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Moderators' Summary: Perceived Performance Differences. Limb Salvage Versus Amputation in the Lower Extremity (Session II)

Andersen, Romney C. MD; Swiontkowski, Marc F. MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: February 2011 - Volume 19 - Issue - p S20–S22
doi: 10.3928/01477447-20100722-02
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Severe extremity trauma is a significant cause of morbidity and disability; these injuries are often considered for amputation. Two studies have shown few differences between amputation and limb salvage outcomes. Functional limitations that result from loss of muscle needed to cover bone and provide limb function are a major factor in the decision to amputate a salvaged limb. Several studies have reported successful management of muscle loss with soft-tissue transfer. Extracellular matrix scaffolds and muscle regeneration using stem cells are promising technologies. However, no single strategy has proved to be effective in the management of limb pain following extremity trauma; a multimodal approach is required for best results. Additional knowledge gaps exist, such as the effect of occupational and physical therapy on the outcome of severe limb injury, factors such as peer visitation and social support networks, and the effect of sex, cultural differences, and patient personality.

From the Orthopaedic Surgery Service, Walter Reed National Military Medical Center, Bethesda, MD (Dr. Andersen), and the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Swiontkowski).

Dr. Andersen or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association. Dr. Swiontkowski or an immediate family member serves as a board member, owner, officer, or committee member of the American Board of Medical Specialties and the American Orthopaedic Association; serves as a deputy editor for the Journal of Bone and Joint Surgery; and serves as a paid consultant to Baxter Healthcare, Eli Lilly, and Wyeth.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, or the US Government.

Copyright 2011 by the American Academy of Orthopaedic Surgeons.

Perceived performance differences exist between limb salvage and amputation in the lower extremity. In this session, patient outcomes, injury characteristics, and complications were explored to identify strategies to improve outcomes and define knowledge gaps in the management of severe lower extremity trauma to determine the focus of future research.

Severe extremity trauma is a significant cause of morbidity and disability, and these injuries are frequently considered for amputation. The decision to amputate an extremity is usually determined by the patient. The Lower Extremity Assessment Project (LEAP) study showed no difference in outcomes with amputation versus limb salvage at 2- and 7-year follow-up. 1,2 Patient characteristics and the patient's environment are the factors that most affect outcomes, regardless of initial surgical treatment (eg, amputation, limb salvage), medical complications, or the extent of residual physical limitations. The LEAP study indicated that outcomes were influenced more by patient economic, social, and personal resources than by the initial treatment. Mutable factors, such as self-efficacy and catastrophizing, can be improved on, and strategies and interventions that address such factors can lead to better outcomes. The Military Extremity Trauma and Limb Salvage (METALS) study, which is still in the data collection phase, is examining service members who sustained these devastating injuries in combat. Thus far, few differences have been found between amputation and limb salvage. Many of the factors that affected outcomes in the LEAP study likely will affect outcomes in the METALS study.

No reliable scoring system exists for predicting early on whether a patient will benefit from amputation versus prolonged limb salvage.3,4 Due to the lack of a scoring system, conversion from limb salvage to amputation sometimes occurs late. Helgeson et al5 showed improved function in patients who underwent late amputation. However, previous studies of late amputation reported less encouraging results.6,7

Morbidity in limb reconstruction is usually related to decreased function of the extremity and to pain. Most functional limitations are the result of posttraumatic arthritis, volumetric muscle loss, and/or major nerve injury. Posttraumatic arthritis is a significant finding following limb salvage surgery. Few strategies are available other than pain control and conventional arthroplasty to address this complication.

Few management methods exist to manage functional muscle loss. Loss of muscle needed to cover bone and provide limb function is the single largest factor for both the surgeon and the patient in deciding whether to amputate a salvaged limb.1 Research is being done on soft-tissue transfer and regenerative medicine techniques to address muscle loss. No significant advance has been made in rotational or free-flap tissue transfer in the past several years. However, several studies have demonstrated favorable outcomes with soft-tissue transfer to manage warrelated injuries.8 The most promising technologies in this area of research are extracellular matrix scaffolds and muscle regeneration using stem cells. These technologies have the potential to afford tissue coverage without compromising function of the donor tissue in rotational and free-tissue transfer. Advanced bracing, which can substitute for lost motor units, is also being explored.

Nerve injury is a serious problem in limb salvage. Functional outcomes following major nerve injuries are limited. Current treatments focus on nerve grafts and nerve transfers. Although much research has been done on nerve repair, issues related to cone regeneration, growth cone specificity, and end-organ atrophy remain poorly understood. Strategies to improve injured nerve function and repair are focused on growth factors and stem cells.

Substantial knowledge gaps exist in the management of severe combat extremity trauma with regard to posttraumatic arthritis, volumetric muscle loss, and nerve injury. These topics should be prioritized in further research.

Chronic pain is a major contributing factor in failed limb salvage and limited function in persons who have undergone amputation. Prolonged reconstructive surgeries may induce memory in the central nervous system. This memory appears to be responsible for phantom limb pain following amputation.9 Reduction in the intensity of acute pain around the amputation site seems to result in reduced memory of the pain by the central nervous system, which may lead to a lesser incidence of phantom pain. Recent advances in pain management include the use of pain catheters as well as better management of opioids and the emergence of new medications. A new generation of implantable pain pumps is also available. No single strategy is effective in the management of limb pain following major extremity trauma, and a multimodal approach is required for best results.

Much is unknown regarding the benefit of osteomyoplasty (ie, Ertl amputation) for below-knee amputation. Strong opinions exist both for and against the use of this technique. Proponents of osteomyoplasty report that patients are extremely satisfied with the outcome and that they function at a high level. Benefits of the technique include a stable distal platform that allows end bearing as well as closure of the medullary canal, which may afford homeostasis, decreased pain, reduced heterotopic ossification, and quicker resolution of edema. Opponents of the procedure note that no studies report superior outcomes with the use of osteomyoplasty, and they point to the long track record of the standard Burgess below-knee amputation. One study showed increased surgical and tourniquet times with the Ertl amputation; however, most studies have shown no difference in long-term function or socket fitting.10 Opponents of osteomyoplasty also note the high complication rate in combat-related amputations. Dougherty11 and Pinzur et al12 found no difference in outcomes in two separate studies comparing the procedures. The authors also noted that modern prostheses are not designed to rely on end-bearing capacity; one study showed no difference in socket fitting between osteomyoplasty and the Burgess amputation technique.12 Most clinicians agree that a long-term prospective study is needed to examine the differences in outcomes, and several such studies are under way. There is agreement that the osteomyoplasty technique is best used as a reconstructive procedure and should be done outside the injury zone. Osteomyoplasty is the procedure of choice in the presence of proximal instability of the tibiofibular joint and interosseous membrane.

Additional knowledge gaps exist regarding the management of severe extremity trauma with amputation versus limb salvage. Little is known about the effect of occupational and physical therapy on the outcome of severe limb injury. Other factors that may or may not have a substantial effect on patient outcomes include peer visitation, social support networks, and the availability of rehabilitation facilities. Patient factors that may affect outcomes are not well identified. For example, the effect of sex, cultural differences, and patient personality on outcome is unknown. All service members undergo a battery of personality tests before deploying to combat, and it would be interesting to determine whether preinjury personality traits or factors exist that might affect outcomes. We are unaware of any study that has correlated preinjury factors with postinjury outcomes. No mechanism exists for systematically collecting preinjury patient information in the civilian population. Thus, the military is in a unique position to examine the effect of preinjury status on outcomes.

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References

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10. Tucker CJ, Kirk KL, Granville R, Wilken JM: Limb-socket kinematics of bone bridging and non-bone bridging in wartime transtibial amputations. Presented at the 51st Annual Meeting of the Society of Military Orthopaedic Surgeons, Honolulu, HI, December 14-18, 2009.
11. Dougherty PJ: Transtibial amputees from the Vietnam War: Twenty-eight-year follow-up. J Bone Joint Surg Am 2001; 83(3):383-389.
12. Pinzur MS, Beck J, Himes R, Callaci J: Distal tibiofibular bone-bridging in transtibial amputation. J Bone Joint Surg Am 2008;90(12):2682-2687.
© 2011 by American Academy of Orthopaedic Surgeons