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Section 2: Upper Limb
amputations should be avoided unless
they are clinically indicated, which is
uncommon. In traumatic amputations,
all devitalized tissue should be meticulously débrided, taking special care to
identify and protect all important neurovascular structures to maximize the
final functional result.
13,14
Negative pressure dressings are effective for staged
surgical treatment because they limit the
frequency of bedside dressing changes,
improve pain control, and provide
surgeons with greater flexibility when
considering soft-tissue reconstruction
options for more complex cases.
15,16
The
timing of final amputation coverage or
closure depends largely on surgeon experience, but a wound bed devoid of
necrotic tissue and infection and a tension-free closure are critical to success.
17
In general, preserving maximal limb
length is preferred in upper limb amputations, but this goal must be balanced
with consideration for wound healing
capacity and residual limb coverage, patient preference, rehabilitation potential, and local prosthetic expertise and
availability. With increasing limb length
and preservation of joints, enhanced
positioning of the terminal residual
limb and/or prosthetic device in space
is achieved, allowing for the best functional results and improved outcomes.
When considering amputation below
the level of the elbow, the scope of the
injury often determines the amputation
level. The requirements and capabilities
of prostheses for each amputation level
must be understood and considered.
Consultation with a prosthetist is recommended early in the decision-making
process.
Concomitant fractures should be
considered for surgical stabilization
when functional limb length or joint
preservation can be achieved, although
higher complication rates can be expected. However, preservation of the
established limb length at the time of
fracture fixation is generally achieved.18
Additional soft-tissue coverage options,
including skin grafts and flaps, should
be strongly considered when residual
tissue flaps provide inadequate cover
age for a distal amputation below the
elbow and shortening the residual limb
will diminish prosthetic fitting options
and functional outcomes. This is perhaps most important in attempts to
preserve the elbow joint but also when
optimizing residual limb length for a
transradial amputation. Using microvascular free-tissue transfer in appropriately selected patients to maximize limb
length and provide durable soft-tissue
coverage has proved successful in upper
limb amputations.
19-21
In the upper limb,
indications for free-tissue transfer include shoulder joint preservation by selecting a transhumeral amputation level,
elbow joint preservation, and preservation of bone greater than 7 cm below
the shoulder or elbow. Relative indications include wrist joint preservation
and skeletal preservation between 5 and
7 cm below the shoulder or elbow.
7,2 2
Although upper limb amputations that
require skin grafts or flaps take longer
to heal, the functional benefits of joint
and/or limb-length preservation usually
outweigh delays in rehabilitation and
prosthetic fitting.
Careful attention to nerves and muscles is critically important in upper
limb amputation because symptomatic
neuromas are common.23 Before final
closure of an upper limb amputation,
all involved sensory and motor nerves
should be identified. All motor branches to muscle flaps within the surgical
field also should be preserved to prevent
muscle denervation that results in loss of
muscle mass for limb padding and possible loss of sites for myoelectric signals.
Nerves should undergo gentle traction
neurectomy to locate neuromas away
from the distal amputation myodesis or
skin closure. Although more aggressive
traction neurectomy was previously recommended for large peripheral nerves
with motor function, preservation of additional nerve length while preventing
more distal exposure of neuromas can
ensure the possibility of future recon-
-
structive surgery.
Stabilizing the musculotendinous
units of the residual limb under physiologic tension at the time of amputation closure serves two main purposes.
First, it facilitates robust coverage over
the distal bone end, providing comfortable padding for the prosthetic socket
while preventing painful bursa formation from mobile muscle units. Second,
optimal contractility characteristics of
the muscle are preserved, improving
muscle signal quality and maximizing myoelectric control of a prosthesis,
while also maximizing terminal residual
limb control for a body-powered prosthesis. Myodesis, the process of attaching musculotendinous units directly
to bone, is the surgical technique that
provides the most stable construct over
the distal bone end. Myodesis is typically performed by suturing the muscle
and/or tendon to the bone end, usually
through drill tunnels with braided nonabsorbable suture, or less commonly, to
periosteum. Myoplasty, which attaches
agonist muscles to antagonist muscles
over the bone end to create physiologic
tension, and myofascial closure, which
sutures muscle and fascia together, are
less stable constructs. These procedures
may be indicated when myodesis cannot be achieved, for secondary muscles
after primary myodesis, or to contour
the remaining muscle bellies before
closure. Although no data support the
superiority of myodesis over myoplasty, myodesis is recommended in upper
limb amputations to provide the most
stable limb and best isolate muscle signals and myoelectric prosthetic control.
Wrist Disarticulation
The advantages of wrist disarticulation
include preservation of forearm rotation when the distal radioulnar joint
(DRUJ) is preserved, elimination of
painful radioulnar convergence compared with transradial amputation,
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
222
Chapter 17: Wrist Disarticulation and Transradial Amputation: Surgical Management
improved weight bearing directly
through the terminal residual limb,
enhanced functional length, and better prosthetic suspension. Historically,
the main disadvantage of wrist disarticulation has been limited available
prosthetic options because of the short
working length and limited space available for the terminal device.24 In 1972,
before the introduction of modern wrist
prostheses, a survey of US surgeons
indicated a preference for distal transradial amputation over wrist disarticulation.25 Even with recent advances in
prosthetic design and materials, which
have greatly improved function for
an individual treated with wrist disarticulation, a preference remains in
many amputation centers for revision
to transradial amputation because of
patient dissatisfaction with outcomes
after wrist disarticulation.7 Consultation with an upper limb prosthetist is
highly recommended when a decision
must be made between preservation of
a wrist disarticulation or revision to a
transradial amputation.
A successful wrist disarticulation
requires a healthy, intact DRUJ.1 Preservation of the triangular fibrocartilage complex and radioulnar ligaments
facilitates stable pronation and supination, with an expected total arc of
approximately 100° to 120°.
5,26,27
The
thick palmar skin of the hand should
be used for distal coverage, but often,
skin flaps for final wound closure will
be dictated by the injury.1 The radial
styloid should be saved for prosthetic
suspension; it can be contoured to prevent prominence and skin irritation or
breakdown at the prosthetic interface.
The ulnar styloid is often excised to prevent soft-tissue prominence distally. It
is crucial to perform myodesis of the
flexor and extensor tendons to maintain
tension in those muscles to provide necessary myoelectric prosthetic function.
Important nerves to identify include
not only the median and ulnar nerve,
but also the superficial radial nerve, the
palmar cutaneous branch of the median
nerve, the dorsal ulnar cutaneous nerve,
and possibly the terminal medial and
lateral antebrachial cutaneous nerves.
These nerves should be divided proximal to the level of amputation closure
using gentle traction neurectomy and
buried under muscle to prevent the development of painful neuromas. One
exception is preservation of cutaneous
nerves to a skin flap required for distal
amputation coverage.7 Additional nerve
techniques, such as cauterization, suture
ligation, and anesthetic injection, have
been described but are not performed
by the author of this chapter because of
a lack of proven efficacy and theoretic
concerns of exacerbating neuropathic
pain.
Wrist Disarticulation:
Surgical Technique
Surgery for wrist disarticulation is
typically performed with the patient
supine and under regional anesthesia.
An indwelling peripheral nerve catheter placed intraoperatively can help
control postoperative pain and aid in
initial recovery. Initial dissection and
amputation is performed using a tourniquet to allow accurate identification
of all structures in a bloodless field.
Under traumatic conditions, all available viable skin flaps are preserved and
considered for final closure. If amputation is performed under elective conditions, skin flaps can be designed to
allow the use of durable palmar skin
over the distal residual limb. The radial
and ulnar arteries are dissected free and
double ligated. Large veins are typically
ligated; small veins can be cauterized.
Peripheral nerves are identified and
dissected, including the median nerve,
ulnar nerve, all branches of the dorsal
sensory radial and ulnar nerves, and any
terminal branches of the lateral and medial antebrachial cutaneous nerves. All
cutaneous nerves to skin flaps intended
for final closure should be preserved.
Gentle traction neurectomy of all nerves
is preferred to place them just proximal
to the myodesis and the distal residual limb surface. This technique should
minimize the likelihood of development
of painful neuromas and preserve maximum nerve length for future limb reconstruction procedures. All crossing
tendons are divided, followed by sharp
amputation at the level of the radial and
ulnar carpal joints, with great care taken
to preserve the triangular fibrocartilage
complex and the dorsal and palmar radioulnar ligaments to maintain DRUJ
function. The radial styloid prominence
should be assessed for minor bone contouring. The ulnar styloid is typically
excised if prominent, but care should be
taken to preserve the foveal attachment
of the triangular fibrocartilage complex.
The tourniquet is released, and strict
hemostasis should be obtained before
final amputation closure.
All hand and wrist flexor and extensor tendons are attached to the distal
radius using braided, nonabsorbable
suture through drilled tunnels, as
is done in the myodesis technique.
Myoplasty can then be performed for
additional muscles to contour the residual limb, provide additional padding, and ensure maximum muscle
working length (Figure 1). Skin flaps
are closed in a tension-free manner in
layers, with resorbable and nonresorbable monofilament sutures. Drains and/
or incisional vacuum-assisted closure
dressings can be placed according to
surgeon preference and the clinical situation. The author of this chapter commonly uses incisional vacuum-assisted
closure dressings for complex closure in
combat-related amputations, although
efficacy has not yet been shown.
28,29
Although dermal substitutes, skin grafts,
and pedicle and free-tissue flaps can be
considered in cases in which primary
skin closure cannot be obtained, in the
practice of the author of this chapter,
this typically indicates consideration of
a more proximal transradial amputation
level with similar functional outcomes.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
223
Section 2: Upper Limb
Figure 1
tunnels. A and B, Primary exor and extensor muscles are sutured to bone. C and D, Myoplasty of additional muscles to the myodesis or antagonist
muscle helps to contour the amputation for nal closure, provides additional padding to the residual limb, and establishes remaining muscles at a
physiologic working length for enhanced functional control of the prosthesis.
Bulky gauze dressings are applied,
followed by a compression dressing to
minimize edema. Splints are typically
not used; certainly not above the elbow
unless clinically indicated to prevent
joint contracture. Postoperative elevation is recommended to reduce swelling and optimize the limb for prosthetic
rehabilitation. The use of specialized
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
224
Illustrations o f the myodesis technique for exor and extensor mu sculotendinous units to b one with nonabsorb able suture through dril l
elevation foam pillows helps improve
patient compliance and minimizes pain.
elbow joints, a long lever arm, and forearm rotation allow the individual with
a distal transradial amputation to easily
Transradial Amputation
Transradial amputation is the most common major upper limb amputation and
has the highest prosthetic acceptance
rates of amputations performed in the
upper limb.6 Preserved shoulder and
position the terminal prosthesis in space.
Transradial amputation is cosmetically
appealing because of the ability to fit
body-powered or myoelectric prostheses
with quick-disconnecting components,
while maintaining equal limb lengths.
Chapter 17: Wrist Disarticulation and Transradial Amputation: Surgical Management
When practical, at least two-thirds
of the forearm should be maintained.
Removal of at least 6 to 8 cm of bone
is recommended to provide a robust
soft-tissue envelope and permit use of
a wide variety of prosthetic options.7
Soft-tissue interposition between the
radius and ulna decreases the potential for painful convergence and instability. This is generally accomplished
with the pronator quadratus for more
distal amputation levels and can be
performed more proximally with one
interposed extensor and/or flexor tendon. Nerves are managed in the same
manner as with wrist disarticulation;
ensuring preservation of motor branches to muscles for myodesis maximizes
myoelectric prosthesis function.
At least 5 cm of residual ulnar length
is required to allow prosthetic fitting and
elbow motion.7 However, useful pronation and supination are not generally
preserved when the planned amputation
level is in the proximal third of the forearm and may affect use of a body-powered prosthesis.
1,8
At this proximal level,
transfer of the distal biceps tendon to the
proximal ulna should be considered.26
The prosthetic and mechanical advantages of the transradial level, coupled
with superior prosthetic acceptance
rates, should prompt the surgeon to
consider all reconstruction options, including free-tissue transfer, to preserve
an amputation at this level.
Transradial Amputation:
Surgical Technique
Many of the surgical principles of transradial amputation (Figure 2) are similar
to those of wrist disarticulation (Figure
3). The procedure is the same up to the
step of applying gentle traction neurectomy of all of the nerves to place them
just proximal to the myodesis and distal
residual limb surface to minimize painful neuromas while preserving maximum nerve length. All crossing tendons
and muscles are divided. To maximize
length, bone cuts are performed with a
cooled sagittal saw to preserve approximately two-thirds of forearm length,
which is usually at least 6 to 8 cm from
the radiocarpal joint. The tourniquet is
released, and strict hemostasis should
be obtained before final amputation
closure. In cases of transradial amputation, the author of this chapter often
uses thrombin spray and gel foam to
help achieve hemostatic control in the
event of a greater amount of cut muscle
and exposed bone surfaces.
As with wrist disarticulation, after
hemostasis is obtained, all hand and
wrist flexor and extensor tendons and
muscles are attached to the distal radius
and ulna through drill tunnels using
nonabsorbable, braided suture. Additional myoplasty can be performed to
improve padding, allow adequate contouring of the residual limb, and to fix
remaining musculotendinous units at
physiologic working lengths. It is important to superimpose tissue between the
radius and ulna to prevent painful radioulnar convergence; a functional, expendable muscle (such as the pronator
quadratus) is typically used distally, or
an extensor and/or flexor tendon is interposed proximally and attached using
myodesis. Skin flaps are closed in a tension-free manner in layers with resorbable and nonresorbable monofilament
sutures. Drains and/or incisional vacuum-assisted closure dressings can be
placed depending on the surgeon’s preference and the clinical situation.
Dermal substitutes, skin grafts, and
pedicle and free-tissue flaps should be
considered in cases in which primary
skin closure cannot be obtained and
maximum length preservation is preferred. Although dermal substitutes can
increase cost, they provide a more durable skin graft and can positively affect
prosthetic comfort and functioning.
30, 31
Tissue flaps should be considered for
elbow joint preservation when at least 5
cm of stable residual ulna remain.
Bulky gauze dressings are applied,
followed by moderate compression
dressing to minimize edema. Splints
are typically not used to prevent iatrogenic joint contracture, especially above
the elbow, unless clinically indicated.
Postoperative elevation is recommended to reduce swelling and optimize the
limb for prosthetic rehabilitation, and
specialized foam pillows can help improve patient compliance and minimize
pain. Early elbow joint range of motion
is begun immediately postoperatively.
Complications
Complications after amputation surgery
distal to the elbow are frequent, especially with higher-energy injury patterns
such as those that occur in combat situations. Infection, wound dehiscence, skin
breakdown, heterotopic ossification,
joint contracture, painful neuromas,
and myodesis failure have been reported
with varied frequencies after both wrist
disarticulation and transradial amputation.23 It is common to have two or
more complications that require surgical
intervention. In transradial amputations
and wrist disarticulations, heterotopic ossification can cause painful bony
prominences, bursa formation, a reduction of forearm rotation, or synostosis
and complete arrest of forearm rotation,
which reduces functional prosthetic use.
Early resection of functionally limiting
or painful heterotopic ossification and
synostosis have effectively restored
forearm rotation, improved function,
and reduced pain.
this chapter routinely excises heterotopic bone that limits forearm motion
within 4 months of injury if the soft-tissue envelope is stable and the bone is
mature on radiographic imaging. CT
and three-dimensional modeling are
important preoperative planning tools
and can be used intraoperatively to
guide surgical dissection in complex
cases. Resecting heterotopic ossification is challenging. Emphasis must be
placed on adequate exposure, identifying all neurovascular structures to prevent critical loss of functional muscle
23,32,33
The author of
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
225
Section 2: Upper Limb
Figure 2
device. The patient had a concomitant ulnar fracture and poor soft-tissue coverage. A, Photograph demonstrates initial amputation before débridement. Photographs obtained following serial débridement show that the amputation meets length requirements (B) but has inadequate soft-tissue
coverage (C). D, Lateral radiograph shows ulnar fracture stabilized with internal xation. E, Photograph shows soft-tissue coverage provided by a free
vascularized anterolateral thigh ap and a biologic dermal substitute, followed by split-thickness skin grafting.
groups, and meticulous hemostasis. Single-dose postoperative radiation therapy and prophylactic NSAIDs have been
used effectively to achieve a low risk of
recurrence.
Chronic pain is a frequent complication of traumatic upper limb amputation, with a prevalence ranging from 7%
to 49%. Pain may be more prevalent in
transradial amputations.23 Although numerous sources of pain have been identified after amputation, the treatment of
neuroma and radioulnar convergence
deserves special attention when considering transradial amputation and wrist
disarticulation.
Many neuromas are an identifiable
cause of chronic pain, which may negatively affect functional use of prostheses,
Images of a short, traumatic transradial amputation in a multiple limb amputee secondary to injury from an improvised explosive
delay return to work and activity, and
result in the use of medication for
chronic pain. Numerous methods are
described in the literature to treat pain-
34
ful neuromas, including nerve repair
and resection and nerve transposition
with muscle implantation.
35-3 7
Although
nerve repair can produce the best results, this treatment is not possible in an
amputee. Simple neuroma excision appears to have the worst outcomes in amputees.37 More recently, targeted muscle
reinnervation or targeted nerve implantation has shown promising results for
the treatment of painful neuromas and
can be performed at the time of a traumatic or an elective amputation.
38-40
Painful radioulnar convergence is
a known complication of transradial
amputation that results from loss of
the DRUJ. The presentation is similar
to that of a patient who has undergone
distal ulna resection with radioulnar
convergence. Symptoms include distal
forearm pain with weight bearing and
forearm rotation along with pain with
squeezing of the forearm that compresses the radius to the ulna. Weight-bearing
radiographs also can elucidate the problem. Interposition of an available muscle
between the distal radius and ulna can
help decrease or eliminate painful radioulnar convergence. Other techniques,
such as allograft interposition, can be attempted if local soft tissue is inadequate,
but this technique is not described in
the literature for transradial amputation.
Synostosis creation or revision to a more
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
226
Chapter 17: Wrist Disarticulation and Transradial Amputation: Surgical Management
Figure 3
tendinous units, and inadequate soft-tissue coverage. After discussion between the patient and the prosthetist, the patient elected a transradial amputation to allow robust myodesis, adequate distal padding, and primary skin closure. A, Photograph of wrist disarticulation after initial débridement
demonstrates inadequate musculotendinous length and soft-tissue coverage. Lateral (B) and AP (C) radiographs of humeral shaft fracture and distal
both-bone forearm fracture. Lateral (D) and AP (E) radiographs of xation of a humerus fracture and amputation at the level of forearm fractures.
F, Photograph show myodesis of extensor and exor tendons to bone through drill tunnels after revision of amputation to the level of the fractures.
G and H, Photographs show myodesis and myoplasty to provide adequate padding over the distal bone ends. I, Photograph shows primary skin
closure that maintains adequate functional length of the residual limb.
proximal level of amputation for short
residual limbs should be considered
(Figure 4).
Outcomes
The loss of one or both upper limbs
is a devastating event. Currently, lost
prehensile function and sensation are
Images of the limb of a patient with a wrist-level disarticulation, concomitant radius and ulna shaft fractures, loss of distal musculo-
not adequately replaced using modern
prosthetic technology. Although prosthetic acceptance rates are frequently
discussed as an outcome measure, existing high-quality evidence is limited
and outdated.
Prosthesis rejection rates for upper
limb amputation are frequently reported
to be 21% to 38%; larger studies typically report a rejection rate higher than
6,41- 43
30%.
When excluding cosmetic
prostheses, the rates are probably
6,41- 43
higher.
High rejection rates have
been loosely associated with poor training, delayed prosthetic fitting, and more
proximal amputations.6 A 1995 survey
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
227
Section 2: Upper Limb
Figure 4
painful radioulnar convergence, heterotopic bone spurs, and a painful ulnar neuroma, resulting in decreased prosthetic use and function. A, Preoperative view of the limb. B, Excess skin is excised. C, Painful bone spurs at the distal radius and ulna are resected. The bone ends are contoured
to eliminate sharp edges. D, Myodesis is performed through bone tunnels with nonresorbable heavy braided suture. E, Available muscle is sutured
to bone between the radius and ulna to prevent painful radioulnar convergence. F, Additional myoplasty is performed to provide adequate distal
padding and re store physiologic worki ng length to the musculotendin ous units to maximize myoele ctric function. G, A painf ul ulnar neuroma is identied and resected. H, Targeted muscle reinnervation is performed from the ulnar nerve to the exor carpi ulnaris muscle to treat a painful neuroma.
I, Postoperative view of the limb.
of upper limb amputations reported
limited usefulness, increased weight,
and residual limb/socket discomfort as
primary reasons for prosthesis rejection.6 Factors associated with increased
prosthetic acceptance include loss of the
dominant limb, absence of pain in the
residual limb, and early prosthetic fitting
within 30 days of amputation.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
228
Photographs demonstrate surgical revision of a transradial amputation with a redundant sof t-tissue envelope, failure of the myodesis,
6,11,4 4
Acceptance rates for prosthesis use
are directly correlated with the level of
amputation, with use increasing progressively at more distal levels of amputation, which correlates with higher
functional scores.
6,11,41,45 -47
The transradial amputation level has the highest
reported prosthesis usage rates, ranging
from 80% to 94%;
6,11,41,47
transhumeral
amputation acceptance rates range from
43% to 83%.
6,11
Shoulder disarticulation
is associated with the lowest reported
prosthesis acceptance rates. Increased
prosthetic weight and complexity, decreased prosthetic functionality, and
difficulty with suspension explain decreasing prosthetic acceptance rates
with higher levels of amputation. Many
Chapter 17: Wrist Disarticulation and Transradial Amputation: Surgical Management
patients are willing to function with
only one upper limb rather than use a
burdensome prosthetic device. Overall,
these data further stress the importance
of exhausting all surgical reconstruction
options to preserve amputation levels
distal to the elbow.
Most individuals who have undergone upper limb amputation are able
to return to work, although one-half
to two-thirds change their occupation
to accommodate the limb loss.
6,11,26
Patients with transradial amputations have
the highest rates of return to work.6 In
the military population, few upper limb
amputees have been found fit for full
duty irrespective of their amputation
level, and even fewer return to active
duty status. During recent conflicts, the
overall return-to-duty rate has ranged
from 8.3% to 16.5%.
7,48,49
Current Innovations
and Future Directions
Phenomenal innovations have occurred
in surgical management and prosthetic advancement over the past decade.
Many technologies have direct application to transradial amputation and wrist
disarticulation. Targeted muscle reinnervation has the potential to help in the
treatment of painful neuromas and may
enhance myoelectric prosthetic function. Although hand allotransplantation
indications are evolving, the transradial
amputation level is the most common
site of transplantation in the upper
limb, with demonstrated improvements
in function and quality of life in properly selected patients.
outcomes for patients with transradial
amputation or wrist disarticulation,
technologies currently being studied
include cortical- and peripheral-nerve–
based prosthetic control, muscle signal
recruitment, radiofrequency-controlled
prostheses, advanced pattern recognition algorithms, improved suspension
systems such as osseointegration, and
the search for functional haptic feedback sensory mechanisms.53 With rapid
50-52
To improve
advancement of emerging technologies
to enhance upper limb prosthetic acceptance and function, it is important
that the surgical team and treating institution develop a coordinated plan of
education throughout the continuum of
care. If institutional resources are inadequate, consideration should be given
to transferring the patient to a center
that specializes in amputation reconstruction and hand allotransplantation.
Summary
Transradial amputation and wrist disarticulation are the most frequently performed amputations in the upper limb,
have the highest prosthetic acceptance
rates, and represent the amputation levels with the greatest functional potential.
Strict attention to skeletal preservation
and soft-tissue stabilization will maximize the residual limb for future prosthetic use and/or novel reconstruction
options. A multidisciplinary approach
to patient care will maximize the clinical result, and a coordinated education
program will ensure that the patient is
well informed as new technologies and
novel surgical procedures become available. Consideration should be given to
transferring a patient to a higher level
of care if local resources are not capable
of providing the comprehensive reconstructive care necessary to maximize the
patient’s functional outcome.
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