General Principles of Limb Salvage Versus Amputation in Adults

Christopher Bibbo DO, DPM, FAAOS, FACS, FACFAS

David J. Polga MD, FAAOS

Samir Mehta MD, FAAOS

Stephen J. Kovach III MD, FACS

Dr. Mehta or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Bioventus, DePuy, a Johnson & Johnson Company, and Smith & Nephew; serves as a paid consultant to or is an employee of Smith & Nephew and Synthes; has received research or institutional support from Becton-Dickinson and Synthes; and serves as a board member, owner, officer, or committee member of the AO Foundation and the Orthopaedic Trauma Association. Dr. Kovach or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Becton Dickinson, Integra LifeSciences, and WL Gore. Neither of the following authors 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: Dr. Bibbo and Dr. Polga.

ABSTRACT

The decision to attempt limb salvage of an injured or diseased limb requires good clinical judgment, knowledge of the pathologic process that put the limb in jeopardy, and an understanding of the social and psychological profile of the patient. Each patient must be treated as an individual, based on current medical and physiologic status. The functional potential of a salvaged limb must be evaluated. Retention of a painful limb that is not used by the patient is to be avoided. However, retention of a limb that may be used to assist even with wheelchair locomotion deserves an attempt at salvage. A nonpainful limb, even with minimal function, may be of significant psychological value to the patient. A few of the factors that require consideration are the patient’s premorbid conditions, psychosocial factors, desires and expectation, social support network, and accessibility to reconstruction services. Knowledge of the general principles of limb salvage versus amputation will aid in providing optimal treatment for these patients.

Introduction

A limb (primarily a lower limb) that is at risk for amputation and being considered for salvage may be simplistically categorized to primarily possess a vascular, infectious, tumorous, or trauma-related etiology. In reality, however, these categories often overlap, increasing the degree of difficulty to achieve limb salvage; unfortunately, difficulties in healing and recovery after an amputation can escalate concurrently.

The general principles of limb salvage versus amputation in adults mandate that the first consideration is always life over limb. Dire circumstances are most commonly encountered in patients with serious infections or multiple traumatic injuries. If limb salvage is contemplated, the surgical team must weigh whether the treatment required for salvage is worse than the condition or the disease state. For example, if salvage of a limb with extensive tibial osteomyelitis is being considered in a patient who is frail, elderly, and has diabetes, the possibility of organ failure, irreversible functional decline, and a stiff nonfunctional limb may indicate amputation as the prudent option. The adage “burn no bridges” is especially important for the at-risk limb. Any procedure must be executed with deference to subsequent surgical interventions: how step one will affect steps two, three, and so forth. An essential component to the overall treatment strategy is that backup management plans must be in place in the event of a change in the patient’s condition.

The principles of limb salvage versus amputation in adults—whether in acute, chronic, or staged settings—mandate the assessment of several key issues that immediately and secondarily surround the patient’s symptoms, including the patient’s physiologic reserve and medical comorbidities; arterial, venous, and lymphatic patency (vascular status); neurologic and psychological/psychiatric statuses;
functional potential and quality of life; surgical site considerations and surgical procedures available from the surgical team or teams; and the availability of multidisciplinary resource teams during the immediate perioperative and rehabilitative phases of treatment. The key assessments in all patients are physiologic reserve, medical comorbidities, and vascular status.

Physiologic Reserve and Medical Comorbidities

A patient must have adequate physiologic reserve to withstand limb salvage. Moreover, all correctable organ system pathologies (eg, renal, endocrine, cardiac, and hepatic) must be addressed to maximize healing of both limb salvage and amputation procedures. The most commonly encountered conditions are acute metabolic and cardiac issues resulting from the circumstances of acute settings, as well as age-related conditions. A patient’s nutritional health and immune competence also must be evaluated to improve healing and help prevent complications caused by infection¹^,² (Table 1). These 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.

TABLE 1 Laboratory Evaluation of Immune and Nutritional Parameters to Help Predict Healing Response to Injury and Surgery

Laboratory Value	Commonly Accepted Normal Range or Threshold	Comments
Prealbumin	Severe risk: <10 mg/dL Moderate risk: 10-17 mg/dL	Overall protein-energy malnutrition; one of the most rapidly changing nutritional parameters to follow in the acute setting.
Albumin	3.5-5.5 g/dL	Overall protein-energy malnutrition; acute trends indicate improvements in nutrition.
Total protein	5.5-8.0 g/dL	Global protein-energy nutrition status of the patient.
Total lymphocyte count	Malnutrition: <1,500 cells/mm³	Protein-energy malnutrition and immune status; low values are considered ominous for healing complications that may not be able to be treated acutely.
Total cholesterol	Severe risk: <50 mg/dL At risk: <150 mg/dL	Overall caloric malnutrition; very low values indicate severe malnutrition, which requires intensive nutritional supplementation; at risk for mortality.

Vascular Status

The principles of evaluating and managing 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, have diabetes, and/or are smokers and may have preexisting cardiac disease. Thus, these patients have important risk factors for perioperative complications. These risk factors must be evaluated (eg, cardiac stress testing), and the patient’s health status should be maximized (eg, catheterization, control of hypertension, and diabetes). Venous outflow also may be diminished in these patients, so adequate planning must be undertaken if limb salvage is planned (eg, 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 experience, direct input from the patient, and a global assessment of quality of life if multiple major revisions are required.

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 inflow must be adequate before limb salvage or amputation can be considered. The less complex Fontaine classification and the more inclusive Rutherford classification of peripheral vascular arterial disease are useful screening tools that use patient symptoms and objective measures (arterial pressures) to allow stratification of patients with preexisting peripheral vascular arterial disease (Table 2).

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, computer-assisted 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.

FIGURE 1 A, Magnetic resonance image of a popliteal fossa tumor (long arrow) involving the popliteal vessels (short arrow). B, Intraoperative photograph of the defect after tumor and vessel resection: clamps are on the arterial residuums, and a saphenous vein graft (arrow) will be used. C, Photograph of the final reconstruction for limb salvage that used reversed saphenous vein for arterial and venous reconstruction, sural nerve grafts for motor nerve reconstruction, and anterolateral thigh free flap for coverage of the soft-tissue defect. (Courtesy of Stephen J. Kovach III, MD, Philadelphia, PA.)

TABLE 2 Classifications of Peripheral Vascular Arterial Disease

Fontaine Classification			Rutherford Classification
Stage	Clinical Findings	Grade	Category	Clinical Findings
I	Asymptomatic	0	0	Asymptomatic
IIa	Mild claudication	I	1	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
		III	5	Minor tissue loss
		III	6	Major tissue loss

TABLE 3 Tools for Arterial Evaluation

	Doppler Examination	CTA	MRA	Arteriography
Indication	Evaluation of flow beyond pulse palpation.	Evaluation of arterial inflow when Doppler examination is limited or preoperative planning requires investigation of arterial lumen.	Same as CTA.	Same as CTA and when percutaneous interventions are being considered.
Utility	Easily performed by clinician at bedside with simple handheld Doppler device to determine phasicity of arterial flow and augmentation of flow by checking retrograde filling of the arterial tree. Advanced color flow and velocity gradients can identify occult intimal lesions.	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.	Same as CTA; longer time for image acquisition and more difficult in extremity arterial evaluation.	Fine details and runoff (operator dependent). To enhance healing, stenting with or without mechanical ablation of lesions can be performed to maximize flow velocity across stenotic areas before limb salvage or amputation.
CTA = computer-assisted arteriography, MRA = magnetic resonance arteriography

Venous outflow is important to control chronic tissue changes as well as the health of tissues in the immediate perioperative period of limb salvage (eg, free tissue transfers) (Figure 2). Surrogate methods to improve venous return and reduce edema, such as intermittent gradient compression devices, frequent medical wraps (eg, calamine/gelatin paste dressings), and compression stockings, are vital to improving venous return and preventing chronic adverse tissue changes. In the immediate postoperative period 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.

FIGURE 3 Intraoperative photographs of a full-length sural nerve graft (A), which was divided into three cables for grouped fascicular repair (B) in a patient with traumatic segmental loss of the common peroneal nerve after an open knee dislocation. (Courtesy of Christopher Bibbo, DO, FAAOS, FACS, Baltimore, MD. All rights reserved.)

Limb edema often is caused by multiple factors, including venous insufficiency, reperfusion overload, and cardiac, renal, and primary/secondary 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, temporary control of edema can be obtained during tissue healing; however, in certain patients (eg, 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.

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 infancy, vascularized lymph node transfer may be helpful in controlling massive edema in patients with refractory edema that impedes healing after limb salvage or amputation.⁵

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 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 that pose special problems in patients with trauma are segmental nerve loss (Figure 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

FIGURE 4 Intraoperative photograph of arm reconstruction with a functional gracilis free-tissue flap. 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, FAAOS, FACS, Philadelphia, PA.)

The loss of nerve segments in a mutilated lower limb is problematic. These cases require specialized techniques, including free vascularized nerve transfers, 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 amputation is already present.

FIGURE 5 Images of nerve free flap. Intraoperative photograph of an arterialized (reverse flow) saphenous vein and nerve free flap for reconstruction of a long segment of both the dorsalis pedis artery and deep peroneal nerve after resection of aggressive tumor. A, Harvested free flap (P = proximal margin, D = distal margin). B, Free flap in situ (white arrow). (Courtesy of Christopher Bibbo, DO, FAAOS, FACS, Baltimore, MD. All rights reserved.)

The treatment of a patient with 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 salvage⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶ (Figure 4). Newer techniques of nerve free flaps may be considered in both the lower and upper extremity (Figure 5).

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. 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 6). 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.

FIGURE 6 Clinical photograph (A) and AP radiograph (B) of the infected lower limb of a 38-year-old patient with type I chronic pain syndrome who smokes and had five surgeries for polymicrobial drug-resistant osteomyelitis (staged as Cierny-Mader type B-IV). The patient elected transtibial amputation. (Courtesy of Christopher Bibbo, DO, FAAOS, FACS, Baltimore, MD. All rights reserved.)

Unique considerations also apply to patients who sustain complete spinal cord injuries or severe closed head injuries. In patients with paraplegia, the level of injury, overall limb function, 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 standing aid, or the limbs assist with sitting and balance, salvage should be considered. Limb salvage of an upper limb is warranted in patients with paraplegia because the upper limb often is the patient’s last resource for independent function. Patients with paraplegia or quadriplegia 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 7). Patients with closed head injuries and an expected poor recovery must be evaluated and treated 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 neurologic conditions who have little chance of 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 affects 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.

Functional Potential and Quality of Life

The assessment of future limb function is made by the treating orthopaedic surgeon in conjunction with input from the physical medicine and 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 their 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 requires 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 also should be available to aid the patient throughout their 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 suppression 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.

FIGURE 7 A, Pelvic radiograph from a patient with septic T5-level paraplegia with massive recurrent decubitus ulcers (after failure of previous rotation flaps), diffuse osteomyelitis, pathologic fracture of the hip and acetabulum, and fixed ankle and knee flexion deformity. 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 fillet flap (D). E, Final AP radiograph of the internal hemipelvectomy resection and creation of the pelvic sling with biologic mesh (dashed circle). F, Final intraoperative photograph of the pelvic resection margins and inset thigh fillet flap. The flap is made slightly large to re-create the silhouette of a limb, as well as provide redundant tissue for possible future needs. (Courtesy of Christopher Bibbo, DO, FAAOS, FACS, Baltimore, MD. All rights reserved.)

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