Multiple, sometimes conflicting management techniques and philosophies exist with regard to the postoperative dressing after a trauma-related amputation. The most commonly used techniques include utilization of soft or rigid dressings and the immediate postoperative prosthesis (IPOP). Each of these has advantages and disadvantages, but when utilized appropriately all are currently acceptable as no method has proven superior with regard to preventing complications or improving outcomes. Regardless of the technique chosen, it is imperative that gentle balanced compression be applied to the residual limb to control swelling, decrease pain, and promote a stable limb volume. We advocate early utilization of elastic shrinkers as soon as postoperative drains are removed. Regardless, a transition from postoperative dressings to elastic shrinkers is warranted as soon as the surgeon is satisfied with the initial wound-healing in order to further stabilize the limb volume and ready the limb for prosthetic wear. In addition, early physical therapy should be initiated to prevent contracture formation.
Trauma-related amputations are frequently performed within the zone of injury, and atypical soft-tissue coverage is relatively common5. The use of a soft dressing allows frequent non-labor-intensive dressing changes and close surveillance of these complication-prone wound closures. Rigid dressings have frequently been utilized in the management of transtibial and more distal amputations. The efficacy of this bandage lies in its ability to control edema, prevent joint contractures, and improve pain control6. Despite multiple studies that have shown a trend toward better wound-healing with a rigid dressing, the soft dressing is still frequently used and recommended after trauma-related amputations because of the ease of wound inspection, the improved ability to mobilize the patients early, and the decreased risk of pressure ulceration, particularly over the patella5,72,90-95.
The immediate postoperative prosthesis (IPOP) was originally proposed shortly after World War I and has been used and modified following World War II, the Korean War, and the Vietnam War96-100. The premise of the IPOP is to immediately fit patients with a temporary prosthesis following an operation. Benefits of the IPOP have been demonstrated mainly in a non-trauma population and include improved psychological outlook, less perceived loss of function, shorter hospital stays, fewer revision operations, and a faster time to initial prosthetic fitting90,94,101,102. Despite these advantages, IPOP use is limited in the trauma population because of expense and time requirements as well as the very real concerns of achieving adequate wound-healing and the early detection of infection and associated injuries that often preclude early mobilization.
The LEAP study continues to heighten the awareness that amputation is not always the best treatment for severe lower-extremity injuries. The study demonstrated in a prospective fashion the short-term complications that accompany this procedure4. Long-term follow-up studies have also indicated that individuals with a trauma-related amputation have long-term residual limb, phantom-limb, back, and joint pain104-107.
Low-back pain appears to be the most common chronic disabling pain experienced by individuals with an amputation. Smith et al.107 reported that 71% of their patients experienced back pain following a unilateral amputation. The study subjects indicated that the back pain was significantly more bothersome than their phantom-limb pain (p ≤ 0.05). The frequency of back pain was also significantly higher after above-the-knee amputations (p ≤ 0.05).
In addition to the chronic pain experienced by individuals who have had an amputation, the most concerning health issue in this population was described by Robbins et al.104 after a review of the long-term health outcomes associated with war-related amputations. They reviewed multiple studies that indicated that individuals with an amputation were at a significantly higher risk of developing and dying of cardiovascular disease than a control group of matched patients (p < 0.05).
Another area that should be evaluated is the ability of patients to return to a productive vocational life following a trauma-related amputation. Substantial evidence suggests that, although the majority of individuals with a trauma-related amputation are able to return to work, they frequently require a change in their occupation following their injury108.
There is a distinct association between acute postoperative pain and chronic amputation-related pain. Patients who report the greatest acute phantom-limb pain are more likely to continue to be affected by phantom-limb pain at both six and twelve months following the operation109. Consequently, attempts have been made to reduce the early pain experienced following an amputation. The long-term positive impact of these techniques is currently being debated, yet the short-term benefits of current anesthesia techniques include increased patient comfort, a decreased narcotic requirement, and slightly earlier mobilization. The goal of these anesthesia techniques is to prevent central neuroplastic changes from occurring through the use of preventive multimodal analgesia. These modalities are aimed at various stages of the nociceptive pathways and include anticonvulsants such as gabapentin and pregabalin, nonsteroidal anti-inflammatory drugs, local nerve-sheath injections of anesthetics, alpha-2 agonists, ketamine, opioids, preemptive epidural injections, and regional nerve blocks110. We believe that the complexity of performing these various anesthesia techniques, the multiple classes of medications, and the often chronic nature of amputation-related pain suggest that a surgeon should consult a pain specialist either prior to or shortly following an amputation. A cooperative effort between the pain specialist and the surgeon will ensure that causes of pain that can be relieved with surgery are addressed while long-term chronic pain is also treated.
The findings of the LEAP study group have heightened the awareness of the psychosocial disability that individuals experience after a lower-extremity amputation5. In that study, 48% of 505 patients who had sustained severe lower-extremity trauma had a positive result on screening for a psychological disorder at three months after the injury. In this same cohort, 42% of 452 patients remained positive for a psychological disorder at twenty-four months after the injury111. Trauma-related amputations represent a life stressor for even the highest functioning individuals. Trauma patients generally do not get time to consider their situation, and often their first thought or discussion regarding amputation occurs when they awaken from anesthesia with the loss of a limb.
In an attempt to address all of these necessary components of rehabilitation after an amputation, including the psychological needs, the United States military has established Amputee Care Programs during the current conflicts as well as during and after all previous conflicts starting with World War I6,112. The establishment of these programs was an attempt to standardize the care as well as pool the resources and expertise in the multidimensional care of military personnel who had had an amputation. The current program was developed with the recognition of the complex multifaceted aspects of a patient’s recovery, and efforts were made to provide support in each of these areas while utilizing a sports medicine-based, activity-oriented rehabilitation program113.
While the implementation of such comprehensive programs is not realistic at all medical trauma facilities, many already exist in one form or another, and those existing inpatient rehabilitation programs can be utilized for individuals with a trauma-related amputation. Pezzin et al.114 demonstrated that patients who were discharged to inpatient rehabilitation after a trauma-related amputation had improved health and vocational prospects.
Despite attention to perioperative and operative details, amputations due to trauma can be fraught with complications. These can range from minor dermatologic problems to major complications requiring multiple return trips to the operating room and possible loss of residual limb length. In a recent investigation by the LEAP study group, >85% of 520 patients who had severe lower-extremity trauma had a complication4. Nearly half of 149 patients who were treated with amputation had either a wound infection or wound necrosis. This supports the early finding of Pierce et al.3 that half of their sixty-one patients who had undergone a trauma-related amputation had a postoperative complication. The most common complications include symptomatic neuromas and phantom and residual-limb pain4. Less frequently reported short and intermediate-term complications include bone spurs, heterotopic ossification, and failure of a myodesis procedure6. In the long term, most amputations are complicated by some degree of chronic residual-limb, phantom-limb, and low-back pain as well as degenerative joint disease of both ipsilateral and contralateral joints104,107,115. As noted, patients who have had an amputation are also at substantial risk of developing cardiovascular disease104.
The long-term follow-up of individuals with a trauma-related amputation throughout and after their initial rehabilitation may identify a substantial proportion with potentially correctable symptomatic complications, including bone spurs, heterotopic ossification, symptomatic neuromas, failure of a myodesis, wound complications, and redundant soft tissue in the form of so-called dog ears (redundant soft tissue at the wound edge that protrudes and is cosmetically unappealing and may result in pain or ulceration within a prosthetic socket). Under these circumstances, it is imperative to maintain a close working relationship with both the patient and his or her prosthetist. Exhaustive nonoperative treatment options should be used for the early management of all of these complications, with the exception of failure of a myodesis. Prosthesis and socket adjustments, padding, and gait training should all be maximized prior to operative intervention.
Operative intervention may be warranted when functional improvement ceases to progress, the patient is still not satisfied with the current use of the prosthesis or with his or her overall function, and a cause of symptoms for which an operation is indicated is identified. In the majority of situations, previous amputation incisions should be utilized and the surgical planes should be carefully developed. Particular attention should be paid to the myodesis. With certain complications such as so-called dog ears, superficial neuromas, or superficial infections, the myodesis may not have to be taken down in order to address the problem. If the myodesis is taken down, preservation of the muscle fascia must be accomplished in order to perform an adequate revision myodesis. Careful dissection through the scarred tissue planes is performed until anatomically identifiable structures are seen. At this time, revision traction neurectomy, revision myodesis, or excision of heterotopic bone can be carried out. In our experience, dramatic pain relief and increased prosthetic wear following operative treatment of complications is common.
During World War I, Ertl developed and popularized a technique for transtibial amputation that created a distal synostosis between the tibia and the fibula in order to provide a more stable, broad, end-bearing residual limb116. Although Ertl’s theories regarding the sealing of the medullary canal and the restoration of so-called normal bone physiology have been largely discarded, his concept has been broadly utilized and frequently modified since that time74,117,118. There is substantial controversy surrounding this procedure, and the functional benefit of the technique remains uncertain. In 2006, Pinzur et al.119 reported the results of a study that suggested that patient-perceived functional outcomes were improved by a bone-bridging procedure. However, in a more recent study comparing the patients in that series with patients in the United States, Pinzur and colleagues120 were unable to demonstrate an advantage over the traditional transtibial amputation described by Burgess et al.31.
To our knowledge, there has been no long-term review of the complications unique to this procedure, which include symptomatic nonunion, malunion, bone-bridge dislocation, and implant-related complications (Figs. 7-A and 7-B)118,121. Further study of the complication rates of these procedures as well as additional, ideally prospective, studies to determine if there is functional benefit of this procedure over traditional techniques must be conducted prior to advocating creation of a bridge synostosis as a preferred method of primary amputation.
Osseointegration is described as structurally and functionally stable fixation and coexistence between bone and controlled synthetic components (usually titanium) providing lasting clinical function without rejection122. Osseointegration has been in clinical use since the 1950s, but its application in amputation surgery was only begun in 1990. It is an experimental technique in which a titanium rod is screwed into a residual bone and then, often at a second surgery, is brought transcutaneously to allow prosthetic limb attachment. Osseointegration has not been approved by the United States Food and Drug Administration (FDA).
Potential benefits of osseointegration include easy and fast donning and doffing of the artificial limb, direct force transmission to the prosthesis, a proper fit every time that always remains in the same position, no restriction of the proximal joint range of motion, and no socket or liner that may cause sweating, sores, and discomfort123,124. Despite these suggested advantages, the concept of osseointegration remains experimental and is associated with substantial complications that have limited its use to date. The most frequent complications include superficial and deep infections, implant loosening, and periprosthetic fracture125. Revision osseointegration surgery or revision to a conventional residual limb following failure of osseointegration frequently requires substantial shortening of the residual limb. The most concerning of these problems is the risk of infection, and continued research efforts are being devoted to developing methods of stabilizing the skin-implant-environment interface around transcutaneous implants126.
Trauma-related amputations are relatively common but are infrequently performed by the majority of orthopaedic surgeons. For this reason, an involved and attentive surgeon is a necessity for optimal outcomes, and a well-performed amputation or revision amputation should always be considered a challenge for even an experienced surgeon. Although these procedures are associated with frequent complications and may lead to poor outcomes, adherence to proper operative techniques and the avoidance of well-documented technical errors can dramatically improve the ultimate functional outcome for the patient. While the treatment of severe lower-extremity trauma can be disheartening to both the patient and the surgeon, a successful result with dramatic functional recovery and a highly functioning individual can be equally rewarding.
Investigation performed at the Walter Reed Army Medical Center, Washington, DC, and the National Naval Medical Center, Bethesda, Maryland
Disclaimer: The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Army, United States Navy, or the Department of Defense.
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