injuries on a digital mannequin adjusted for height and weight. Theoretical fluid requirements were then calculated using the Parkland formula for the first 24 h, and Herndon formula for the second 24 h, taking into consideration the effects of the amputation on residual burn size.

RESULTS AND CONCLUSIONS

This study demonstrated that amputation can have an unpredictable effect on burn size that results in a significant deviation from predicted fluid resuscitation volumes. This discrepancy in fluid estimation may cause iatrogenic complications due to over-resuscitation in burn-injured casualties. Combining a more accurate estimation of postamputation burn size with goal-directed fluid therapy during the resuscitation phase should enable burn care teams to optimise patient outcomes.

Care for the patient with burns in the trauma rehabilitation setting

Caring for patients who are recovering from severe burns is not common in most rehabilitation settings. Nursing challenges include patients' physical and psychological changes and their high care demands. Harborview Medical Center, a regional level 1 burn and trauma center in Seattle, Washington, accepted these nursing challenges and developed a successful plan of care consistent with current evidence. This article describes Harborview Medical Center's trauma rehabilitation nursing experiences while caring for patients with burns. Our experiences may assist other rehabilitation units that serve patients with burns. Says one burn survivor: "Nurses make a huge difference in recovery, as they are there 24 hours a day. It is their touch, their caring, and their listening that aid the patient in his journey from fire victim to burn survivor."

Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis

The purpose of this study was to examine the epidemiology and outcomes of posttraumatic upper (UEA) and lower extremity amputations (LEA). The National Trauma Databank version 5 was used to identify all posttraumatic amputations. From 2000 to 2004 there were 8910 amputated patients (1.0% of all trauma patients). Of these, 6855 (76.9%) had digit and 2055 (23.1%) had limb amputation. Of those with limb amputation, 92.7 per cent (1904/2055) had a single limb amputation. LEA were more frequent than UEA among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt in 83 per cent; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001), whereas motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA. Patients with LEA were more likely to require discharge to a skilled nursing facility; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. Although single limb amputation did not impact mortality, the need for multiple limb amputation was an independent risk factor for death.

A case-matched controlled study on high-voltage electrical injuries vs thermal burns

The aim of this study was to provide an increased level of evidence on surgical management of high-tension electrical injuries compared with thermal burns using a case-controlled study design. Sixty-eight patients (64 males, 4 females, aged 33.7 +/- 13 years) with high-tension electrical burns were matched for age, gender, and burnt extent with a cohort of patients sustaining thermal burns. Data were analyzed for cause of accident (occupational vs nonoccupational), concomitant injuries, extent of burn and burn depth, surgical management, complications, and hospital stay. High-tension electrical burn patients required an average of 5.2 +/- 4 operations (range, 1-23 operations) compared with 3.3 +/- 1.9 (range, 1-10 operations) after thermal burns (P = .0019). Amputation rates (19.7% vs 1.5%), escharotomy/fasciotomy rates (47% vs 21%), and total hospitalization days (44 d vs 32 d) were significantly higher in high-tension electrical injuries (P < .05). Creatinine kinase levels were significantly elevated during the first 2 days in patients with subsequent amputations. Free flap failure was observed during the first 4 weeks after the trauma, whereas no flap failure occurred at later stages. Local, pedicled, and distant flaps were used in 15% of the patients. The mortality in both groups was 13.2% vs 11%, respectively (nonsignificant). High-voltage electrical injury remains a complex surgical challenge. When performing free flap coverage, caution must be taken for a vulnerable phase lasting up to 4 weeks after the trauma. This phase is likely the result of a progressive intima lesion, potentially hazardous to microvascular reconstruction. The use of pedicle flaps may resemble an alternative to free flaps during this period.

Pattern of limb amputation in a Kenyan rural hospital

Causes of limb amputations vary between and within countries. In Kenya, reports on prevalence of diabetic vascular amputations are conflicting. Kikuyu Hospital has a high incidence of diabetic foot complications whose relationship with amputation is unknown. This study aimed to describe causes of limb amputations in Kikuyu Hospital, Kenya. Records of all patients who underwent limb amputation between October 1998 and September 2008 were examined for cause, age and gender. Data were analysed using the statistical package for Social Sciences (SPSS) for Windows Version 11.50. One hundred and forty patients underwent amputation. Diabetic vasculopathy accounted for 11.4% of the amputations and 69.6% of the dysvascular cases. More prevalent causes were trauma (35.7%), congenital defects (20%), infection (14.3%) and tumours (12.8%). Diabetic vasculopathy, congenital defects and infection are major causes of amputation. Control of blood sugar, foot care education, vigilant infection control and audit of congenital defects are recommended.

Rehabilitation methods for the burn injured individual

Physiatrists play a critical role in managing the medical and functional consequences of serious burn injuries. Goals of rehabilitation include wound healing, scar prevention, hypertrophic scarring suppression, full range of motion, strengthening, and independent mobility and activities of daily living. This article is an overview of burn rehabilitation principles and patient management. The ultimate rehabilitation goal is independence in all spheres of an individual's life. Achievement of independence depends on the commitment of the injured individual and the entire health care team.

Thermal and electrical injuries

Through progress in wound management, resuscitation, intensive care treatment, and a coordinated rehabilitation process, modern burn care has been able to deliver substantial increases in survival and improvement in functional outcomes for burn victims. The development of regionalized burn centers has contributed greatly to this progress. As the field of burns matures, burn centers are preparing to meet future challenges through collaborative efforts in disaster management and outcomes research.

Seven years' experience with Integra as a reconstructive tool

The bilayered dermal substitute Integra (Integra Life Sciences Corp., Plainsboro, NJ) was developed and has been widely used as primary coverage for excised acute burns. Our take has been slightly different, finding it most useful in the management of complex soft-tissue loss and threatened extremities as the result of tendon, joint, or bone exposure. Often tasked to fill significant volume loss, we have become adept at stacked multiple-layer applications. Creative use of this material has resulted in unexpected successes with distal limb salvage; the technique takes its place beside adjacent tissue transfer, composite flaps, and vascular pedicle flaps in our burn reconstructive practice. A prospective registry (44 patients) has been kept during the past 7 years that catalogs wounds with complex soft-tissue loss treated with Integra grafts. Many of these patients were at risk of extremity loss because of exposed tendons, joints, or bone. Integra was applied after 1:1 meshing. With profound soft-tissue defects, multiple layers of Integra were serially applied 1 to 2 weeks apart for reconstitution of soft-tissue contours. Local Integra graft infections were managed by silicone unroofing followed by topical sulfamylon liquid dressings. Wounds addressed included fourth-degree burns, necrotizing fasciitis, pit-viper envenomations, and total abdominal wall avulsion in one patient after being run over by a bus. Patients generally were free of pain from their wounds during the maturation phase of the Integra neodermis. Restoration of tissue contour was significantly better when using multiple layers for deep defects. Second and third layers of Integra were successfully applied after an abbreviated first graft maturation period of 7 days. Epithelial autografts on multilayer Integra applications frequently "ghosted"; they would auto-digest to dispersed cells followed subsequently by the reappearance of a confluent epithelial layer. Final grafted skin morphology over palmar and plantar surfaces assumed the type and fingerprint pattern of the original tissues. Infections were readily visible. Early recognition kept them to easily treated circumscribed areas, which did not jeopardize the entire wound. Lengths of stay were long (range, 2-246 days) but not significantly greater than with traditional techniques. The specific reconstructive use of Integra permitted unexpected salvage of several threatened extremities by protecting exposed tendons, bones and joints. Long-term histologic examination revealed unexpected persistence of Integra collagen. Large volume loss wounds benefited from the ability to fill voids with multilayered applications.

Severe post-burn hyperextension of metatarsophalangeal joints in a child with bilateral foot contracture

Achieving a stable plantigrade foot after repair of complex post-burn deformities poses a particularly difficult challenge for the foot and ankle surgeon. We report an unusual case of a child with severe bilateral forefoot contracture deformities treated by soft tissue release and lengthening, and conventional wound coverage with split-thickness skin grafting.

Burns and Amputations: A 24-Year Experience

Although the management of the severely burnt extremity poses a significant therapeutic dilemma, burn injuries resulting in amputation are uncommon, In such cases, however, amputation can reduce the rate of mortality. In a total of 1858 patients from January 1980 to January 2004, there were 34 amputations in 27 patients. There were 23 men (age range, 14-64 years) and 4 women (age range, 34-85 years). The majority of amputations from burns caused by flame injury predominantly after motor vehicle accidents, with only eight cases resulting from high-voltage electrical injury. Nine patients required immediate amputations, with the rest being delayed. There were three deaths, with a survival rate of 89%. The majority of single lower-limb amputees and only one of seven bilateral amputees were independently mobile. The presence of pre-existing psychiatric disease significantly impaired rehabilitation. Free tissue transfer and the usage of bioengineered materials may help reduce the incidence of amputations.

Postburn Subtalar Dislocation in a Major Foot Contracture

An unusual postburn contracture, which consists of calcaneal bone dislocation and severe dorsiflexion contracture of foot and toes, is presented. To our knowledge, subtalar dislocation as the result of postburn contracture has not been previously reported in the literature.

Osteocutaneous pedicle flap of the foot for salvage of below-knee amputation level after burn injury

Lower extremity amputations are occasionally required after high-voltage electric and deep thermal burns. The extensive loss of skin and soft tissue after these injuries may make it difficult to fashion below-knee amputation that will readily tolerate a prosthesis. We have found an osteocutaneous pedicle fillet flap of the foot useful in the salvage of below-knee amputation after severe burn injury. Three patients have undergone this procedure after burn injury, 1 with burn secondary to high-voltage electric injury and 2 after deep thermal burns. All became ambulatory with artificial prostheses. There were no postoperative infections and no need for further revisions. The osteocutaneous pedicle fillet flap of the foot has proven to be a reliable form of below-knee stump coverage in patients with extensive soft tissue necrosis after burn injury.