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Hanwright PJ, Suresh V, Shores JT, Souza JM, Tuffaha SH. Current Concepts in Lower Extremity Amputation: A Primer for Plastic Surgeons. Plast Reconstr Surg 2023; 152:724e-736e. [PMID: 37768220 DOI: 10.1097/prs.0000000000010664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the goals of lower extremity reconstruction and identify clinical scenarios favoring amputation. 2. Understand lower extremity amputation physiology and biomechanics. 3. Review soft-tissue considerations to achieve durable coverage. 4. Appreciate the evolving management of transected nerves. 5. Highlight emerging applications of osseointegration and strategies to improve myoelectric prosthetic control. SUMMARY Plastic surgeons are well versed in lower extremity reconstruction for traumatic, oncologic, and ischemic causes. Limb amputation is an increasingly sophisticated component of the reconstructive algorithm and is indicated when the residual limb is predicted to be more functional than a salvaged limb. Although plastic surgeons have traditionally focused on limb salvage, they play an increasingly vital role in optimizing outcomes from amputation. This warrants a review of core concepts and an update on emerging reconstructive techniques in amputee care.
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Affiliation(s)
- Philip J Hanwright
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Visakha Suresh
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jaimie T Shores
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jason M Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center
| | - Sami H Tuffaha
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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The Major Extremity Trauma Research Consortium: Development and Impact of an Orthopaedic Trauma Research Program. J Am Acad Orthop Surg 2023; 31:945-956. [PMID: 37671450 DOI: 10.5435/jaaos-d-23-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 09/07/2023] Open
Abstract
The Major Extremity Trauma Research Consortium (METRC) is a unique and ongoing military-civilian collaboration that resulted in the largest orthopaedic trauma research enterprise to date. The Consortium was established in September 2009 with funding from the Department of Defense. It employs a centralized data coordinating center and has grown into a network of nearly 400 investigators at 70 clinical centers. METRC conducts large multicenter clinical research studies selected and designed to improve outcomes among severely injured military and civilian patients with extremity trauma. Over the past decade, the consortium has implemented 35 such studies distributed among 19 principal investigators, enrolled more than 23,000 patients, published 61 articles, and received more than $150 million in funding from the Department of Defense, Patient Centered Outcomes Research Institute, and National Institutes of Health. This unique multidisciplinary research platform is a powerful community capable of addressing the challenging issues related to the evaluation, treatment, and recovery after severe extremity trauma. This body of work received the 2023 Elizabeth Winston Lanier Kappa Delta Award. An overview of the METRC development, organization, and research focus areas is presented.
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Harrington CJ, Wade SM, Hoyt BW, Tintle SM, Potter BK, Souza JM. A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage. J Orthop Trauma 2023; 37:361-365. [PMID: 36750445 DOI: 10.1097/bot.0000000000002582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma. DESIGN Retrospective review. SETTING Level II trauma center. PATIENTS 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014. INTERVENTION We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS Early and late amputation rates, time to amputation, reason for amputation. RESULTS 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. CONCLUSIONS This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
- Uniformed Services University-Walter Reed Department of Surgery, 4301 Jones Bridge Road, Bethesda, MD; and
| | - Jason M Souza
- Departments of Plastic and Reconstructive Surgery and Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43212
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Wade SM, Harrington CJ, Hoyt BW, Melendez-Munoz AM, Potter BK, Souza JM. Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness. Mil Med 2023; 188:e584-e590. [PMID: 34591089 DOI: 10.1093/milmed/usab403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. MATERIALS AND METHODS We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. RESULTS Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. CONCLUSION Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.
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Affiliation(s)
- Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Jason M Souza
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Lalchandani GR, Hung NJ, Janghala A, Terry M, Morshed S. Total Talar and Navicular Extrusions: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00057. [PMID: 37440687 DOI: 10.2106/jbjs.cc.20.00517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
CASE A 15-year-old adolescent boy sustained both talar and navicular extrusions after a dirt-bike accident. The talus and navicular were discarded during initial debridement because of contamination. Given extensive soft-tissue injury and bone loss, the patient's family opted for transtibial amputation, as described by Ertl, over limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation were performed. CONCLUSION Transtibial amputation is a viable treatment option for total talar and navicular extrusions, particularly if an optimal functional outcome is unachievable with limb salvage. Simultaneous osteomyoplastic reconstruction and acute targeted muscle reinnervation can potentially decrease neuroma formation and phantom limb pain.
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Affiliation(s)
- Gopal R Lalchandani
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Nicole J Hung
- University of California San Francisco, San Francisco, California
| | - Abhinav Janghala
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Michael Terry
- Division of Plastic and Reconstructive Surgery, UCSF Department of Surgery, San Francisco, California
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
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Hyperbaric oxygen adjuvant therapy in severe mangled extremities. Injury 2021; 52:3511-3515. [PMID: 34256945 DOI: 10.1016/j.injury.2021.06.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 06/15/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mangled Extremity Severity Score (MESS) was first described more than 30 years ago by attempting to predict the need for empiric amputation. In severe traumatic crush and blast injuries, achieving satisfactory limb salvage may be difficult. Notably, a MESS of 7 or higher is consistently predictive of amputation. Additionally, Hyperbaric Oxygen Therapy (HBOT) has been described for many purposes, and related studies have reported HBOT showed benefits in wound healing properties. OBJECTIVE The study aimed to evaluate the results of a prospective series of a new modality of adjuvant HBOT for severe mangled extremities. METHOD A total of 18 patients were evaluated for clinical and radiographic review. Current standard treatments followed by adjuvant HBOT were administered, and the mean follow-up period was 22 months. Time to wound closure, the number of surgeries and adjuvant HBOT treatment were analyzed for patient clinical evaluation. Complications and limb amputation rates were also recorded. RESULT Most clinical findings on follow-up were good to excellent after adjunctive HBOT. Minimal soft tissue infection was recorded, and limb salvage was successful in most cases. Only 1 patient (5.56 %) needed limb amputation because of a dying limb with chronic refractory osteomyelitis. CONCLUSION HBOT is an excellent adjunctive option in severely mangled extremities. Nevertheless, the main treatments are eliminating infection and managing surgery, and are promising in the recovery of severe extremity injuries. Although the MESS was evaluated at 7 or higher, limb salvage procedures followed by HBOT should be considered.
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Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am 2021; 103:1588-1597. [PMID: 33979309 DOI: 10.2106/jbjs.20.01320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation. METHODS This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work. RESULTS The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval [CI] = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns. CONCLUSIONS Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Effect of Severe Distal Tibia, Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury. Arch Phys Med Rehabil 2021; 103:409-417.e2. [PMID: 34425087 DOI: 10.1016/j.apmr.2021.07.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA. DESIGN Secondary analysis of observational cohort study. SETTING A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328). INTERVENTIONS None. MAIN OUTCOME MEASURES The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week. RESULTS Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31). CONCLUSIONS Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.
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American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary for Limb Salvage or Early Amputation. J Am Acad Orthop Surg 2021; 29:e628-e634. [PMID: 33878076 DOI: 10.5435/jaaos-d-20-00188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 02/21/2021] [Indexed: 02/01/2023] Open
Abstract
Clinical Practice Guideline for Limb Salvage or Early Amputation is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to address treatment for severe lower limb trauma below the distal femur by either amputation or limb salvage by providing evidence-based recommendations for key decisions that affect the management of patients with lower extremity trauma. This guideline contains 11 recommendations to evaluate the decision factors important for limb salvage versus early amputation. In addition, the work group highlighted the need for better research in the treatment and the shared decision making process of high-energy lower extremity trauma.
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Schnetzke M, El Barbari J, Schüler S, Swartman B, Keil H, Vetter S, Gruetzner PA, Franke J. Vascular impulse technology versus elevation for the reduction of swelling of lower extremity joint fractures: results of a prospective randomized controlled study. Bone Joint J 2021; 103-B:746-754. [PMID: 33789481 PMCID: PMC9950846 DOI: 10.1302/0301-620x.103b4.bjj-2020-1260.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. METHODS A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). RESULTS The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (ppreop = 0.05; pdischarge < 0.001) and need for narcotics (ppreop = 0.064; ppostop = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. CONCLUSION Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746-754.
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Affiliation(s)
- Marc Schnetzke
- German Joint Centre Heidelberg, ATOS Clinic Heidelberg, Heidelberg, Germany,Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany,Correspondence should be sent to Marc Schnetzke. E-mail:
| | - Jan El Barbari
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Svenja Schüler
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Benedict Swartman
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Holger Keil
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Sven Vetter
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Paul Alfred Gruetzner
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Jochen Franke
- Department for Traumatology and Orthopaedics, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
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Functional Limb Restoration Through Amputation: Minimizing Pain and Optimizing Function With the Use of Advanced Amputation Techniques. Ann Surg 2021; 273:e108-e113. [PMID: 33378296 DOI: 10.1097/sla.0000000000003942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the role of advanced orthoplastic techniques in harnessing the full potential of elective amputation as a functionally restorative procedure. SUMMARY OF BACKGROUND DATA Once considered the unfortunate consequence of failed reconstructive efforts, recent outcomes studies have prompted a re-evaluation of the role of amputation in the management of complex extremity trauma. However, even as amputation is appropriately afforded greater consideration as part of the reconstructive algorithm, reconstructive techniques that are commonly utilized in pursuit of limb salvage are rarely applied to amputation. METHODS The following case demonstrates the successful application of orthoplastic reconstructive techniques to achieve optimal pain and functional outcomes in a 41-year-old active duty soldier who underwent an elective transtibial amputation after prolonged, limb salvage. RESULTS The patient presented with a large osteocutaneous proximal tibial defect secondary to trauma and subsequent osteomyelitis. The patient underwent a free scapular-parascapular fasciocutaneous flap to provide soft tissue coverage and facilitate the skeletal reconstruction necessary for either continued limb salvage or amputation. Due to tibial allodynia and severely limited ankle function, the patient subsequently elected for amputation in favor of continued limb salvage. Thus, a transtibial amputation was performed concurrently with a pedicled vascularized fibula to address the proximal tibial defect. A modified agonist-antagonist myoneural interface procedure was used to maximize post-amputation function, with creation of regenerative peripheral nerve interface constructs to prophylax against neurogenic pain. After the operation, the patient achieved improved function of the extremity with the use of a prosthesis and reported substantially improved pain while remaining on active duty in a warfighting military occupational specialty. CONCLUSIONS By addressing all of the reconstructive components commonly considered in limb salvage, an orthoplastic approach to amputation surgery can minimize pain and maximize the rehabilitative potential of the amputee.
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Ladlow P, Bennett N, Phillip R, Dharm-Datta S, McMenemy L, Bennett AN. Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma. J ROY ARMY MED CORPS 2018; 165:330-337. [PMID: 30415216 PMCID: PMC6839716 DOI: 10.1136/jramc-2018-001082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022]
Abstract
Introduction Individuals with delayed below-knee amputation have previously reported superior clinical outcomes compared with lower limb reconstruction. The UK military have since introduced a passive-dynamic ankle-foot orthosis (PDAFO) into its rehabilitation care pathway to improve limb salvage outcomes. The aims were to determine if wearing a PDAFO improves medium-term clinical outcomes and what influence does multidisciplinary team (MDT) rehabilitation have after PDAFO fitting? Also, what longitudinal changes in clinical outcomes occur with MDT rehabilitation and how do these results compare with patients with previous lower extremity trauma discharged prior to PDAFO availability? Methods We retrospectively evaluated levels of mobility, activities of daily living, anxiety, depression and pain in a heterogeneous group of 23 injured UK servicemen 34±11 months after PDAFO provision. We also retrospectively analysed 16 patients across four time points (pre-PDAFO provision, first, second and final inpatient admissions post-PDAFO provision) using identical outcome measures, plus the 6 min walk test. Results Outcomes were compared with previous below-knee limb salvage and amputees. Before PDAFO, 74% were able to walk and 4% were able to run independently. At follow-up, this increased to 91% and 57%, respectively. Mean depression and anxiety scores remained stable over time (p>0.05). After 3 weeks, all patients could walk independently (pre-PDAFO=31%). Mean 6 min walk distance significantly increased from 440±75 m (pre-PDAFO) to 533±68 m at last admission (p=0.003). The ability to run increased from 6% to 44% after one admission. Conclusions All functional and most psychosocial outcomes in PDAFO users were superior to previous limb salvage and comparable to previous below-knee amputees. The PDAFO facilitated favourable short-term and medium-term changes in all clinical outcome measurements.
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Affiliation(s)
- Peter Ladlow
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK
| | - N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK.,Blatchford, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK
| | - R Phillip
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK
| | - S Dharm-Datta
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK
| | - L McMenemy
- Centre for Blast Injury Studies (CBIS), Imperial College London, London, UK
| | - A N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, UK.,National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
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Affiliation(s)
- Jowan G Penn-Barwell
- Orthopaedic Trauma Surgeon, Institute of Naval Medicine, Gosport, Hampshire, UK.
| | - Philippa M Bennett
- Orthopaedic Trauma Surgeon, Institute of Naval Medicine, Gosport, Hampshire, UK
| | - Andrew C Gray
- Orthopaedic Trauma Surgeon, Institute of Naval Medicine, Gosport, Hampshire, UK
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