Cover Story

Consider entire patient in salvage, amputation decisions

Targeted muscle reinnervation, osseointegration may provide solutions to prosthetic issues.

Upper extremity injuries are one of the most common presented in the ED, accounting for 20% to 40% of injuries, according to a report published by Kevin C. Chung, MD, and his colleagues.

However, Mark A. Mighell, MD, associate professor at University of South Florida and instructor of surgery for the military, noted most patients admitted to the hospital for severe upper extremity trauma also present with multiple other injuries. He said their treatment calls for a multidisciplinary approach that involves trauma, orthopedic, vascular and plastic surgeons.

Brent T. Wise, MD, said the goal of treating patients who have traumatic upper extremity injuries is to provide them with a viable, innervated and functional arm. When patients opt for amputation, adequate limb preservation will give them the best chance for prosthesis use, he said.

Source: The University of Kansas Health System

“Managing the mangled extremity requires a multidisciplinary team and a major trauma center. This is best accomplished in a major trauma center where the appropriate clinicians are accessible,” Mighell, commander of the U.S. Navy, retired, told Orthopedics Today. “You need to be where you have all of the subspecialties available to manage that patient.”

Focus on providing function

Once the patient is stabilized and life-threatening injuries have been addressed, Chung and his colleagues noted surgeons should perform a more detailed extremity exam. With the primary goal being to provide the patient with a viable, innervated and functional arm, Brent T. Wise, MD, orthopedic surgeon at the University of Kansas Health System, noted surgeons need to make sure the patient has adequate blood supply.

“Obviously, if there is no blood supply to the extremity, it cannot be salvageable or you have to do some type of intervention to restore the blood flow. That is something that has to be done within a relatively urgent fashion, if there is no blood supply to the limb,” Wise said.

Erin A. Miller, MD, and her colleagues noted in a report that surgeons should assess perfusion of the limb, with warm ischemia time exceeding 4 to 6 hours associated with an increased risk of compartment syndrome, infection and muscle death.

“If warm ischemia time exceeds 6 hours, the incidence of amputation is going to go up,” Mighell said. “It does not mean amputation is inevitable, but what we want to avoid is not getting any blood flow nourishment to the nerves, to the muscle, to the tissue of the limb [because] the cells will die.”

Mark A. Mighell

Mighell noted patients with either vascular injuries or a prolonged period of warm ischemia time should undergo a fasciotomy.

The nerves and neurologic status of the limb should also be assessed, according to Wise.

“It does not do much good if you do a beautiful surgery and put things together with plates and screws and have a great-looking X-ray, if the person has no muscular attachments or muscles do not work because the nerves are damaged or the blood supply is not adequate,” Wise told Orthopedics Today.

He added that bony involvement and what needs to be done as far as fixation of fractures and reducing and restoring joints should also be assessed.

R. Glenn Gaston

Possible complications in these scenarios include nonunion of bony fractures, as well as bony overgrowth or heterotopic ossification, according to R. Glenn Gaston, MD, fellowship director of the Hand and Upper Extremity Fellowship at OrthoCarolina and chief of hand surgery at Atrium Musculoskeletal Institute.

Soft tissue coverage

One major obstacle among patients with severe upper extremity trauma is soft tissue coverage, a technique that has been improved with the use of negative-pressure wound therapy, according to Miller and her colleagues.

Gaston noted timing of soft tissue coverage in patients with soft tissue defects is critical and coverage should be completed as early as possible to minimize complications.

At the University of Kansas Health System, Wise said surgeons start with minimal soft tissue coverage, such as being able to close the skin and have the tissue covering the bones and hardware. However, if there are still areas of exposed bone or metal from implants, he said surgeons need to use a skin flap.

“We start with local tissue flaps, which are taking muscle from the extremity and moving it to a different location to cover the area that needs to be covered,” Wise said. “If there is no viable muscle locally in the area, then we are talking about taking tissue from a different part of the body and transferring it along with the blood vessels to the arm to cover up and to reattach to the blood vessels in the arm.”

Once a patient begins to heal, Wise noted surgeons need to be aware of any wound healing difficulties and the potential for infection, which can be reduced through debridement of non-viable tissue and use of antibiotics throughout the course of the procedure.

Sources who spoke with Orthopedics Today noted patients should be made aware of the possibility of extreme pain and function loss even with removal of non-viable tissue, as well as stiffness, disfigurement and dysfunction.

“Once [patients] are through that acute phase where we are free of infection and our wounds are healing, then it is just a matter of physical therapy and rehab and monitoring their function and maximizing that in any way,” Wise said.

Mental health complications

In addition to the surgical team, David C. Ring, MD, PhD, associate dean for comprehensive care and professor of surgery and psychiatry at Dell Medical School, the University of Texas at Austin, noted it is important to have occupational or physical therapists, psychologists and social workers involved postoperatively. The mental health complications that can pre-exist or develop after injury, and may benefit from postoperative management, include depression or post-traumatic stress disorder, substance misuse, financial trouble, unemployment and homelessness.

David C. Ring

“As orthopedic surgeons, we say, ‘My job is to get the bone healed,’ or ‘My job is to get the person walking again.’ But, if you do not think about it and are not intentional about it, there is nobody to guide somebody through the emotional aspect of losing your life role, losing part of your identity, having your body be forever changed, and having to get used to that, how scary the injury was that you worry about being able to support your family, all of the things that come along [with it],” Ring told Orthopedics Today. “We should expect everyone to be going through a difficult, emotional recovery and we should be prepared to help with that.”

Surgeons may also help reduce mental health complications and promote faster healing by preparing patients for the possibility of painful movements after surgery, according to Ring.

“We can anticipate that people are going to be shy to do painful exercises because it is going to feel harmful. That is the way the human mind works,” Ring said. “So, if we anticipate that, we can help guide people and re-orient those thoughts so that they have a different story in mind, which is that ‘movers heal quicker’ and ‘movers heal better’.”

Limb salvage vs amputation

Jason H. Ko, MD, MBA, noted more severe complications in patients with severe upper extremity trauma include amputation, blood clots — including deep vein thrombosis and pulmonary emboli — and death.

Concerning limb salvage vs. amputation, surgeons should take into account patient risk factors, such as smoking status, whether the patient has diabetes, immunocompromised status, their age and overall health, Gaston said.

Mighell noted younger patients may have a lower risk of undergoing amputation because they are more likely to not become hypotensive and to have better collateral blood flow.

“At some point [surgeons] have to think about weighing the risks and the benefits of the surgery with regard to patients’ overall health status, and sometimes we make decisions based on whether we think an older, unhealthy patient can even withstand, not only one long surgery, but maybe a series of multiple surgeries over the next few weeks to months without causing any more major problems to their overall health,” Ko, associate professor for plastic and reconstructive surgery and orthopedic surgery at Northwestern University Feinberg School of Medicine, told Orthopedics Today.

Ko noted the decision to salvage or amputate the limb also depends on the “zone of injury” and how extensive and how proximal it is. He said another key consideration for whether the patient undergoes limb salvage or amputation is the extent of the injuries to the blood vessels and the nerves.

“Even if you replant or salvage the limb, if the nerves to the hand are not working, then you are essentially salvaging a useless extremity that could be significantly painful,” he said.

Chung and his colleagues noted use of the mangled extremity severity score (MESS) may help predict upper extremity limb loss through the assessment of severity of skeletal or soft tissue injury, severity and duration of limb ischemia, severity of shock and the patient’s age. However, these authors noted the MESS is not an effective predictor of salvage.

“The mangled extremity severity score is basically what we have to discriminate between salvageable and doomed limbs in the setting of lower extremity trauma,” Mighell, Editorial Board Member for Orthopedics Today, said. “It can be helpful in upper extremity trauma, but it is by no means ... an absolute indication that some patients can have their limbs amputated.”

Prosthetic options

Although restoring normal function to the limb may seem better than amputation and prosthesis, Ko noted the discussion of limb salvage vs. amputation is multifaceted and complex.

Jason H. Ko

“You can salvage a limb, but if it is painful ... [and] does not move, then the question is how good of a limb is it and is it actually better than an amputation and prosthesis?” Ko said.

However, despite great prosthetic options available for lower limb amputations, Wise noted the same cannot be said for the prostheses used after upper extremity amputations.

“There are continuing to be advances with myoelectric prostheses and hands that can function and be controlled with whatever parts of your functioning muscle that you have. There is still nothing like the human hand and it is a big functional loss [with] any amputation in the upper extremity,” he said.

One way surgeons can provide patients with the best chance of being able to use a prosthesis that will work for them is by trying to preserve as much of the limb as possible during the course of debridement and acute care, according to Wise.

Moving up the arm, the options for prostheses are fewer and less functional, “so, we are always trying to preserve as much length and as much of the extremity as we can,” he said.

Prosthetic research

Several sources who spoke with Orthopedics Today also noted that prostheses need to be refined to be more lifelike and more functional.

“We are obviously lightyears away from Star Wars and Luke Skywalker amputated arms and having a lifelike functional hand like he does, but with enough technology ... we certainly may get to a point fairly close to that,” Wise said.

One area of prosthetic research that could be explored is the best modes of recovery, according to Ring. This would involve analyzing whether a more rapid recovery and use of a prosthesis provides better mental and social outcomes for patients compared with a “drawn out reconstruction with a disfigured and limited limb at the end,” Ring, Orthopedics Today Editorial Board Member, said.

“Should we be amputating more [severe upper extremity trauma injuries] and should we be salvaging more of these? Who is doing better long term? Patients who have one surgery and an amputation or the patient who had to have 20 surgeries or are left with a painful limb that does not have the best function?” Wise said. “Looking at those long-term outcomes are important to guide us a little bit more. We have good studies like that for the lower extremity, but we do not have studies like that in the upper extremity to the same scale.”

Targeted muscle reinnervation

In patients who choose to undergo amputation, many surgeons now perform targeted muscle reinnervation (TMR), which was developed at Northwestern University and has been shown to minimize the risk of neuromas and residual limb pain and phantom limb pain, as well as increase the number of muscles available for the prostheses to work with, according to Gaston.

“When [an individual] loses a limb, the nerves that [are amputated] are still connected to the brain and can still send signals,” Gaston said. “So, if we re-purpose those nerves and put them into different muscles by cutting the innervation to a certain muscle and reinnervating it with the nerve of our choice, we can bring the nerve’s function back to the limb.”

Despite the positive results seen with TMR, Gaston noted researchers, surgeons and others who work in this area are still learning which muscles produce the best outcomes.

“The recipes, if you will, have not been worked out completely as to if there are certain nerve transfers that fare better in these patients,” he said.

Osseointegration, where a metal rod is implanted into the bone allowing for a more secure fit for the prosthesis, has been another area of research regarding both upper and lower extremity amputations, according to Ko. Currently, research on osseointegration for finger amputations is being performed by Ko and his colleagues at Northwestern University in the Shirley Ryan AbilityLab.

“The other area that the Department of Defense is interested in is providing prostheses with sensory feedback, meaning bionic hands that can provide the sense of touch. That is something that there is a lot of research going into,” he said.

Treat the whole patient

Ko noted that although patients can be advised by a panel of experts about whether to keep their limb or undergo amputation, it is a difficult and personal choice and, ultimately, the patient’s decision.

“The question of limb salvage comes down to how good of a salvaged limb [the patient has] and then deciding whether they want to move forward with keeping it or amputating it,” Ko said. “Everyone wants to save the limb, but sometimes a good prosthesis is better than a bad salvaged limb.”

Overall, Gaston said surgeons should remember they are “taking care of the whole patient, not just the arm.”

“If it comes down to the fact that you are going to lose your arm, but you are going to live, there is no person who would rather die than have their arm. No extremity is worth a life,” Mighell said. – by Casey Tingle

Disclosures: Gaston reports the Reconstructive Center for Lost Limbs visiting surgeon program receives educational and financial support from Hanger Clinic. Ko reports he is a speaker for Checkpoint Surgical. Ring reports he has royalty agreements from Wright Medical and Skeletal Dynamics. Mighell and Wise report no relevant financial disclosures.

Click here to read the Point/Counter, “How do post-traumatic amputation considerations differ for the upper and lower extremities?”

Upper extremity injuries are one of the most common presented in the ED, accounting for 20% to 40% of injuries, according to a report published by Kevin C. Chung, MD, and his colleagues.

However, Mark A. Mighell, MD, associate professor at University of South Florida and instructor of surgery for the military, noted most patients admitted to the hospital for severe upper extremity trauma also present with multiple other injuries. He said their treatment calls for a multidisciplinary approach that involves trauma, orthopedic, vascular and plastic surgeons.

Brent T. Wise, MD, said the goal of treating patients who have traumatic upper extremity injuries is to provide them with a viable, innervated and functional arm. When patients opt for amputation, adequate limb preservation will give them the best chance for prosthesis use, he said.

Source: The University of Kansas Health System

“Managing the mangled extremity requires a multidisciplinary team and a major trauma center. This is best accomplished in a major trauma center where the appropriate clinicians are accessible,” Mighell, commander of the U.S. Navy, retired, told Orthopedics Today. “You need to be where you have all of the subspecialties available to manage that patient.”

Focus on providing function

Once the patient is stabilized and life-threatening injuries have been addressed, Chung and his colleagues noted surgeons should perform a more detailed extremity exam. With the primary goal being to provide the patient with a viable, innervated and functional arm, Brent T. Wise, MD, orthopedic surgeon at the University of Kansas Health System, noted surgeons need to make sure the patient has adequate blood supply.

“Obviously, if there is no blood supply to the extremity, it cannot be salvageable or you have to do some type of intervention to restore the blood flow. That is something that has to be done within a relatively urgent fashion, if there is no blood supply to the limb,” Wise said.

Erin A. Miller, MD, and her colleagues noted in a report that surgeons should assess perfusion of the limb, with warm ischemia time exceeding 4 to 6 hours associated with an increased risk of compartment syndrome, infection and muscle death.

“If warm ischemia time exceeds 6 hours, the incidence of amputation is going to go up,” Mighell said. “It does not mean amputation is inevitable, but what we want to avoid is not getting any blood flow nourishment to the nerves, to the muscle, to the tissue of the limb [because] the cells will die.”

PAGE BREAK
Mark A. Mighell

Mighell noted patients with either vascular injuries or a prolonged period of warm ischemia time should undergo a fasciotomy.

The nerves and neurologic status of the limb should also be assessed, according to Wise.

“It does not do much good if you do a beautiful surgery and put things together with plates and screws and have a great-looking X-ray, if the person has no muscular attachments or muscles do not work because the nerves are damaged or the blood supply is not adequate,” Wise told Orthopedics Today.

He added that bony involvement and what needs to be done as far as fixation of fractures and reducing and restoring joints should also be assessed.

R. Glenn Gaston

Possible complications in these scenarios include nonunion of bony fractures, as well as bony overgrowth or heterotopic ossification, according to R. Glenn Gaston, MD, fellowship director of the Hand and Upper Extremity Fellowship at OrthoCarolina and chief of hand surgery at Atrium Musculoskeletal Institute.

Soft tissue coverage

One major obstacle among patients with severe upper extremity trauma is soft tissue coverage, a technique that has been improved with the use of negative-pressure wound therapy, according to Miller and her colleagues.

Gaston noted timing of soft tissue coverage in patients with soft tissue defects is critical and coverage should be completed as early as possible to minimize complications.

At the University of Kansas Health System, Wise said surgeons start with minimal soft tissue coverage, such as being able to close the skin and have the tissue covering the bones and hardware. However, if there are still areas of exposed bone or metal from implants, he said surgeons need to use a skin flap.

“We start with local tissue flaps, which are taking muscle from the extremity and moving it to a different location to cover the area that needs to be covered,” Wise said. “If there is no viable muscle locally in the area, then we are talking about taking tissue from a different part of the body and transferring it along with the blood vessels to the arm to cover up and to reattach to the blood vessels in the arm.”

Once a patient begins to heal, Wise noted surgeons need to be aware of any wound healing difficulties and the potential for infection, which can be reduced through debridement of non-viable tissue and use of antibiotics throughout the course of the procedure.

Sources who spoke with Orthopedics Today noted patients should be made aware of the possibility of extreme pain and function loss even with removal of non-viable tissue, as well as stiffness, disfigurement and dysfunction.

PAGE BREAK

“Once [patients] are through that acute phase where we are free of infection and our wounds are healing, then it is just a matter of physical therapy and rehab and monitoring their function and maximizing that in any way,” Wise said.

Mental health complications

In addition to the surgical team, David C. Ring, MD, PhD, associate dean for comprehensive care and professor of surgery and psychiatry at Dell Medical School, the University of Texas at Austin, noted it is important to have occupational or physical therapists, psychologists and social workers involved postoperatively. The mental health complications that can pre-exist or develop after injury, and may benefit from postoperative management, include depression or post-traumatic stress disorder, substance misuse, financial trouble, unemployment and homelessness.

David C. Ring

“As orthopedic surgeons, we say, ‘My job is to get the bone healed,’ or ‘My job is to get the person walking again.’ But, if you do not think about it and are not intentional about it, there is nobody to guide somebody through the emotional aspect of losing your life role, losing part of your identity, having your body be forever changed, and having to get used to that, how scary the injury was that you worry about being able to support your family, all of the things that come along [with it],” Ring told Orthopedics Today. “We should expect everyone to be going through a difficult, emotional recovery and we should be prepared to help with that.”

Surgeons may also help reduce mental health complications and promote faster healing by preparing patients for the possibility of painful movements after surgery, according to Ring.

“We can anticipate that people are going to be shy to do painful exercises because it is going to feel harmful. That is the way the human mind works,” Ring said. “So, if we anticipate that, we can help guide people and re-orient those thoughts so that they have a different story in mind, which is that ‘movers heal quicker’ and ‘movers heal better’.”

Limb salvage vs amputation

Jason H. Ko, MD, MBA, noted more severe complications in patients with severe upper extremity trauma include amputation, blood clots — including deep vein thrombosis and pulmonary emboli — and death.

Concerning limb salvage vs. amputation, surgeons should take into account patient risk factors, such as smoking status, whether the patient has diabetes, immunocompromised status, their age and overall health, Gaston said.

Mighell noted younger patients may have a lower risk of undergoing amputation because they are more likely to not become hypotensive and to have better collateral blood flow.

PAGE BREAK

“At some point [surgeons] have to think about weighing the risks and the benefits of the surgery with regard to patients’ overall health status, and sometimes we make decisions based on whether we think an older, unhealthy patient can even withstand, not only one long surgery, but maybe a series of multiple surgeries over the next few weeks to months without causing any more major problems to their overall health,” Ko, associate professor for plastic and reconstructive surgery and orthopedic surgery at Northwestern University Feinberg School of Medicine, told Orthopedics Today.

Ko noted the decision to salvage or amputate the limb also depends on the “zone of injury” and how extensive and how proximal it is. He said another key consideration for whether the patient undergoes limb salvage or amputation is the extent of the injuries to the blood vessels and the nerves.

“Even if you replant or salvage the limb, if the nerves to the hand are not working, then you are essentially salvaging a useless extremity that could be significantly painful,” he said.

Chung and his colleagues noted use of the mangled extremity severity score (MESS) may help predict upper extremity limb loss through the assessment of severity of skeletal or soft tissue injury, severity and duration of limb ischemia, severity of shock and the patient’s age. However, these authors noted the MESS is not an effective predictor of salvage.

“The mangled extremity severity score is basically what we have to discriminate between salvageable and doomed limbs in the setting of lower extremity trauma,” Mighell, Editorial Board Member for Orthopedics Today, said. “It can be helpful in upper extremity trauma, but it is by no means ... an absolute indication that some patients can have their limbs amputated.”

Prosthetic options

Although restoring normal function to the limb may seem better than amputation and prosthesis, Ko noted the discussion of limb salvage vs. amputation is multifaceted and complex.

Jason H. Ko

“You can salvage a limb, but if it is painful ... [and] does not move, then the question is how good of a limb is it and is it actually better than an amputation and prosthesis?” Ko said.

However, despite great prosthetic options available for lower limb amputations, Wise noted the same cannot be said for the prostheses used after upper extremity amputations.

“There are continuing to be advances with myoelectric prostheses and hands that can function and be controlled with whatever parts of your functioning muscle that you have. There is still nothing like the human hand and it is a big functional loss [with] any amputation in the upper extremity,” he said.

PAGE BREAK

One way surgeons can provide patients with the best chance of being able to use a prosthesis that will work for them is by trying to preserve as much of the limb as possible during the course of debridement and acute care, according to Wise.

Moving up the arm, the options for prostheses are fewer and less functional, “so, we are always trying to preserve as much length and as much of the extremity as we can,” he said.

Prosthetic research

Several sources who spoke with Orthopedics Today also noted that prostheses need to be refined to be more lifelike and more functional.

“We are obviously lightyears away from Star Wars and Luke Skywalker amputated arms and having a lifelike functional hand like he does, but with enough technology ... we certainly may get to a point fairly close to that,” Wise said.

One area of prosthetic research that could be explored is the best modes of recovery, according to Ring. This would involve analyzing whether a more rapid recovery and use of a prosthesis provides better mental and social outcomes for patients compared with a “drawn out reconstruction with a disfigured and limited limb at the end,” Ring, Orthopedics Today Editorial Board Member, said.

“Should we be amputating more [severe upper extremity trauma injuries] and should we be salvaging more of these? Who is doing better long term? Patients who have one surgery and an amputation or the patient who had to have 20 surgeries or are left with a painful limb that does not have the best function?” Wise said. “Looking at those long-term outcomes are important to guide us a little bit more. We have good studies like that for the lower extremity, but we do not have studies like that in the upper extremity to the same scale.”

Targeted muscle reinnervation

In patients who choose to undergo amputation, many surgeons now perform targeted muscle reinnervation (TMR), which was developed at Northwestern University and has been shown to minimize the risk of neuromas and residual limb pain and phantom limb pain, as well as increase the number of muscles available for the prostheses to work with, according to Gaston.

“When [an individual] loses a limb, the nerves that [are amputated] are still connected to the brain and can still send signals,” Gaston said. “So, if we re-purpose those nerves and put them into different muscles by cutting the innervation to a certain muscle and reinnervating it with the nerve of our choice, we can bring the nerve’s function back to the limb.”

PAGE BREAK

Despite the positive results seen with TMR, Gaston noted researchers, surgeons and others who work in this area are still learning which muscles produce the best outcomes.

“The recipes, if you will, have not been worked out completely as to if there are certain nerve transfers that fare better in these patients,” he said.

Osseointegration, where a metal rod is implanted into the bone allowing for a more secure fit for the prosthesis, has been another area of research regarding both upper and lower extremity amputations, according to Ko. Currently, research on osseointegration for finger amputations is being performed by Ko and his colleagues at Northwestern University in the Shirley Ryan AbilityLab.

“The other area that the Department of Defense is interested in is providing prostheses with sensory feedback, meaning bionic hands that can provide the sense of touch. That is something that there is a lot of research going into,” he said.

Treat the whole patient

Ko noted that although patients can be advised by a panel of experts about whether to keep their limb or undergo amputation, it is a difficult and personal choice and, ultimately, the patient’s decision.

“The question of limb salvage comes down to how good of a salvaged limb [the patient has] and then deciding whether they want to move forward with keeping it or amputating it,” Ko said. “Everyone wants to save the limb, but sometimes a good prosthesis is better than a bad salvaged limb.”

Overall, Gaston said surgeons should remember they are “taking care of the whole patient, not just the arm.”

“If it comes down to the fact that you are going to lose your arm, but you are going to live, there is no person who would rather die than have their arm. No extremity is worth a life,” Mighell said. – by Casey Tingle

PAGE BREAK

Disclosures: Gaston reports the Reconstructive Center for Lost Limbs visiting surgeon program receives educational and financial support from Hanger Clinic. Ko reports he is a speaker for Checkpoint Surgical. Ring reports he has royalty agreements from Wright Medical and Skeletal Dynamics. Mighell and Wise report no relevant financial disclosures.

Click here to read the Point/Counter, “How do post-traumatic amputation considerations differ for the upper and lower extremities?”