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Section 1: General Topics
surgeries place great stress on a patient,
especially an elderly patient with major medical comorbidities. However, in
many of these patients, successful limb
salvage can be obtained with proper
medical and surgical management.
Musculoskeletal Tumors
Physiologic Reserve
and Comorbidities
Patients with cancer who are faced
with limb salvage or amputation are
unique in that primarily pathologic lesions and the stage of the lesion determine the appropriate treatment option.
Figure 12
ease who had a massive nonhealing infected elbow wound on his
nondominant upper limb after total elbow arthroplasty. A, Clinical
photograph of the chronically infected elbow wound that exposed
the arthroplasty implant. B, Lateral radiograph shows the loose, infected elbow arthroplasty. C, Lateral uoroscopic image after bony
and soft-tissue débridements, removal of the infected implant, and
insertion of antibiotic-impregnated polymethyl methacrylate beads.
D, Intraoperative photograph. After control of the acute infection, a
exor carpi ulnaris muscle rotation ap was used to reduce the deep
potential space and provide a base for resurfacing the soft-tissue defect of the e lbow. E, Intraoperative photograph. A split-thickness skin
graft was placed over the exor carpi ulnaris muscle ap, and an Ilizarov ring xator was a pplied to stabilize the elb ow reconstruction. T his
method was important to counteract the patient’s elbow tremor and
relieve pressure on the soft-tissue reconstruction. F, Final photograph
of the healed elbow reconstruction. (Courtesy of Christopher Bibbo,
DO, FACS, Marsheld, WI.)
Images of an 84-year-old man with Parkinson dis-
Patients undergoing adjuvant or neoadjuvant chemotherapy or radiation may
become acutely ill and malnourished,
but this is a short-term complication
and is correctable with dietary supplements. In contrast, patients with tumor
recurrence may require multiple bouts
of chemotherapy over a long treatment
period. The use of anthracycline-based
agents often results in irreversible cardiomyopathy; however, with the exception of those with Ewing sarcoma,
most patients in need of limb salvage
have not been treated with an anthracycline-based agent unless they were
enrolled in an experimental protocol.29
The patient with musculoskeletal sarcoma usually is otherwise healthy
(unless associated with a multiple neoplastic syndrome), and reconstructive
efforts are usually immediate with a
single-stage limb salvage procedure. In
patients with musculoskeletal oncology who are physiologically unable to
meet the challenge of limb reconstruction, primary amputation below the
pelvic girdle may be the best option.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
52
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 13
traoperat ive photograph of the nal wou nd after débridem ents and culture-sp ecic antibiotics. C, Clinical p hotograph of successful li mb salvage after
protection in a ne-wire external xator and the use of collagen-based ingrowth matrix, negative-pressure dressings, and skin grafting. (Courtesy of
Christopher Bibbo, DO, FACS, Marsheld, WI.)
Arterial, Venous, and
Lymphatic Patency
The timing of external beam radiation
therapy in relation to reconstructive
limb salvage is important. A balance
must be struck with early neoadjuvant
external beam radiation versus adjuvant
radiation because local or free-tissue
flap reconstruction in radiated fields
is difficult and prone to complications.
Thus, larger flaps with vascular pedicles
outside of the field of radiation may be
required. Brachytherapy may allow for
the concentrated application of radiation, limit the field of exposure, and be
performed in the single-setting treatment of musculoskeletal sarcomas.
Neurologic Status
When major motor nerves are sacrificed
during an oncologic resection, tendon
A, Intraoperative photograph of a necrotizing infec tion in a patient who has type 1 diabetes, vascular disease, and renal failure. B, In-
transfer or extensive bracing often is
required. If radiation therapy is not required, it is possible that free functional
muscle transfers can be used to provide
function.
7-16
However, if extensive postoperative radiation is likely to result in
postradiation fibrosis of a functional
muscle transfer, it may be best to consider other acute reconstructive techniques
or delay a free functional muscle transfer.
Sensory nerve preservation is usually
of less concern, but techniques using
local flaps with sensory nerve splitting
and transfer have been successful in
providing soft-tissue coverage and protective sensation.
30
salvage in a patient with cancer. Influential factors include the type of cancer,
the oncologic stage and grade of the sarcoma, 5- and 10-year survival rates for
the involved cancer, and the patient’s age
and preoperative functional capacity. Although the surgical and medical care of
patients with musculoskeletal tumors
can be challenging, there is often time
for more planning and more certainty
in expected outcomes in this patient
population. In addition, advances in the
perioperative management of patients
with tumors
31,32
as well as refinements
in limb salvage implants have made limb
salvage a goal among orthopaedic oncologists and reconstructive surgeons33
Functional Potential
and Quality of Life
The patient’s quality of life is a critical
determinant when considering limb
(Figure 15). A multidisciplinary team
approach that includes an orthopaedic
oncologist, a reconstruction surgeon, a
medical oncologist, a general medicine
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
53
Section 1: General Topics
Figure 14
fully managed with débridements, antibiotics, tibiocalcaneal fusion, and ne-wire external xation. A, Intraoperative photograph of the lateral left
ankle demonstrates severe ankle varus instability and the extent of the wound. B, AP weight-bearing radiograph of the left ankle shows the severe
varus instability. C, Lateral radiograph demonstrates conguration of the ne-wire ring external xator that was applied immediately after extensive
débridement. The external xator allowed immediate partial weight-bearing mobilization. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
practitioner, a radiation oncologist, a
physical therapist, and a prosthetist can
best manage these complex cases.
Trauma
Physiologic Reserve and
Medical Comorbidities
The decision to proceed with limb salvage or amputation in a patient who
sustains a severe traumatic injury is
clinically challenging. Clinicians typi
cally determine the overall magnitude
of injury to a limb based on the fracture
pattern, degree of soft-tissue injury, level
of contamination, and vascular status
(Figures 16, 17, 18 and 19). Occasionally, decision making is simplified if the
patient is in extremis and emergent amputation (often a complete amputation)
contributes to saving the patient’s life.
The decision to salvage or amputate
a severely injured lower limb has long
been a vexing problem. The Lower
Extremity Assessment Project (LEAP)
study evaluated the outcomes of lower limb salvage versus amputation in
patients sustaining high-energy injuries.34 Data from the study challenged
Images of a patient with ankle Charcot neuroarthropathy with a deep, infe cted soft-tissue wound and osteomyelitis that was success-
previous paradigms in that outcomes for
limb salvage or amputation may be more
influenced by a patient’s socioeconomic
status, personal resources, and overall
psychosocial health than by the degree
of bodily injury alone.34 Thus, limb injuries that often were determined to be
either salvageable or requiring amputation are now evaluated on a spectrum
that considers socioeconomic factors,
-
outpatient resources, premorbid conditions, the magnitude of the injury, and
potential therapeutic interventions.
The primary assessment of the patient also should include checks for
pulses, skin temperature, and capillary
refill at and below the zone of injury.
A Doppler probe is used to evaluate
nonpalpable pulses, listen for bruits
(audible sounds associated with waveform changes), and determine the anklebrachial index. An ankle-brachial index
of less than 0.9 in an otherwise healthy
young adult (no history of PVAD or diabetes) indicates a potential vascular
injury and requires further analysis.35
Such analysis may include a noninva-
Arterial Injury
Early vascular assessment and a recognition of arterial disruption are critical
for successful limb salvage. Prolonged
ischemia times result in irreversible
cell damage and death that may be so
extensive that amputation is required.
Arterial inflow may be caused by arterial
transection, thrombosis, or physical interruption by a displaced fracture. Thus,
it is essential that the injured limb be
provisionally reduced to lower the risk
of deformity that may cause blood vessels to kink (Figure 16).
sive color Doppler ultrasonography,
computer-assisted arteriography, or arteriography. A doubling of the flow velocity across the area of injury indicates
an occult intimal lesion. When concern
for vascular injury exists, a vascular surgeon should be consulted.
The time from vascular injury to
reperfusion of the tissues is a factor often considered when attempting limb
salvage. It is generally thought that revascularization becomes a relative contraindication after 6 hours from the time
of injur y.
36,37
Limb ischemia is so critical
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
54
in trauma patients that ischemia times
beyond 6 hours elevate the severity of
injury on several injury scoring sys-
38-40
tems.
However, the role of collateral
flow states in major axial arterial injuries
can influence outcomes and should be
considered on a case-by-case basis.
In the setting of unstable fractures
and vascular injury, there is no universal
agreement on the sequence of fracture
stabilization versus vascular repair.
41,42
The logical approach is to perform the
most expedient sequence of orthopaedic
or vascular procedures to temporarily
stabilize or reperfuse the limb, followed
by more definitive procedures.
Neurologic Status
Peripheral nerve injury is common with
limb trauma and becomes increasingly
more likely with the increasing severity
and volume of soft-tissue injuries. Often,
a complete neurologic examination of
the limb can be difficult in the acute
setting (for example, the presence of a
decreased Glasgow Coma Scale score,
intubation, or massive soft-tissue injury with limb deformity), and a cursory baseline examination is all that is
afforded. Surgical exploration and inspection are critical, as well as follow-up
secondary survey examinations.
Loss of plantar foot sensation was
thought to be an important factor in
deciding between limb salvage and
amputation. However, Bosse et al43 reported that, based on health-related
quality-of-life activities and the percentage of individuals returning to work at
12 or 24 months after amputation, loss
of plantar sensation alone should not
be considered as a factor for deciding
between limb salvage and amputation in
patients with severe lower limb trauma.
Functional Potential
and Quality of Life
Data from the LEAP Study Group have
shown that previous predictive scoring
systems (for example, the Mangled Extremity Severity Score) have little use,
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 15
Wounds were closed a nd covered with medial and later al gastrocnemius aps and sk in graft. (Courtesy of David A. Erlich, MD, Philadelphia, PA.)
Figure 16
reduction and “traveling traction” provided return of pulses and provisional stabilization and restoration of leg length (B). (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
and limb salvage may have equivalent
outcomes to amputation in properly
selected patients.
that outcomes are influenced by the
following factors: rehospitalization for
Intraoper ative photograph of a proximal t ibia modular prosthesis for l imb salvage.
AP radiographs of a high-grade pilon fracture (A) with loss of pulses. Immediate
a major complication, less than a high
school education, a household income
44-48
The data indicate
below the federal poverty line, nonwhite
race, no insurance or Medicaid coverage, a poor social support network, a
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
55
Section 1: General Topics
Figure 17
foot resulting in a high-grade Tscherne soft-tissue injury with open ankle and calcaneus fractures;
note degloving of the skin distally. This patient had a history of one vessel run-o (a single vessel
limb), and the wound was highly contaminated. Amputation was elected as nal management in
the subacute setting. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
Intraoperative photograph (A) and lateral radiograph (B) of traumatic injury to the
low level of self-efficacy, smoking, and
legal system involvement for injury
compensation.
44-48
Availability of Multidisciplinary
Resources
A resource-intensive process is required
for the treatment of patients who sustain severe, limb-threatening, traumatic injuries—whether limb salvage
or amputation is undertaken. A variety
of medical practitioners are involved
with the care of these patients, starting
soon after the injury and throughout the
course of treatment. Rehabilitation efforts for these patients have not been the
subject of extensive research, and efforts
have traditionally focused on return of
physical function. Although rehabilitation is certainly an important area of
emphasis, experience from the LEAP
Study Group has indicated that mental
health also should be given attention
during a patient’s recovery.
49
Figure 18
distal tibia. C, AP radiograph taken after serial débridements of contaminated and subsequently infected bone; bone transport was performed over
a temporary intramedullary nail using the Weber technique. (Courtesy of Christopher Bibbo, DO, FACS, Marsheld, WI.)
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
56
A, Intraoperative photograph of a severe degloving injury of the distal tibia. B, Lateral radiograph best demonstrates loss of the
Chapter 4: General Principles of Limb Salvage Versus Amputation in Adults
Figure 19
after serial débridements, xation of radial and ulnar fractures with locking plates, and soft-tissue
coverage with an anterolateral thigh free ap. (Courtesy of Stephen J. Kovach III, MD, Philadelphia,
PA.)
The determinants of patient satisfaction identified in the LEAP study offer
areas on which to focus rehabilitation
efforts and resources. Five factors were
identified and significantly associated
with patient satisfaction 2 years after
injury: faster walking speed, a higher
physical function score on the Sickness
Impact Profile, lower pain intensity, no
depression, and return to work.49 Beyond the acute hospital setting, a skilled
set of therapists, qualified rehabilitation
and long-term acute care facilities, and
a system for long-term patient follow-up
are mandator y.
A, Intraoperative photograph of a mangled upper limb. B, Photo graph of the limb
requiring an emergent, life-saving amputation, few clear guidelines exist.
The patient’s status, including psychosocial and premorbid functional status, along with the soft-tissue, bone,
vascular, and neurologic status of the
injured or diseased limb must be considered. In general, after appropriate
counseling regarding the anticipated
treatment course and outcomes, erring
on the side of limb salvage is preferred
for most patients. With this in mind,
reasonable functional outcomes with
complex limb salvage using advanced
surgical techniques are feasible for most
patients. Patients who require or elect
Summary
Regardless of the injury or the underlying disease process, decision making for
to proceed with amputation must be
treated according to established guide-
lines and techniques.
limb salvage versus amputation is complex. Other than a patient in extremis
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© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
59
Chapter 5
General Principles of Limb Salvage
Versus Amputation in Children
Federico Canavese, MD, PhD Joseph Ivan Krajbich, MD, FRCS(C)
Abstract
Many indications exist for limb salvage surgery and amputations, including trauma, neoplastic disease, vascular disease, and congenital limb deformities. However, age, etiology,
goals, and the challenges of each surgical technique inuence the choice of procedure to
treat the individual patient. Overall, amputations are relatively less common in children
than adults.
Major advances in medical technology over the past 30 years have resulted in an increased
number of treatment options for patients facing potential limb loss. Various limb salvage
techniques, more sophisticated amputation techniques, and more functional prosthetic
devices are now available to the treatment team. e rational choice of procedure is primarily inuenced by patient age; other pertinent factors include etiology, comorbidities,
functional demand, healing potential, and overall life expectancy.
Keywords: amputation; children; etiology; infection; limb salvage;
purpura fulminans; trauma; tumor
Introduction
In the past few decades, few subspecialties of orthopaedic surgery have
experienced as marked an evolution as
the field of limb salvage (limb sparing)
surgery. Various conditions that in the
past required amputation can now be
treated with a limb salvage procedure.
Even when amputation is necessary,
current techniques frequently facilitate
a more functional and more distally
amputated residual limb. Advances in
imaging (MRI and CT), microvascular
surgery, external fixation techniques,
nerve repair, internal fixation, and
vacuum suction dressings for complex
wounds have changed how orthopaedic
Dr. Krajbich or an immediate family member serves as a board member, owner, ocer, or committee member of the Association of Children’s Prosthetic and Orthotic Clinics and the Scoliosis
Research Society and is a member of a speakers’ bureau or has made paid presentations on behalf
of K2m. Neither Dr. Canavese nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or
indirectly to the subject of this chapter.
surgeons approach patients who may
require amputation.
In addition, the wide availability of
allograft tissue (especially bone), the
advent of commercially available biologic modifiers of bone healing (such
as bone morphogenetic proteins), and
advances in the fields of anesthesia and
resuscitation have further contributed
to the evolution of limb salvage surgery.
Although the treatment of malignant tumors of the limbs has led to advances in
limb salvage surgery, the relevant advanced techniques are now widely used
in any situation in which the limb is at
risk, such as trauma, infection, vascular abnormalities, and congenital limb
deficiencies in children. Even with the
available salvage options, amputation
remains the procedure of choice in
many instances. An insensate, poorly
perfused, and/or functionally useless reconstructed limb is a poor alternative
to a properly selected amputation and
modern prosthesis fitting.
The best procedure for a given situation depends on both objective and
subjective factors. Age and skeletal maturity in children, etiology, anatomic
involvement, comorbidities, and overall life expectancy are objective criteria.
Functional demands and expectations,
as well as the cultural and psychologic
acceptance of a given procedure are subjective criteria. The surgeon’s expertise
and the availability of modern medical
technology and prosthetic and orthotic
services also play an important role in
choosing a procedure. Even when amputation, either terminal or intercalary,
is required, various limb salvage techniques can result in a more functional
residual limb. This chapter discusses
decision making regarding the best
approach to a given problem based on
objective principles and published outcome studies.
Differences in Pediatric
and Adult Patients
The etiology of amputation differs between adult and pediatric patients (Ta-
ble 1) In adults, most amputations are
performed for complications of peripheral vascular disease, followed by trauma and tumors; burn injuries may also
necessitate amputation. The most frequent causes of amputation in children
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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