Limb Salvage

Limb-sparing procedures have become possible because of advances in imaging, reconstructive surgery, microsurgery, and cancer treatment. Improved methods of resuscitation and time-sensitive transport have decreased ischemia time. Optimal skin and soft tissue closure with pedicle flaps and microvascular free flaps allows the surgeon to meet the initial goal of critical limb length and the later goal of skin durability for long-term socket use. Whether it is tumor, trauma, or congenital malformation, the decision to attempt salvage with reconstruction or amputation remains difficult. The best decision is one formed by the consensus of the experienced trauma, oncology, and rehabilitation specialists. Upper and lower limb characteristics are different and must be kept in mind when considering limb salvage or amputation. The upper limb is non–weight-bearing. It remains functional with significant sensory impairment, which is different from the lower limb. An upper limb that preserves only assistive function is still often more functional than one with a prosthetic replacement.

Injury scores were developed for severe trauma-related limb injuries, to help determine which vascular injury patients would benefit from primary amputation versus an attempt at limb salvage. Their validity has been questioned. The mangled extremity syndrome is defined as significant injury to at least three of the four tissue groups (skin/soft tissue, nerve, vessel and bone).²⁴ The mangled extremity scoring systems have been shown to be poor predictors of amputation or salvage with regard to functional outcome.^18,39,48 Ly et al.³⁷ concluded that the available injury severity scores are not predictive of functional recovery of patients who undergo reconstruction surgery. Bosse et al.,⁶ using the Sickness Impact Profile, presented evidence that the functional outcomes from limb salvage and reconstruction after severe trauma were the same at 2 years for those who underwent amputation. Finally, in this salvage-versus-amputation equation, no significant long-term psychological outcome advantage has been reported for limb salvage surgery compared with amputation.⁴⁵ Consequently, objective measures have not functionally supported the natural desires of the patient and the tendency of the trauma team to make all attempts at salvaging the limb.

In severe limb trauma that includes defects from burns and tumor resection, the appropriate soft tissue restoration is an essential component of the overall treatment. This is common both to limb salvage and amputation, especially when critical lengths are being preserved. It requires a vascularized flap that can protect the neurovascular and musculotendonous structures (Box 12-3). The pedicle flap is one where a local muscle inclusive of the overlying skin is moved over with it own blood supply to fill a large defect. A microvascular free flap is one in which the donor tissue is taken from a different site and the microvasculature of the donor tissue is anastomosed to the available vessels in the site of the defect. The feasibility of limb salvage is determined partly by the ability to reconstruct the soft tissue defect. In the upper limb, few pedicle flap options are available to repair significant defects. The recent advancement of microvascular reconstruction techniques and free flaps from sites like the rectus abdominus have promoted the option of limb salvage and preserved limb length.

Once it has been decided that amputation is more appropriate than limb salvage, the team must plan the most distal level possible, based on principles of wound healing and functional prosthetic fitting. Skin flaps now afford closures that were not historically possible. The skin closure must be without tension and should be done so that nonadherent, strategically placed, mobile scars are produced. It is the artful surgeon who crafts the distal residual limb with the appropriate muscle padding, rather than producing a bony atrophic limb or one with excessive preservation of soft, redundant tissue that makes it difficult to fit the prosthetic socket. Stable distal muscle padding can be accomplished through myodesis, in which the deep layers are sutured directly to the periosteum. It can also be accomplished by myoplasty, in which the superficial antagonistic muscles are sutured together and to the deeper muscle layers. These techniques typically produce muscle padding with sufficient balance and tension.

Although these are the conventional surgical techniques to address the residual muscle tissue, myoplasty presents a challenge downstream when attempting to localize an optimal myoelectrode placement, because the muscles that are sutured together tend to contract simultaneously. The ideal distal muscle stabilization occurs with tenodesis. If the muscle is preserved with its tendon, the tendon can be sutured to the periosteum.

Neuroma formation is the normal and expected consequence of nerve division. Nerves should be gently withdrawn from the wound, sharply divided, and allowed to retract under cover of soft tissue. The goal is to locate the ends of incised nerves away from areas of external contact such as the socket interface, so the cicatrix will remain asymptomatic.

For those with malignant tumors, 70% to 85% are treated by limb salvage without compromising the oncologic result.⁵⁰ The goal of this type of surgery is to preserve function, prevent tumor recurrence, and enable the rapid administration of chemotherapy or radiation therapy. In the tumors of the hand, ray resection is done. In the wrist, multiple options are available such as an endoprosthesis implant or an allograft or vascularized bone transplant (e.g., fibula). For the elbow an endoprosthetic reconstruction is the best possible option. The humerus is similar to the wrist in that an endoprosthesis, or an allograft, or a vascularized bone transplant can be used. For tumors of the scapula or proximal humerus, a forequarter amputation or flail arm is prevented by reconstruction with a combination of an endoprosthesis and allograft. These types of reconstruction would not be possible without major improvements in radiography, chemotherapy, radiotherapy, and staging.⁵⁰

The complication rate is much higher after limb salvage than after amputation in the oncology population. These complications can be divided into early and late. The earliest complications include infection, wound necrosis, and neurapraxia. The late complications include aseptic loosening, prosthetic fracture and dislocation, and graft nonunion.⁴ Consequently additional surgery is often necessary. Advancements in resection techniques, radiation, and chemotherapy have improved both functional limb survival and life expectancy. Serletti et al.,⁴⁵ using the Enneking Outcome Measurement Scale, reported the functional outcome as “excellent” or “good” in greater than 70% of the patients who had reconstruction after resection of limb sarcomas. The Enneking Outcome Measurement Scale is an outcome tool that assesses seven characteristics of upper limb use: ROM, stability, deformity, pain level, strength, functional activity, and emotional acceptance. Limb salvage has cosmetic advantages, but whether the quality of life of these patients is superior to that of those who undergo amputation is unclear.

Reimplantation of traumatically amputated limbs is now possible, especially in children, because of the potential for successful neurologic recovery.³⁰ Effective treatment of the patient and the ischemic, detached body part requires appropriate early cooling and prompt reimplantation within the initial 12-hour window. Predictors of successful reimplantation include adequate preservation, contraction of the muscle in the amputated limb after stimulation, the level of injury, and no tobacco use. The best predictor of success is the serum potassium level in the amputated segment. If the serum potassium level is higher than 6.5 mmol/L, reimplantation should be avoided.⁵¹

Reimplantation is indicated in levels from the distal forearm to the fingers. The more proximal to the wrist, the greater the amount of ischemic muscle mass and the more complex the metabolic and surgical demands. Approximately 85% of replanted parts remain viable. Sensory recovery with two-point discrimination occurs in 50% of adults.³⁵ The functional results are more promising in children, but the viability rate is lower because of the technically demanding microvascular surgery. Major limb reimplantation entails significant metabolic disturbance and risk. It requires scrupulous medical management. Reimplantation is contraindicated in those with crushed and mangled limbs and those with atherosclerosis. Because nerves transected in the proximal arm must regenerate over a considerable length, only limited motor return is typically seen in the forearm and hand. Useful function of the wrist and hand is unusual and limited at best. Function can often be improved by converting these patients to transradial prosthetic wearers. Unfortunately it means performing a transradial amputation after successful transhumeral reimplantation. This is known as segmental reimplantation, in which portions of compromised limbs are salvaged that would otherwise have been discarded.

During the past 10 years, collaboration between hand surgeons and immunologists has led to successes in hand transplantation. Recent advances learned from clinical organ transplant immunosuppression known as composite tissue allograft (CTA) have permitted hand transplantation to progress beyond the first one done in the United States in 1997. CTA is the term used to describe transplantation of multiple tissues (skin, muscle, bone, cartilage, nerve, tendon, blood vessels) as a functional unit. In addition to the usual problems of identifying an organ donor, selecting a donor for a hand transplant must involve additional and careful emphasis on matching skin color, skin tone, gender, ethnicity and race, and the size of the hand. After a hand has been lost, much time can pass before a donor is found. Representation of the hand in the individual’s brain is lost because of cortical reorganization during this time. Researchers have learned through functional magnetic resonance imaging that after transplantation, amputation-induced cortical reorganization is reversed to reestablish the hand “image.”⁵ During transplantation the surgeon repairs the tissues in the following order: bone fixation, tendon repair, artery repair, nerve repair, and vein repair. The surgery can last from 12 to 16 hours, almost double that of heart and liver transplants. Immunosuppression after CTA is composed of two elements: treating the patient with monoclonal antibodies on the day of transplant, followed by a donor bone marrow infusion several days later. Typical postoperative complications include vessel thrombosis, infections, and rejection. Rejection can appear as a spotty, patchy, or blotchy rash. It could appear anywhere on the transplant and is usually painless. As rejection appears first in the skin, the clinical team and patients are encouraged to carefully watch for the signs. Unlike internal organ transplants, where rejection is difficult to detect early, it is relatively easy to monitor in the hand, allowing for early biopsy and treatment. Recovery is relatively slow, requiring an extensive program of occupational therapy. As of this printing the longest reported patient follow-up has been 43 months. This patient, a paramedic instructor, is now reportedly able to start intravenous lines and perform endotracheal intubation.

Amputation

Hand function is vital in our competitive and industrialized society. There are many techniques for reconstruction of the hand. It is much better to have a painless hand with some grasp function and sensation preserved than to have a prosthesis. The most important part of the hand is the opposable thumb. The goal is to preserve as much of the sensate thumb as possible. Phalangization (Figure 12-3) of the metacarpals is a reconstructive technique in which the web space is deepened between the digits to provide more mobile digits. This works well for the thumb especially if the first metacarpal is adjusted to create opposition to the thumb. Pollicization (Figure 12-4) is the process of moving a finger with its nerve and blood supply to the site of the amputated thumb. This allows fine and gross grasp through opposition. A prosthesis for a hand amputation is inferior to the functional outcomes achieved with reconstructed hands.⁹ In reconstructing the hand, three issues should be considered: (1) preservation of sensitivity to the grasping surface; (2) the consequences of scarring; and (3) cosmetic acceptability.

FIGURE 12-3 Phalangization of the metacarpals is a reconstructive technique in which the web space is deepened between the digits, providing more mobile digits. (A) Amputated thumb. (B) Web space deepened. (C) Final web space deepened to provide more mobility.

FIGURE 12-4 Pollicization is the process of moving a finger with its nerve and blood supply to the site of the amputated thumb. (A) Amputated thumb including metacarpal. (B) Index finger to be moved. (C) Final index finger in the thumb’s place.

Wrist disarticulation involves removal of the radius and ulna to the styloid processes, because there is no benefit to retaining the carpal bones. It retains the distal radial-ulnar joint, preserving more forearm rotation. The prosthetic attachment to the bulbous end is enhanced if the distal radial flare is retained for suspension. Burkhalter et al.¹⁰ indicate that it is important that the radial and ulnar styloids be resected slightly to minimize the discomfort the amputee will experience in active supination and pronation within the prosthetic socket. Tenodesis of the major forearm muscles stabilizes these groups and improves functional outcome, including myoelectric performance. Pronation and supination, as well as full elbow motion, are preserved with wrist disarticulation. Some will argue that (1) the wrist disarticulation creates a complicated prosthetic situation with difficult socket fabrication; (2) conventional wrist units are too long and cannot be used; and (3) it is harder to fit with a myoelectric prosthesis because there is no room to conceal the electronics and power supply.

Transradial amputation involves the myodesis of the forearm muscles and equal volar and dorsal skin flaps for closure. It is extremely functional, with forearm rotation and strength that is proportional to the length retained. The shorter the transradial amputation, the more the elbow and humerus are needed for suspension. Preserving the elbow joint is paramount because of the functional outcome possible with prosthetic enhancement. If the amputation must be very proximal, then an ulna 1.5 to 2 inches long is still adequate to preserve the elbow joint. To fit this very short residual limb with a prosthesis, it might be helpful to detach the biceps and reattach it to the ulna.³⁶

A couple of special situations arise with transradial amputations. One is when the forearm bone is considerably longer than the other and the longer bone can be covered with an adequate soft tissue envelope. Rather than decrease prosthetic function by shortening the longer bone, it may be preferable to create a one-bone forearm. Another is the Krukenberg amputation (Figure 12-5), which transforms the residual ulna and radius into digits that have significant forceful prehension and retained ability to manipulate because of preserved sensation. This is an option for patients who have at least 4 inches of residual limb, those with bilateral amputation, and those with limited prosthetic facilities. It can be fitted with conventional as well as myoelectric prostheses.

FIGURE 12-5 The Krukenberg amputation transforms the residual ulna and radius into digits that have significant forceful prehension and retained ability to manipulate because of preserved sensation.

Elbow disarticulation allows the transfer of humeral rotation to the prosthesis through the myodesis of the biceps and triceps, and it preserves a stronger lever. Although the skin flaps are approximately equal, the posterior muscle flap remains longer than the anterior muscle flap, to wrap around and cushion the end of the humerus. The ultimate position of the scar is not critical with modern total-contact sockets, but beware of the vulnerable skin over the medial epicondyle. The full humeral length precludes the use of a myoelectric elbow. Elbow disarticulation causes some prosthetic fitting challenges because the outside “elbow” hinge creates a bulky limb that is longer and asymmetric compared with the opposite limb. Disarticulation is the level of choice for juvenile amputees. The high incidence of residual limb revision because of bony overgrowth is avoided, and humeral growth is preserved. It remains controversial who is a good candidate for elbow disarticulation, but modern prosthetic fabrication techniques can overcome the socket and cosmetic difficulties.^12,14

Transhumeral amputations are performed at or proximal to the supracondylar level. The humerus is sectioned at least 3 cm from the joint to allow for fit of the prosthetic elbow mechanism. Transhumeral amputations should be performed with minimal periosteal stripping to prevent the occurrence of bony spurs. Rough edges should be removed, but beveling of the bone is unnecessary. All possible length should be preserved to transmit glenohumeral motions through the prosthesis. To help preserve humeral length, at times it should be considered whether free-flap coverage and skin graft coverage are possible alternatives to allow primary closure. The anterior and posterior fascias over the flexor and extensor muscle groups are sutured together to cover the end of the humerus. Biceps and triceps myoplasty preserves strength for prosthetic control and myoelectric signals. Myodesis is rarely needed.³⁸ Performing a more proximal amputation at the level of the surgical neck, which is the site of insertion of the pectoralis major, results in the same function as if a shoulder disarticulation had been done. This is because independent motion of the humerus is no longer possible. However, because the terminal device is controlled by active shoulder girdle motion, the humeral head should be preserved when amputation has to be done proximally.

Amputations through the glenohumeral and scapulothoracic articulations, shoulder disarticulation and forequarter amputation, respectively, are rare, and both result in loss of normal shoulder contour. Advances in vascular surgery have made reestablishment of blood flow to severely traumatized limbs effective, but reimplantation of a limb amputated through the shoulder girdle is seldom feasible. The cosmetic deformity of both of these amputations is significant. When possible, retention of the scapula is far less disfiguring and of psychological benefit to the patient. Personal concerns of having standard clothing fit supersede more complex concerns of functional restoration. In shoulder disarticulation, the rotator cuff tendons should be sutured together over the glenoid wing. The deltoid is attached to the inferior glenoid and lateral scapular border to fill the subacromial space. In forequarter amputation, the pectoralis major, latissimus dorsi, and trapezius are sutured together to form additional padding and contour over the chest wall. During forequarter amputation, osteotomy of the clavicle should be performed at the lateral margin of the sternocleidomastoid insertion to preserve contour of the neck.

Preamputation

The team approach to amputee rehabilitation begins in the preamputation phase whenever possible. The surgical team joins forces with the rehabilitation team to educate and counsel each other and the patient. It is important to include family members and other supporting individuals in the counseling. A plan of the surgery must be made that takes into account an understanding of the healing potential and the most realistic and optimal functional prosthetic restoration. This is based on the information flow between the rehabilitation team and the surgical team. Important discussions need to be held with the patient about the planned surgical outcome and postsurgical period. This should include a discussion about the different types of pain that might occur, the prevention of possible complications, and a preview of potential functional outcome. It is important to acknowledge the loss and mitigate the fear with education. A powerful intervention is to have a trained amputee volunteer, a “peer visitor,” who has successfully gone through a similar limb loss and can give support to the patient throughout the recovery process.

Acute Postamputation

This phase begins with an understanding that the decision to amputate is emotionally powerful for the patient, family, and clinical team. Amputation is not a failure but rather reconstructive surgery that creates improved functional possibilities and resumption of one’s life. The focus of the immediate postamputation period is to control pain and edema, promote wound healing, prevent contractures, initiate remobilization, and continue the supportive counseling and education (Box 12-4). This must be individualized to meet the needs of each patient. Surgical site infection needs to be seriously considered when pain, drainage, and edema are increasing despite the reasonable control measures instituted. The earlier an infection is eradicated, the earlier the time-sensitive prosthetic phase can begin. The goal for rehabilitation is for patients to acquire the skills and equipment needed to achieve prosthetic acceptance and holistic reintegration back into their own lives. It is imperative that the prosthesis be introduced at the earliest possible time after amputation.

The team has a responsibility to explain and give visualization of the postamputation treatment phases, from the early postoperative phase through rehabilitation and community reentry. Each team member (including the surgeon, physiatrist, prosthetist, and rehabilitation therapists) has specific duties related to physical, educational, and psychological support through these phases. An amputee peer visitor, preferably someone who has been formally trained, is a team member who has a distinct vantage point because of real-life experience. The Amputee Coalition of America (ACA), which is the national nonprofit limb loss advocacy group in the United States, can serve as a comprehensive source of information to persons with limb loss and their professional team. This includes locating ACA-trained peer visitors and regional support groups.

Pain control requires an early, aggressive approach that considers the multiple potential pain generators in the postsurgical period. The patient-controlled analgesia systems are often the first-line treatment by the surgical team. This is transitioned to regularly scheduled long- and short-acting oral narcotic medications. It is imperative to maintain consistent pain control. Loss of adequate pain control is painful for the patient and disrupts the timely pursuit of the rehabilitation program. The escalation of the doses of opiates needs to be avoided, if possible, by addressing other pain generators. Understanding the characteristics of postsurgical residual limb pain and phantom pain allows the clinical team to choose pain interventions wisely. Residual limb pain is located in the remaining limb and generated from the soft tissue and musculoskeletal components. Phantom limb pain is pain in the absent limb and is considered neuropathic.¹⁷ The nonsteroidal antiinflammatory drugs and nonopiate pain relievers are helpful, and these can diminish the need for higher doses of opiates. Opiates administered at safe doses are often ineffective against phantom pain. Careful attention should be given to the description, timing, and quality of the pain complaint to tease out the central neuropathic pain component inclusive of painful phantom sensations versus peripheral nerve–generated pain. Peripheral nerve pain is more intense at night, and it is characterized as burning, stabbing, and buzzing. Phantom sensations occur in greater than 70% of amputees and do not have to be treated unless painful and disruptive. The use of medications known for controlling neuropathic pain and sensations, such as some anticonvulsants and antidepressants, can also diminish the need for opiates.

The new amputee should be taught how to change the dressings and self-administer the desensitization techniques. Desensitization techniques help to eliminate the hypersensitivity to touch. They include compression, tapping, massage, and application of different textures. These techniques are performed for 20 to 30 minutes three times per day as tolerated by the skin and scar.²² The use of modalities such as transcutaneous nerve stimulation, heat, and cold are also useful adjuvants for pain and diminish opiate need. Ramachandran and Rogers-Ramachandran⁴³ have reduced phantom pain using mirrors to visually trick the brain. Because the loss of a limb is emotionally “painful,” the team should address and acknowledge this. It should be kept in mind that from the individual’s psychological standpoint, it might be more socially acceptable to express the psychological pain in terms of generalized pain complaints. It is important to address the psychological pain early, through grief counseling, peer visitation, and education.

Edema control begins once the last suture or staple is placed by the surgeon. If there is no contraindication and the surgeon has the appropriate training, an immediate postoperative rigid dressing (IPORD) can be placed in the operating room. This is a special cast placed on the residual limb by the surgeon or certified professional. The control of edema leads to earlier wound healing and improved pain control through the reduction of pain mediators in the accumulated “third-spaced fluid.” Typically additional shrinkage of the residual limb occurs after the initial IPORD placement, necessitating its early replacement. The rigid dressing can be removed in 5 to 7 days and replaced with a fresh cast. The attachment of joints and a terminal device to this rigid dressing creates an immediate postoperative prosthesis that can allow early functional use of the residual limb. The IPORD is the preferred treatment approach for the transradial amputation, and if healing progresses without issue, the second cast can be replaced with the first prosthesis.¹⁹

Traumatic upper limb loss is often accompanied by large tissue defects, burns, and wound contamination from complex infections. These make immediate postoperative techniques impossible. In these cases, once drains and negative pressure dressings are discontinued, a soft compressive dressing can be placed to control edema and initiate shaping of the residual limb.

The ideal residual limb shape is cylindrical. The dressing should be placed and replaced by a trained clinician. It should extend beyond the proximal joint to maximize suspension and improve edema control. Those not placed correctly can create problems with distal edema accumulation, skin breakdown, and abnormal shaping (such as a dumbbell shape). The healing surgical and trauma sites frequently have patches of sensory impairment and should be monitored by the team. This is especially the case in properly using the compressive dressings to prevent pressure sores. Once the skin has closed, dressings are replaced with “shrinkers,” a silicone liner, or both. Edema control is a lifelong daily management issue for most amputees.

The control of pain and residual limb edema allows for early functional remobilization of the residual limb, which in turn helps prevent contracture formation. Contractures are not fully reversible, and it is critical to begin remobilization as early as possible. Techniques for prevention of elbow flexion and shoulder adduction contractures should be reinforced with the patient and team. This can be difficult in the setting of uncontrolled pain, burns, and other complex trauma factors such as fractures, brain or spinal cord injuries, spasticity, and systemic illness.

The formation of heterotopic bone impairing joint function and ROM should be considered in these complex trauma cases and can be diagnosed with the help of laboratory testing and triple-phase bone scan. The treatment of heterotopic ossification beyond trying to maintain ROM is limited, and surgical intervention is not feasible until the heterotopic bone matures at approximately 12 to 18 months after injury.²³ Proper limb positioning and frequent monitoring of joint mobility are necessary. Any loss of ROM in a joint of the residual limb can have significant effects on functional use of the prosthesis. The loss of ROM needs to be investigated and aggressively managed to maximize range.

Preprosthetic training begins with the early postsurgical therapy visit and continues until prosthetic fitting is completed. Prosthetic fabrication and fitting ideally should be completed within 4 to 8 weeks after surgery. Early prosthetic fitting is important, because prosthetic acceptance declines if fitting is delayed beyond the third postoperative month.²⁰ Preprosthetic training is critical to maintain motivation and create an easier transition to prosthetic use. Amputation results in a loss of body symmetry. This imbalance results in shoulder elevation and scapula rotation on the affected side, as well as loss of neutral positioning of the residual limb. Close attention must be paid to the individual’s awkward or compensatory body motions when approaching an object. The rebalancing begins with observing and correcting static postures in the mirror. The mirror remains an important tool in conscious recognition and correction of the abnormal positioning. The amputee is encouraged to use muscle memory to relearn correct postural and limb positioning control.²² As remobilization progresses, emphasis is placed on recognizing the abnormal postures and positioning that occur with basic activities of daily living (ADLs).

ADLs are mastered with one hand and, when appropriate, with the use of adaptive equipment. The amputee progresses from independence with basic hygiene to the advanced homemaking tasks. Hand dominance is retrained when necessary, especially with handwriting and keyboarding. Repetitive tasks can be used for strengthening. These tasks include fine motor exercises with nuts and bolts or tweezers, as well as gross motor exercises with equipment and mirrors. Proprioceptive neuromuscular facilitation is a particularly effective approach that enables the therapist to work in diagonal planes, vary the amount of resistance, and concentrate on specific areas of weakness. Isometric exercises are effective in creating muscle bulk for stabilization of the arm in the socket of the prosthesis. The stability of the prosthesis depends on both the bulk of the stabilizing musculature and the amputee’s ability to voluntarily vary residual limb configuration. Because balance is often disrupted in a new amputee, the goals should include strengthening of the trunk, core, and lower limbs using isometric exercise and aerobic training. Depending on level of loss, the upper limb amputee should begin to practice several motions that will be needed to control the prosthesis (Box 12-5).

BOX 12-5 Specific Movements Necessary to Control a Prosthesis and Maintenance of Range of Motion

Specific Movements Necessary to Control a Prosthesis

• Scapular abduction: Spreading the scapulas apart alone and in combination with humeral flexion will provide the tension needed on the figure-of-eight harness to open the terminal device.

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