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Section 1: General Topics
Tab le 1
Laboratory Evaluation of Immune and Nutritional Parameters to
Help Predict Healing Response to Injury and Surgery
Laboratory Value
Prealbumin Severe risk: <10 mg/dL
Albumin 3.5-5.5 g/dL Overall protein-energy malnutrition; acute trends indicate improve-
Total protein 5.5-8.0 g/dL Global protein-energy nutrition status of the patient
Total lymphocyte
count
Total cholesterol Severe risk: <50 mg/dL
also must be evaluated to improve
healing and help prevent complications
caused by infection
parameters should be identified, with
appropriate management strategies initiated immediately. However, because
timing often is critical in limb salvage
procedures and amputations, complete
correction of immune and nutritional
deficits often is not feasible; correction
must simply be initiated and continued
throughout the perioperative period and
through hospital discharge.
Commonly Accepted Normal
Range or Threshold
Moderate risk: 10-17 mg/dL
Malnutrition: <1,500 cells/mm
At risk: <150 mg/dL
should be maximized (for example,
catheterization, control of hypertension,
1,2
(Table 1). These
and diabetes). Venous outflow also may
be diminished in these patients, so adequate planning must be undertaken if
limb salvage is planned (for example, saphenous mapping for an arterial-venous
loop to provide a vascular axis for a free
flap). Peripheral vascular disease typically is progressive, and multiple peripheral vascular revisions may be required.
The use of limb salvage in this setting
may be guided by the surgeon’s experi-
3
ence, direct input from the patient, and
Vascular Status
The principles of evaluating and treat-
a global assessment of quality of life if
multiple major revisions are required.
ing peripheral vascular disease are particularly important because adequate
vascularity is a critical factor when deciding on limb salvage or amputation.
Adequate arterial inflow is mandatory
for all patients undergoing limb salvage,
whether in the setting of infection, trauma, the immediate coverage of defects
after tumor resection (Figure 1), or complications from external beam radiation.
Patients with peripheral vascular disease often are elderly, diabetic, and/or
smokers and may have preexisting cardiac disease. Thus, these patients have
important risk factors for perioperative
complications. These risk factors must
be evaluated (for example, cardiac stress
testing), and the patient’s health status
Considerations for Limb
Salvage or Amputation
Peripheral Vascular
Arterial Disease
Adequate arterial blood supply to the
tissues is necessary for normal tissue
metabolism and healing, and arterial in-
flow must be adequate before limb sal-
vage or amputation can be considered.
The less complex Fontaine classification
and the more inclusive Rutherford clas-
sification of peripheral vascular arterial
disease (PVAD) are useful screening
tools that use patient symptoms and
objective measures (arterial pressures)
to allow stratification of patients with
preexisting PVAD (Table 2).
Comments
Overall protein-energy malnutrition; one of the most rapidly changing
nutritional parameters to follow in the acute setting.
ments in nutrition.
Protein-energy malnutrition and immune status; low values are
considered ominous for healing complications that may not be able
to be treated acutely.
Overall caloric malnutrition; very low values indicate severe malnutri-
tion, which requires intensive nutritional supplementation; at risk for
mortality.
Newer classification schemes for predicting outcomes have been presented
and are being validated.3 However, the
most basic and often simplest methods
to help determine successful healing after limb salvage or amputation are still
the direct physical examination and an
arterial evaluation. Arterial assessment
includes both noninvasive and invasive
evaluations. Physical examination of
pulses along with a bedside Doppler
examination are quick and easy initial
examinations. Arteriography, computerassisted arteriography, and magnetic
resonance arteriography are evaluation
tools to better assess and plan the technical execution of a surgical procedure
and have their relative merits (Table 3).
Transcutaneous oxygen measurements
are supplemental and of greater use in
the noninvasive evaluation of chronic
wound healing potential. Such measurement provides information pertaining to
a site-specific area but has limitations
when edema is present and is highly
operator dependent; its greatest utility
is when amputation is selected and
data on healing potential are desired
at a certain level of amputation. All of
these evaluations, however, must be
tempered with experience and sound
clinical judgment.
Venous outflow is important to control chronic tissue changes as well as
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
42
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 1
after tumor and vessel resection: clamps are on the arterial stumps, and a saphenous vein graft (arrow) will be used. C, Photograph of the nal reconstructi on for limb salvage that used r eversed saphenous vein fo r arterial and venous recons truction, sural ner ve grafts for motor ne rve reconstructio n,
and anterolateral thigh free ap for coverage of the soft-tissue defect. (Courtesy of Stephen J. Kovach III, MD, Philadelphia, PA.)
Tab le 2
Stage Clinical Findings Grade Category Clinical Findings
the health of tissues in the immediate
perioperative period of limb salvage
(for example, free tissue transfers) (Fig-
ure 2). Surrogate methods to improve
venous return and reduce edema, such
as intermittent gradient compression devices, frequent medical wraps (for example, calamine/gelatin paste dressings),
and compression stockings, are vital
to improving venous return and preventing chronic adverse tissue changes.
In the immediate postoperative period
A, MRI of a popliteal fossa tumor (long arrow) involving the popliteal vessels (short arrow). B, Intraoperative photograph of the defect
Classications of Peripheral Vascular Arterial Disease
Fontaine Classification Rutherford Classification
I Asymptomatic 0 0 Asymptomatic
IIa Mild claudication
IIb Moderate to severe claudication 2 Moderate claudication
III Ischemic rest pain 3 Severe claudication
IV Ulcer/gangrene II 4 Ischemic rest pain
I
III
of limb salvage (after free-tissue transfers to maintain an amputation level or
salvage an entire limb), mild elevation,
adequate pharmacologic anticoagulation, and dangling protocols assist in
preventing venous occlusion, which, if
severe, can result in microanastomotic
arterial thrombosis.
Limb edema often is caused by
multiple factors, including venous insufficiency, reperfusion overload, and
cardiac, renal, and primary/secondary
1 Mild claudication
5 Minor tissue loss
6 Major tissue loss
lymphatic insufficiency. The effects of
chronic edema resulting from any of the
primary causes can be compounded by
a secondary etiology as well as poor
nutrition (low serum albumin/protein
level, resulting in low serum oncotic
pressure). Regardless of the cause, edema is believed to result in a relative reduction of local tissue oxygen perfusion,
thus potentiating poor healing. Edema
may delay wound healing or result in
tissue ulceration.4 In most patients,
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
43
Section 1: General Topics
Tab le 3
Tools for Arterial Evaluation
Doppler Examination CTA MRA Arteriography
Indication Evaluation of ow beyond
pulse palpation
Utility Easily performed by clinician
at bedside with simple
handheld Doppler to
determine phasicity of
arterial ow and augmentation of ow by checking
retrograde lling of the arterial tree. Advanced color
ow and velocity gradients
can identify occult intimal
lesions.
CTA = computer-assisted arteriography, MRA = magnetic resonance arteriography.
Evaluation of arterial in-
ow when Doppler examination is limited or
preoperative planning
requires investigation
of arterial lumen.
Evaluation of major
arterial network to
determine patency of
vessels for preoperative
planning; especially
useful in patients not
suited for MRI. Easier to
interpret than MRA.
Patients who have undergone a
mastectomy or axillary dissection may
have chronic edema in the upper limbs.
Primary lymphatic patency should be
investigated in the setting of massive
refractory edema that is uncontrolled
by medical maximization and standard
control methods, such as manual edema
control programs, edema pumps, and
garments. Preoperative investigations
include dye-based and scintigraphic
lymphangiograms. Although in its in
fancy, vascularized lymph node transfer
may be helpful in controlling massive
edema in patients with refractory edema
that impedes healing after limb salvage
5
Figure 2
partial ap necrosis secondary to poor venous outow. (Courtesy of Christopher Bibbo,
DO, FACS, Marsheld, WI.)
Postoperative photograph of
or amputation.
Nerve Injury and Psychological
and Psychiatric Conditions
Acute nerve injury is most likely to occur
in patients as the result of a traumatic
injury or in those with musculoskeletal
temporary control of edema can be obtained during tissue healing; however,
in certain patients (for example, those
with Milroy disease, those treated with
radiation, or patients who have undergone lymph node dissection), edema in
the lower limb may impede successful
limb salvage.
tumors as a result of the oncologic resection. Acute nerve injury is not a reliable predictor of success or failure of
either limb salvage or amputation.6 In
general, nerve transections are amenable
to direct grouped fascicular repair. The
recovery of nerve injuries is expected
at a rate of 1 mm/day. Nerve injuries
Same as CTA Same as CTA and when percu-
Same as CTA; longer
time for image
acquisition and
more dicult in
extremity arterial
evaluation.
taneous interventions are
being considered.
Fine details and run-o (opera-
tor dependent). To enhance
healing, stenting with or
without mechanical ablation
of lesions can be performed
to maximize ow velocity
across stenotic areas before
limb salvage or amputation.
that pose special problems in trauma
patients are segmental nerve loss (Fig-
ure 3) and severe brachial plexopathies
with nerve root avulsion. Nerve transfer and grafting techniques are available that will produce good functional
results in the upper limb.
6
The loss of nerve segments in a mutilated lower limb is problematic. These
cases require specialized techniques, including free vascularized nerve trans-
-
fers, in situ nerve transfers, and muscle
and tendon transfers or tenodesis. In a
patient being treated with a limb salvage
protocol in whom vascular, bony, and
soft-tissue issues have been successfully
managed or who has a limb with only
an isolated nerve injury, strong consideration should be given to the continuation of limb salvage efforts. This is
especially true if some motor function
is anticipated. Pure sensory deficits in
a lower limb in an otherwise supple
limb are not necessarily indications for
amputation. Appropriate bracing and
skin protection measures may allow the
limb to assist in functional ambulation.
Salvage should be given even greater
consideration in an upper limb because
of the devastating nature of upper limb
amputations, especially if a lower limb
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
44
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 3
repair (B) in a patient with traumatic segmental loss of the common peroneal nerve after an open knee dislocation. (Courtesy of Christopher Bibbo,
DO, FACS, Marsheld, WI.)
Intraoperative photographs of a full-length sural nerve graft (A), which was divided into three cables for grouped fascicular
amputation is already present.
The treatment of a limb with isolated,
long-segment nerve loss can be managed
with grouped fascicular nerve grafting
accompanied by a long recovery period;
however, there is the potential for irreversible muscle wasting. In patients with
nerve loss accompanied by composite
tissue loss (nerve plus bone, muscle,
and skin) or late loss of function, free
functional muscle transfers have become
a valuable tool for accomplishing limb
7-16
salvage
(Figure 4).
Patients with chronic pain syndrome
(type I or II) who experience trauma or
massive infection require special consideration. In these patients, the limb
may have substantial tissue changes
and limited function before the traumatic injury or the onset of infection.
Figure 4
tissue ap. Motor branch to gracilis muscle (inset, white dashed circle) is anastomosed to the
proximal musculocutaneous nerve using subcostal nerve grafts (white arrow). Arterial and venous
vessels are microanastomosed to branches of the brachial vessels. (Courtesy of L. Scott Levin,
MD, Philadelphia, PA.)
Intraoperative photograph of arm reconstruction with a functional gracilis free-
In addition to the physical state of the
limb, these patients frequently have
substantial psychological disability that
manifests as anxiety or depressive disorders, including posttraumatic stress
disorder (Axis I disorder), which may be
compounded by their current traumatic
injury (Axis III disorder).17 These patients should undergo a thorough neuropsychiatric evaluation as part of the
global salvage versus amputation evaluation. The patient’s psychological and
psychiatric profile weighs heavily into
the equation that determines functional
recovery and overall quality of life. In up
to 50% of patients with type I chronic
pain syndrome, pain will worsen with
amputation;18 nevertheless, the patient
may elect amputation after thorough
counseling (Figure 5). Limb salvage
procedures can also result in substantial
additional physiologic stress for these
patients, deterioration of their mental
health status, and worsening of their
pain syndrome. However, appropriate
multidisciplinary counseling, careful
planning, and realistic expectations
can achieve reasonable outcomes after
limb salvage.
Unique considerations also apply to
patients who sustain complete spinal
cord injuries or severe closed head injuries. In patients who are paraplegic,
the level of injury, overall limb function,
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
45
Section 1: General Topics
Figure 5
old patient wi th type I chronic pain sy ndrome who smokes and had ve sur geries for polymicro bial
drug-resistant osteomyelitis (staged as Cierny-Mader type B-IV). The patient elected transtibial
amputation. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
and the care setting are critical in determining whether to proceed with limb
salvage or amputation. For example, if
the patient has the potential to use a
“stander” platform, or the limbs assist
with sitting and balance, salvage should
be considered. Limb salvage of an upper
limb is warranted in paraplegic patients
because the upper limb often is the
patient’s last resource for independent
function. Patients who are either paraplegic or quadriplegic with an at-risk limb
require thorough evaluation. If the limb
is a liability to the patient’s near-term
overall health or survival, amputation
may be the best option (Figure 6). Patients with closed head injuries and an
expected poor recovery must be evaluat-
Clinical photograph (A) and AP radio graph (B) of the infecte d lower limb of a 38-year-
having a functional or useful limb require a preemptive psychological and
psychiatric evaluation along with a global assessment of future quality of life,
with or without the limb. The surgeon
must remember that all patients value
an intact body image, which directly af
fects mental health and global quality
of life. Thus, the value of a psychological and psychiatric evaluation and an
open dialogue with the surgical team,
which concentrates on realistic goals,
outcomes, and patient desires, are vitally
important. In situations in which limb
preservation or amputation is required
to preserve life, the surgical team may
have to make a decision without input
from the patient.
ed and managed in the acute setting (life
over limb), but the long-term sequelae
of their brain injuries, including useful
functional status, must be considered.
Patients with progressive neurolog-
ic conditions who have little chance of
Functional Potential
and Quality of Life
The assessment of future limb function
is made by the treating orthopaedic sur-
geon in conjunction with input from the
physical medicine and the rehabilitation
teams. Typically, motor function and patient motivation are the key factors in
achieving optimal function and quality
of life. The patient’s perception of his or
her future quality of life may be strongly
influenced by the surgical team leader’s
expertise and experience; therefore, it
is important that the surgeon provide
an unbiased assessment of the pros and
cons of limb salvage and amputation.
Multidisciplinary Resources
Complex limb salvage or major amputation surgery require a comprehensive,
sophisticated set of surgical services,
including trauma, oncologic, orthopaedic, plastic reconstructive, and vascular
disciplines. Ancillary services, including physical medicine, rehabilitation,
prosthetics and orthotics, physical and
occupational therapy, psychology, psychiatry, and discharge planning should
also be available to aid the patient
throughout his or her hospitalization
and during the rehabilitation phases of
recovery.
Infection in an Adult
The need to consider limb salvage in
the setting of musculoskeletal infections
is common. Severe necrotizing infections may occur in otherwise healthy
-
patients, but patients who are immunocompromised are more likely to have an
at-risk limb and systemic sepsis. In addition, these patients often have diabetes
and poor glucose control. Other at-risk
subgroups include patients with pharmacologic immune suppression, such as
those who have had a solid organ transplant and are steroid dependent; those
receiving tumor necrosis factor-α and interleukin-6 suppression for conditions
such as rheumatoid arthritis or Crohn
disease; and patients with cancer. Infection control is essential because continued infection results in tissue death and
local and regional arterial and venous
thrombosis, which perpetuate the process of tissue necrosis.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
46
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 6
current decubitus ulcers (after failure of previous rotation aps), diuse osteomyelitis, pathologic
fractur e of the hip and acetabulum, an d xed ankle and knee exion deformit y. Intraoperative photographs show the massive decubitus ulcer that extended to the hip joint and pathologic fracture
(B), enucleation of the infected femur (C), and creation of the thigh llet ap (D). E, Final AP radiograph of the inter nal hemipelvectomy res ection and creation of th e pelvic sling with biol ogic mesh
(dashed circle). F, Final intraoperative photograph of the pelvic resection margins and inset thigh
llet ap. The ap is made slightly large to re-create the silhouette of a limb, as well as provide redundant tissue for p ossible future needs . (Courtesy of Christophe r Bibbo, DO, FACS, Marsheld, WI.)
Bacterial infections remain the most
common type of infections, whether
the primary source is the integument
or muscle.19 Direct extension of the infection into other tissues can be rapid,
especially in necrotizing infections. The
immediate goals of limb salvage are
to halt further spread of the infection
(thus limiting systemic toxicity and the
A, Pelvic radiograph of a patient with septic T5-level paraplegia with massive re-
amount of local tissue destruction) and
preservation of the integrity of the major
and secondary vessels of the limb.
Fungal infections are suspect for
underlying immune suppression and
may involve soft tissue and bone and
disseminate to internal organs. Fungal infections in patients who are immunocompromised may be extremely
Figure 7
blastomycosis, with concomitant involvement
of the spleen, liver, and skin, in an immunocompromised patient. A staged reconstruction
of the calcaneus using multiple débridements,
uconazole/voriconazole antifungal beads,
and massive autologous bone grafting resulted in salvage of the patient’s foot. (Courtesy of
Christopher Bibbo, DO, FACS, Marsheld, WI.)
MRI scan of a massive calcaneal
difficult to eradicate and often have high
morbidity and mortality rates, necessitating consideration of amputation.
However, if the patient has adequate
physiologic reserve to tolerate multiple
wide débridements and long-term antifungal therapy and the potential for use
of a functionally salvageable limb, then
attempts at limb salvage are warranted
(Figures 7 and 8).
When acute or chronic osteomyelitis is present, thorough débridement
is needed. The patient’s comorbidities
and the extent of the osseous infection
are critical factors when undertaking
limb salvage for osteomyelitis. The
Cierny-Mader classification for chronic
adult osteomyelitis (Table 4) provides
categoric descriptive items that should
be considered; however, this tool cannot
dictate treatment plans. The key assessments as outlined in this chapter also
must be examined. Evaluation tools for
osteomyelitis include plain radiographs
and indium-111/technetium dualwindow scans with “spot” CT and MRI.
The most reliable method for the
diagnosis of osteomyelitis is the analysis of deep bone cultures surgically
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
47
Section 1: General Topics
Figure 8
operative photograph of the limb. Purpuric skin discoloration may be seen in mucormycosis infections along with dark discoloration of the deep soft
tissues. Intraoperative photographs of the limb salvage procedure that included multiple débridements and an amphotericin rod and beads, parenteral liposomal amphotericin, wide resection of the involved skin and bone, followed by a peroneus brevis ap (B) and use of a ne-wire frame (C).
D, Final radiograph showing successful limb salvage with tibiotalar fusion. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
Tab le 4
Anatomic
Location
I = Medullary
II = Supercial
III = Localized
IV = Diuse
An extensive mucormycosis infection developed in the lower limb of a patient with type 1 diabetes after an open ankle fracture. A, Pre-
Cierny-Mader Classication of Adult (Chronic) Osteomyelitis
Type A Host Type B Host Type C Host
Healthy patient; nor-
mal response to
stress and trauma;
normal response
to infection.
Comorbidities
compromise
both healing and
the response to
treatment.
Comorbidities
so severe that
treatment is worse
than disease;
treatment is to observe and palliate
or amputate.
stabilization, and restoration of bone
and soft-tissue integrity are needed
(Figure 10).
Infected joint prostheses with nonhealing wounds that expose the implant
present a considerable challenge to successful limb salvage. However, diligent
care and adherence to the principles of
adequate débridements, culture- specific
antibiotics, bony stabilization, and
wound coverage, may allow the limb
to be salvaged; more challenging cases
may require flap coverage (Figures 11
obtained from a patient who has not
been given antibiotics for 5 to 7 days
before the specimen is obtained. Osteomyelitis is a biologically complex
disease. Deep bone specimens must
be obtained because surface areas will
be heavily contaminated. Specimens
should be sent for aerobe, anaerobe,
acid fast, and fungal cultures. Specimens with negative cultures should
be held for bacterial 16S polymerase
chain reaction testing and, if appropriate, 18S polymerase chain reaction
testing for fungal infections. However,
patients with the most complex cases
of osteomyelitis may still warrant limb
salvage, even if an unstable soft- tissue
envelope is present (Figure 9).
Infection in the Upper Limb
Infections of the upper limb are less
common, with hand infections comprising the bulk of upper limb infections.
Nonetheless, upper limb amputations
are very disabling, so every effort should
be made to preserve an infected limb. In
patients with diabetes, upper limb infections are extremely serious, especially
when osteomyelitis is present. Multiple
staged irrigations and débridements,
and 12) or late functional free-flap tissue
transfers (Figure 4).
Because the upper limb has highly
specialized functions, limb salvage is
the preferred option if feasible. When
salvage is not possible, amputation and
prosthetic fitting should be considered.
In the past, upper limb prostheses provided limited function; however, current techniques to augment function,
such as targeted muscle reinnervation
techniques, hold promise for regaining
motor group function that will facilitate the improved use of upper limb
prostheses.
20
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
48
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 9
soft-tissue envelope. A, Clinical photograph of the unstable soft-tissue envelope. B, AP radiograph shows diuse grade IVB osteomyelitis. C, Oblique
radiograph shows posttraumatic osteonecrosis of the femoral head and neck (arrow). D, Intraoperative photograph of the proximal tibial ring block
for proximal tib ial distraction osteo genesis. Soft-tissue and b one resection margins ar e seen at the distal third of the le g. E, Intraoperative photograph
of the reverse sural ap coverage over the soft-tissue defect. F, Full-length radiograph of the limb with knee reconstruction in progress. A total hip
arthropl asty was perf ormed to regain hip func tion and limb length f rom the contribution of th e pelvic girdle. G, Postoper ative nal clinical photogr aph
after full healing of the bone and soft tissue. H, Final postoperative AP radiograph. The bifocal Ilizarov method of distal compression and proximal
distraction osteogenesis restored bone length and alignment. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
Images demo nstrate limb salvage in a 35-ye ar-old man w ho is an alcoholic and smoker and w ho has tibial osteomyelitis and an u nstable
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
49
Section 1: General Topics
Figure 10
tempts at stab ilization of a distal radiu s fracture. Clinical volar (A) a nd dorsal (B) photographs of th e infected hand and dist al forearm. C, AP radiograph
of the wrist demonstrating diuse osteomyelitis. D and E, Intraoperative photographs of wide débridements of soft-tissue and bone. F, Radiograph
shows Ilizarov stabilization. G, Intraoperative photograph of pan-wrist fusion after administration of parenteral antibiotics and obtaining negative
bone cultures. H, Conversion to a hinged e xternal ring xator w ith distractive/compressive s truts. Negative- pressure dressing is seen on th e volar wrist
surface. I and J, Final postoperative p hotographs show successful limb s alvage after healing o f the volar skin grafts . Osseous union allowed remov al of
the external xator, which was followed by aggressive edema reduction and hand therapy. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
Foot Infection in Patients
With Diabetes
Diabetic foot infections in patients 65
years or older occur at a rate of 6%,
with a concordant 11% mortality rate
that increases to approximately 22% after a lower limb amputation.21 Diabetic
ulcers range in severity from an ulcer at
the tip of a toe to massive ulcers with
infection of an entire limb (Figure 13).
Aggressive débridements, the use of
negative-pressure dressings (including antibiotic/antiseptic instillation),
hyperbaric oxygen therapy, and proper management of diabetes have been
Diuse osteomyelitis and sepsis developed in a 74-year-old right-hand–dominant patient with type 1 diabetes after three failed at-
successful in salvaging the foot in most
diabetic patients with foot infections.
However, many patients with diabetes
and foot infections are challenging to
treat because of multiple preexisting
medical comorbidities. These patients
require metabolic control and optimization of cardiovascular health and
peripheral vascular system functions
to allow successful limb salvage. Medical management is needed to control
blood glucose levels, and dialysis needs
and electrolyte balance must be optimized. The patient should be carefully evaluated for cardiac disease; a low
threshold for perfusion stress testing
and catheterization is warranted. If
the patient does not have adequate
physiologic reserve and the reversal
of coexisting medical comorbidities
is not possible, then primary amputation should be considered. However, in
the absence of contraindications, limb
salvage can achieve positive results,
allowing a patient to have a useful
limb for locomotion in the home or
community.
If limb salvage is planned for an
infected lower limb, it is necessary
to ensure that the limb has adequate
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
50
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 11
treated with ex tensive débridement and polyethylene insert exchange (B), and an extended medial gastrocnemius myocutaneous ap (C). (Courtesy
of Christopher Bibbo, DO, FACS, Marsheld, WI.)
vascularity and will be useful to the
patient (for example, helping to propel a wheelchair or allowing full
ambulation). It is important that the
salvage procedure does not create circumstances that will place the limb
or the patient’s life at future risk. For
example, when multiple toes require
amputation, resulting in a foot with
one or two toes, the salvaged toes, foot,
and limb are at greater risk of injury
and infection. In this setting, isolated
toe salvage may not be prudent, and a
higher-level amputation (for example,
transmetatarsal) may provide a more
durable, stable limb.
Efforts for salvage or amputation to
the transtibial level are encouraged.
However, even in patients with diabetes and PVAD, limb salvage by methods
such as free tissue transfer can result
in good long-term results after revascularization; thus, amputation is not the
automatic choice in all patients with
dysvascular disease or diabetes.
Intraoperative photographs of an acutely exposed and infected but well-xed total knee replacement with a soft-tissue defect (A),
Charcot Neuroarthropathy
in Patients With Diabetes
Charcot neuroarthropathy is a debilitating disorder that affects up to 2.5% of
patients with diabetes. First described
in patients with tabes dorsalis, it is now
recognized as a complex problem that
involves neuropathy, an overall altered
metabolic state that results in an imbalance of the neurohumoral regula tory
mechanisms of the bones and joints of
the foot and the ankle. On a cellular
basis, an inciting event appears to trigger cell-signaling pathways, resulting
in an imbalance of osteoclastic and os-
outcome from the Charcot process resulting in a spectrum of resultant deformities. If altered weight bearing and
poor diabetic control remain untreated, skin breakdown, ulceration, and
soft-tissue and bony infections may
result. Limb salvage is an option in patients with Charcot neuroarthropathy,
even when severe open wounds and
bone loss are present (Fig u re 14). In
the experience of the lead author of
this chapter (CB), the management of
physiologic parameters (namely blood
glucose control) is of utmost importance
for acute and long-term success.
teoblastic activity.27 If the patient has
substantial loss of bone mineral density,
22-25
a neuropathic dislocation will develop
and frank Charcot bone destruction
may ensue,28 causing loss of periarticular bony stability, joint destruction, and
varying degrees of collapse of the foot
and the ankle.
Protected weight bearing and strict
26
diabetic control will cause the process to
enter a resolution phase, with the final
Physiologic Reserve
and Comorbidities
In the setting of acute necrotizing or pu-
rulent infections, the first consideration
is preservation of life over limb. It should
be recognized that the use of antibiot-
ics or antifungal medications with their
attendant toxicities, multiple débride-
ments with blood loss, and the possi-
bility of multiple future reconstructive
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
51
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