Advances in body armor, prehospital management, tourniquet use, and casualty evacuation in recent U.S. military conflicts in Iraq and Afghanistan have increased the survivability of severe combat injuries.1 Because the extremities remain vulnerable, military orthopaedic surgeons are treating a larger number of severe extremity injuries, including traumatic amputations and mangled extremities at risk for amputation.2,3 Anatomic and physiologic conditions, surgeon experience, and patient wishes and expectations influence the decision to pursue early amputation or limb salvage, which remains controversial. The objective is to determine the course of action that best aligns with each patient's interests and goals.
Prerequisites for limb salvage are the ability to obtain a well-perfused and mechanically stable limb with a durable terminal extremity. Vascular injury requires urgent revascularization to ensure adequate perfusion. Temporary stability is typically achieved with a monolateral external fixator. Serial debridements must be performed until a stable soft tissue envelope amenable to reconstruction is obtained.4 Patients must understand that the course of limb salvage is rarely linear, and late unanticipated procedures to address complications and for limb optimization are common. Managing patient expectations is crucial at the initiation of limb salvage, and patients must acknowledge that a prolonged therapy and rehabilitation course should be expected.
Standard Advanced Trauma Life Support protocols should dictate initial treatment of patients with high-energy lower extremity trauma. Hemorrhage control, management of life-threatening injuries, and resuscitation are immediate priorities. Tourniquets should be used liberally in the prehospital setting and should be removed in a controlled environment such as the operating room.5,6 Systemic antibiotics should be administered early in the resuscitation process.7
Care of the limb-at-risk starts with ensuring adequate perfusion. Temporary shunting with either commercially available Javid or Argyle shunts or with improvised shunting materials such as intravenous or 12 Fr pediatric feeding tubing can be used in the austere setting when definitive repair cannot be performed.8 There are little data to support whether vascular repair or temporary fixation should occur first so long as both are performed expeditiously and the vascular repair is long enough to support physiologic range of motion.9
The initial debridement is arguably one of the most important aspects of limb salvage and should be performed with the plan for reconstruction in mind. Sharp aggressive debridement that removes devitalized, nonviable, and contaminated tissue is mandatory. Because high-energy injuries tend to evolve over time, many wounds require multiple debridements. Depending on the physiologic status of the patient, it may be wise to retain questionably viable tissue determined to be important for reconstruction, but if the physiologic burden of the injury is too great, a more aggressive approach to borderline tissues is warranted. Whenever possible, incisions made to extend traumatic wounds for debridement should be made in line with extensile approaches so as not to interfere with future surgical approaches. Fasciotomies should be performed liberally.
After debridement, high-volume, low-pressure irrigation with normal saline is preferred.10,11 High-pressure pulsatile lavage or soaps in irrigation fluid initially decrease bacterial burden but have been associated with a rebound in bacterial burden above baseline at 48 hours.10 Conversely, potable water decreases bacterial burden similarly to sterile saline, is readily available, and is often an attractive source of irrigation in the austere environment.12
Monolateral external fixation is commonly used to obtain temporary stability of severely injured limbs before definitive reconstruction. Ideally, pins should be placed remote from open wounds, the zone of injury, the site of potential permanent implants, and future surgical approaches so no bridges to definitive fixation are burned.13
At the initial or subsequent debridement, polymethylmethacrylate antibiotic–impregnated beads or other local antibiotic delivery devices can be used to decrease the risk of deep infection.14,15 These can be incorporated into an impermeable “bead pouch” or used with a negative-pressure wound therapy (NPWT) dressing.16 Many compelling indications for NPWT exist, including concurrent stabilization of complex soft tissue wounds. However, recent studies in animal models reveal that NPWT plus antibiotic depot decreases the bacterial count better than NPWT alone but is associated with a higher bacterial count than antibiotic beads used alone.17
DEFINITIVE MANAGEMENT AND LIMB RECONSTRUCTION
Definitive limb reconstruction requires a stable patient and extremity.18 Associated injuries, such as blast-related pulmonary and dermatologic sequelae (eg, burns), should be addressed before definitive treatment of major orthopaedic injuries.19 When the ultimate goal is creating a stable functional limb, the orthopaedic surgeon must simultaneously stimulate bone healing, address soft tissue defects, and eradicate infection if present.
Reconstruction of Bone Defects
Locked intramedullary nails, external fixators (uniplane, multiplane, or ring), and plate fixation have all been used to definitively treat lower extremity fractures from wartime injuries. Lerner et al20 report 91% union with time to bone consolidation ranging from 3 to 54 months using provisional uni- or multiplanar external fixation transitioned to definitive ring fixation 5–7 days after injury. The authors emphasize that allowing full weight bearing in ring fixators enhances physiologic bone healing and improves mobility, particularly in patients with bilateral lower extremity injuries.
Creation of induced deformity through acute shortening is useful for lower extremity fractures associated with significant bone or soft tissue loss.20–23 Concomitant angulation minimizes the need for additional bony debridement, preserves length, and maximizes soft tissue coverage.20 Beltran et al24 describe rotation of a local muscle flap (Gradual Expansion Muscle flap) into the concavity of the deformity to provide expandable osseous coverage. After realignment, compression–distraction through the fracture site or at a remote corticotomy can be used to restore length.23 Many authors recommend that this technique be reserved for defects up to several centimeters, but no consensus has been achieved, and it has been used to treat tibial defects up to 22 cm.20–23,25 Acute shortening has successfully been used after vascular reconstruction for defects up to 8 cm.26,27
For less contaminated injuries, segmental bone loss can cautiously be addressed by massive bone grafting using a variety of techniques, including creation of an induced membrane with secondary grafting, autogenous bone grafting with corticocancellous grafts or with suction–irrigation reaming, and vascularized bone grafting.28 The Masquelet technique has been recently described for use in combat injuries.29 Suction–irrigation reaming using devices such as the Reamer/Irrigator/Aspirator (Synthes, West Chester, PA) has been used to treat posttraumatic nonunions but has not been reported specifically for combat injuries or in an austere environment.30 Celikoz et al31 used a combination of autografts, free vascularized fibula grafts, and distraction osteogenesis to treat 175 tibia, ankle, and foot combat injuries. However, the authors report limited (less than 20%) autograph survival for complete calcaneal defects and recommend primary amputation for massive bone loss involving the calcaneus.
Soft Tissue Reconstruction
Historically, management of soft tissue defects has been based on an algorithmic “reconstructive ladder” designed to help surgeons identify the simplest method of wound closure. In the setting of massive soft tissue devitalization or loss from projectile and blast injuries, soft tissue transfer procedures—including regional/rotational flaps and free flaps—are being used for increasingly complex extremity injuries.
Conflicting data exist about the role of rotational versus microvascular free flaps for the coverage of lower-extremity injuries. Prospective observational data from the Lower Extremity Assessment Project (LEAP) Study Group provides information about flap coverage among patients with open-tibia fractures.32 Soft tissue coverage was performed at a mean of 7 days postinjury. In patients with OTA type C fractures, treatment with a rotational flap was 4.3 times more likely to result in a complication requiring additional surgery than was treatment with a free flap. The authors note important baseline differences between the 2 groups and question whether unrealized injury to the tissue used for rotational flaps could have adversely impacted these flaps' viability.
In contrast, Burns and the Skeletal Trauma Research Consortium report higher failure rates for free compared with rotational flaps (27% and 7%, respectively; P = 0.08) and a corresponding decrease in secondary amputation rate (36% vs. 9%; P = 0.03) among a cohort of patients with combat-related open-tibia fractures.33 The authors hypothesize that the delay in definitive soft tissue treatment (mean 19 days postinjury) allowed the zone of injury to fully demarcate, decreasing the risk of rotating suboptimal tissue for coverage.
The utility of flaps is limited by traumatic vascular injury resulting in a single-vessel limb, underlying plaque disease, medical comorbidities, and—for free flaps—the necessity of a surgeon comfortable in microsurgical techniques. Complications include anastomosis thrombosis or failure, hematoma or seroma formation, flap depression, infection, and flap necrosis. In some situations, cross-leg free flaps can be used in limbs lacking vessels for anastomosis.31,34
NPWT has been recently adopted for use in complex wounds. It can improve microcirculation, control tissue edema, enhance wound contraction, and decrease bacterial counts.17 NPWT can stabilize a wound by creating a healthy granulating bed over exposed bone, tendons, and implants which previously would have necessitated free tissue transfer.35 Ullmann et al36 proposed that vacuum-assisted closure using NPWT and acute limb shortening be considered in lieu of free flaps when severe local tissue damage or vascular injury precludes free tissue transfer. High-quality studies objectively evaluating this technology's effectiveness in the clinical environment are lacking.35
Infection prevention and complication management are integral to successful limb salvage. Analysis of injuries sustained during conflicts in Iraq and Afghanistan reveals that 27% of combat-related Gustillo–Anderson type III open-tibia fractures developed a deep infection.37 Moreover, both deep infection and osteomyelitis were significantly associated with late amputation (>12 weeks after injury) among combat-related open-tibia fractures undergoing limb salvage.38 After nonunion, infection was the most common reason for readmission among extremity-injured service members.39 It also decreased the rate of return to duty among service members with open-tibia fractures.40
In 2008 and 2011, orthopaedic surgeons and infectious disease physicians from civilian and military institutions compiled evidence-based guidelines for prevention of combat-related extremity infections.7,41 The authors recommend early antimicrobial coverage with a first-generation cephalosporin but found no evidence for penicillin or aminoglycoside administration. Future studies are needed to identify strategies that decrease systemic antibiotic load and combat antibiotic resistance.
The LEAP study found no differences in functional outcomes 2 and 7 years after injury among civilian patients with open-tibia fractures who underwent limb salvage or amputation.32 These results have been challenged by surgeons treating active duty service members because of inherent differences in injury mechanism among the populations studied. Escalated improvised explosive device use in 2004 and 2005 resulted in increased rates of multiple extremity injuries, amputations, and mangled extremities among the combat wounded.
The Military Extremity Trauma Amputation/Limb Salvage (METALS) study reported better functional outcomes in service members injured between 2003 and 2007 who had undergone lower extremity amputation compared with those who opted for limb salvage.42 During the study period, patients undergoing limb salvage experienced delayed weight bearing, prolonged treatment time in circular external fixation, and limited high-end function. Additionally, limb salvage patients witnessed their amputee counterparts achieving higher levels of function including walking, running, and returning to recreational sports at a much faster pace.43,44 The improved pain and function seen early in the amputee population seemed to adversely affect those undergoing limb salvage, resulting in increased requests for delayed amputation.44–47
A paradigm shift occurred between 2008 and 2009, when limb salvage patients began aggressive rehabilitation while undergoing osseous and soft tissue treatment in circular external fixation. The addition of a customized foot plate attached to the end of the circular external fixator allowed improved gait mechanics and weight bearing in patients with ankle-spanning external fixation.43 Patients who were previously treated with prolonged periods of nonweight bearing and immobilization began strengthening and performing plyometrics and agility exercises. A healthy environment of competition in the peer group seemed to accelerate recovery and improve self-efficacy and physical and psychologic function.43,44,48,49 The ability to aggressively rehabilitate in circular external fixation maintained lower extremity and core strength, easing patients' transitions to running and sports once the fixator was removed.43,44,49,50
Many limb salvage patients sustained muscle compartment weakness, neuromas, and peripheral nerve damage and poorly tolerated off-the-shelf ankle–foot orthoses. Thus, a custom-made energy-storing carbon fiber ankle–foot orthosis was designed: the Intrepid Dynamic Extraskeletal Orthosis (IDEO). The IDEO improves gait velocity, ankle power, and push off compared with off-the-shelf designs.44,51
The Return To Run (RTR) Clinical Pathway was created at the Center For the Intrepid at the San Antonio Military Medical Center to couple advances in surgical technique with aggressive rehabilitation and custom orthotics.49 It enrolls limb salvage patients soon after transfer to the hospital from the battlefield. Its treatment protocol has 2 phases. The first phase, initiated while in circular external fixation, is focused on strength training, functional movement, and core muscle strengthening to improve force-generating ability. Once osseous and soft tissue healing has been completed and the circular external fixator is removed, patients are fitted with an IDEO and proceed to the second phase, which focuses on running, cutting, jumping, and military-specific training.47
The relatively poor outcomes of limb salvage patients demonstrated in the METALS study may be attributed to the period before implementation of the IDEO and RTR Clinical Pathway. Together, these 2 developments have improved patient-based outcomes, validated performance measures, and improved return-to-military duty rates, at the same time decreasing patients' desire for late amputation.47,48 These successful outcomes have also been shown in patients presenting late (ie, >2 years from injury), which is in contrast to previous studies that demonstrated increased disability as time passes.45,47 Maximal function with an IDEO requires very little ankle or foot motion, and thus, patients with ankle, hindfoot, or midfoot fusions have been able to return to running, basketball, softball, skydiving, and even combat arms military deployments.44
Critics of the RTR and IDEO limb salvage success note that the results were limited to a single institution's results. However, Ortiz et al52 reported similar translational results at a different military institution after the therapists were taught the nuances of the RTR clinical pathways. A multicenter prospective observational study is ongoing through the Major Extremity Trauma Research Consortium to assess the impact of the IDEO and RTR at 3 different military treatment facilities.
Blood flow restriction training has recently emerged as a novel strength training method for limb salvage patients using significantly lower loads, thereby protecting articular and osseous reconstructions. Blood flow restriction uses a specialized tourniquet system to reduce vascular inflow and completely occlude venous outflow in the affected extremity. The hypoxic environment allows fast-twitch anaerobic muscle fiber recruitment within the target muscle group at loads as low as 10% of a one-repetition max. Current literature demonstrates that augmenting traditional rehabilitation exercises, which are low load in nature and have minimal effect on muscle, with a tourniquet system may be a way to combat one of the primary obstacles in trauma rehabilitation—loss of muscle size and strength—at the same time protecting complex osseous or articular reconstructions.53–55
Recent national and international events have highlighted some of the recent advances in limb salvage and emphasized the need for orthopaedic surgeons who understand the nuances of this treatment pathway. In the aftermath of the 2014 Boston Marathon bombings, 2015 Paris shooting massacre, and 2016 Brussels bombings, lessons learned from the military conflicts in Iraq and Afghanistan were used to treat civilians with limb-threatening injuries (Table 1). Continued research and support is needed to advance the care of wounded service members and civilians alike.
In conclusion, limb salvage continues to be a viable long-term solution to high-energy lower extremity injuries when the patient, surgeon, and therapist understand the length and complexity of reconstruction and rehabilitation. Recent advances in limb salvage techniques and rehabilitation pathways have improved patients' functional abilities and return-to-military duty rates to equal to or greater than those of their amputee counterparts.
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