Secondary Logo

Journal Logo

Volumetric Muscle Loss

Grogan, Brian F. MD; Hsu, Joseph R. MDSkeletal Trauma Research Consortium

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: February 2011 - Volume 19 - Issue - p S35–S37
Articles
Free

Prevention of infection, as well as bone covering and healing, is paramount in the management of limb injury with associated muscle injury. Volumetric muscle loss (VML) is the traumatic or surgical loss of skeletal muscle with resultant functional impairment. No standardized evaluation protocol exists for the characterization and quantification of VML. Clinical photographs and video recordings, range of motion measurements, manual muscle strength testing, and isokinetic muscle function testing may prove to be useful in documenting VML. Current treatment options include functional free muscle transfer and the use of advanced bracing designs. Advances in powered bracing and regenerative medicine may one day provide additional therapeutic options. Further research on VML is warranted.

From the Department of Orthopaedics and Rehabilitation, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX (Dr. Grogan), and the US Army Institute of Surgical Research, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center (Dr. Hsu).

Dr. Hsu or an immediate family member serves as a board member, owner, officer, or committee member of the Society of Military Orthopaedic Surgeons and has received research or institutional support from the Geneva Foundation. Neither Dr. Grogan nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the United States Government. The authors are employees of the US Government, and this work was prepared as part of their official duties.

J Am Acad Orthop Surg 2011;19 (suppl 1):S35-S37

High-energy civilian trauma and combat-related extremity wounds often involve injury to both bone and soft tissue. Management of these injuries is initially centered on achieving bone healing and on preventing or treating infection.1 Even with bone healing and adequate management of infection, some patients demonstrate persistent functional deficits related to tissue loss resulting from their initial injuries and related surgical procedures. We define volumetric muscle loss (VML) as the traumatic or surgical loss of skeletal muscle with resultant functional impairment. VML is a substantial treatment challenge for military physicians.

Extremity wounds constitute the majority of injuries sustained by soldiers during Operation Enduring Freedom and Operation Iraqi Freedom. 2 These wounds occur secondary to an explosion in >75% of cases.2 Masini et al3 established that extremity injuries “require the greatest utilization of resources for inpatient treatment in the initial postin-jury period, cause the greatest number of disabled soldiers, and have the greatest projected disability benefit costs.” VML undoubtedly contributes to this burden;4 however, the impact of VML in these injuries is poorly documented, difficult to characterize, and poorly understood. Additional research is required to understand the significance of VML for patients and the military health care system.

Evaluation and treatment of patients with VML requires the expertise of a multidisciplinary team that includes orthopaedic surgeons, physical and occupation therapists, and orthotists and/or prosthetists. Effective communication among team members depends in part on the accurate characterization of the injuries and functional deficits. Accurate representation of a patient's injuries is difficult because of the varied distribution of injury types and wound locations. The establishment of a standardized protocol for the characterization and quantification of VML could facilitate patient care and may prove valuable in tracking patient progress and conducting future research.

Most of our current work on VML has focused on the lower extremity because we are seeing an increased number of wounded service members who request late amputation due to functional deficiencies following limb reconstruction.5 VML can be subdivided into two categories: partial compartment loss and total compartment loss. Total compartment loss is characterized by the loss of the nerve that supplies the involved compartment. Lower extremity injuries can be further subdivided into above-knee and below-knee VML. Currently, treatment options are more limited for above-knee VML than for below-knee VML (Table 1).

Table 1

Table 1

Current protocol at our institution for the evaluation of patients with VML consists of clinical photographs and videos, range of motion (ROM) measurement, manual muscle strength testing, and isokinetic muscle function testing. Photographs are obtained to document the extent of wounds and atrophy of surrounding muscles. Videos facilitate gait analysis and the evaluation of other functional movements.6 These images can be added to the electronic medical record to facilitate access by all members of the medical team. A goniometer is used to collect ROM measurements. Manual muscle testing is documented using the British Medical Research Council scale.7 A Biodex System 3 isokinetic dynamometer (Biodex Medical Systems, Shirley, NY) is used to further assess muscle function.8–10 This protocol, which supplements the standard history and physical examination conducted at office visits, standardizes the evaluation of VML and facilitates coordinated care by the medical team.

Current management options for VML include functional free muscle transfer and the use of advanced bracing. Research into regenerative medicine and powered bracing is ongoing.

Functional free muscle transfer has been used at civilian medical centers to restore motor function and joint movement.11–13 Lin et al12 reported successful functional free muscle transfer for the management of traumatic composite soft-tissue and motor unit defects of the lower extremity. Although promising, these procedures are complex; success hinges on using a highly skilled surgical team and on proper patient selection. Donor site morbidity and the technical expertise required to perform these techniques may limit widespread use. Furthermore, results with free tissue transfer have been mixed in patients with combat-related extremity injuries.14

Advances in regenerative medicine, such as the use of extracellular matrix scaffolds and mesenchymal stem cells, hint at future therapeutic options for the management of VML.15–18 Research into a biologic scaffold solution for VML is under way.19 However, extracellular matrix scaffolds are limited to patients with partial compartment loss above or below the knee. Use of biologic scaffold is limited because it requires the presence of a nerve and remaining adjacent muscle in the compartment. 15 Stem cell solutions may have similar limitations.

Advanced bracing strategies are currently being employed by the limb salvage team at our institution.20 These braces are carbon fiber, energystoring ankle-foot orthoses; their construction combines lessons learned from both bracing and prosthetics. Although these braces have the advantage of being a nonsurgical treatment option, they require custom fabrication and are expensive to build. We use advanced bracing for partial and total compartment loss below the knee. Bracing solutions have not yet been developed for compartment loss above the knee. Powered bracing is one potential solution to above-knee VML, but bulk and weight limit the use of this technology.

VML is a significant cause of disability for civilian patients with high-energy trauma and for service members with combat-related extremity wounds. However, it is difficult to evaluate and quantify. A standardized protocol that includes photographs, video, ROM measurements, manual muscle strength testing, and isokinetic muscle function testing can facilitate documentation and management of VML. Current treatment options include functional free muscle transfer and bracing. Future treatment may incorporate regenerative medicine techniques or powered bracing. Further research is needed to better characterize, understand, and treat VML.

Back to Top | Article Outline

References

1. Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R: Lower Extremity Assessment Project (LEAP) Study Group: Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009;23(1):1-6.
2. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB: Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64(2):295-299.
3. Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR: Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2009;23(4):261-266.
4. Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. Battlefield orthopaedic injuries cause the majority of long term disabilities. J Am Acad Orthop Surg 2011;19(suppl 1):S1-S7.
5. Huh J, Stinner D, Burns TC, Hsu LA Jr: Complications and soft tissue injury contribute to late amputation. Presented at the Advanced Technology Applications for Combat Casualty Care Conference, St. Pete Beach, FL, August 16-19, 2010.
6. Brunnekreef JJ, van Uden CJ, van Moorsel S, Kooloos JG: Reliability of videotaped observational gait analysis in patients with orthopedic impairments. BMC Musculoskelet Disord 2005;6:17.
7. British Medical Research Council: Aids to the Investigation of Peripheral Nerve Injuries, ed 2. London, England: Her Majesty's Stationery Office, 1943.
8. Drouin JM, Valovich-McLeod TC, Shultz SJ, Gansneder BM, Perrin DH: Reliability and validity of the Biodex system 3 pro isokinetic dynamometer velocity, torque and position measurements. Eur J Appl Physiol 2004; 91(1):22-29.
9. Feiring DC, Ellenbecker TS, Derscheid GL: Test-retest reliability of the biodex isokinetic dynamometer. J Orthop Sports Phys Ther 1990;11(7):298-300.
10. Montgomery LC, Douglass LW, Deuster PA: Reliability of an isokinetic test of muscle strength and endurance. J Orthop Sports Phys Ther 1989;10(8):315-322.
11. Doi K, Hattori Y, Tan SH, Dhawan V: Basic science behind functioning free muscle transplantation. Clin Plast Surg 2002;29(4):483-495, v-vi.
12. Lin CH, Lin YT, Yeh JT, Chen CT: Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007;119(7):2118-2126.
13. Moneim MS, Omer GE: Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J Hand Surg Am 1986;11(1):135-139.
14. Burns TC, Stinner DJ, Possley DR, et al: Does the zone of injury in combat-related type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma, in press.
15. Valentin JE, Badylak JS, McCabe GP, Badylak SF: Extracellular matrix bioscaffolds for orthopaedic applications: A comparative histologic study. J Bone Joint Surg Am 2006; 88(12):2673-2686.
16. Beattie AJ, Gilbert TW, Guyot JP, Yates AJ, Badylak SF: Chemoattraction of progenitor cells by remodeling extracellular matrix scaffolds. Tissue Eng Part A 2009;15(5):1119-1125.
17. Cerletti M, Jurga S, Witczak CA, et al: Highly efficient, functional engraftment of skeletal muscle stem cells in dystrophic muscles. Cell 2008;134(1):37-47.
18. De Bari C, Dell'Accio F, Vandenabeele F, Vermeesch JR, Raymackers JM, Luyten FP: Skeletal muscle repair by adult human mesenchymal stem cells from synovial membrane. J Cell Biol 2003; 160(6):909-918.
19. Mase VJ Jr, Hsu JR, Wolf SE, et al: Clinical application of an acellular biologic scaffold for surgical repair of a large, traumatic quadriceps femoris muscle defect. Orthopedics 2010;33(7): 511.
20. Owens J, Blair J, Hsu JR: Return to recreational sporting activity after limb salvage. Presented at the 20th Annual Meeting of the Limb Lengthening and Reconstruction Society, New York, NY, July 16-17, 2010.
© 2011 by American Academy of Orthopaedic Surgeons