INTRODUCTION: WHAT IS OLD IS NEW
After nearly 15 years at war, the number of newly wounded warriors has dramatically decreased and, thus, the words of Dougherty and Demaio discussing Major General Norman T. Kirk and amputee care during World War II seem predictive:
War surgery and amputation care are a discontinuous practice, which means they must be subsequently relearned with every conflict.1
The Department of Defense Amputee database indicates that over 1600 wounded warriors have lost nearly 2300 limbs in the recent conflicts. It is through their misfortune that we have learned a great deal about amputation surgery and the treatise that follows attempts to highlight some of these lessons so that the amputee care in the next war will not prove quite as discontinuous. Moreover, it is crucial that the lessons applicable to our civilian patients be realized. Although less than 20% of nearly 200,000 amputations being performed annually in the United States are for the sequelae of trauma, these posttraumatic amputees make up nearly half of the surviving amputees.2,3 Basic, but critical lessons regarding amputation surgery and amputee care that have been learned (or relearned) during the Global War on Terrorism are summarized in Supplemental Digital Content 1 (see Table, https://links.lww.com/BOT/A758).
COMPLICATIONS AND THE CHALLENGE OF RETURNING TO DUTY
In 1924, General Norman T. Kirk suggested in his monograph entitled Amputations, that surgeons did not have long-term follow-up on their patients and were largely unfamiliar with what factors influenced their patient's outcomes.1,4 In 1991, Pierce et al5 published a study aptly titled The plight of the traumatic amputee in which he highlighted the fact that nearly 51% of his 61 patients developed an anatomic complication related to their amputation. The Lower Extremity Assessment Project (LEAP) study group also recognized the difficult postoperative course of the amputee and is largely responsible for an increased interest and attention to amputation surgery. The LEAP study reported a rehospitalization rate of 29.8% and a 14.5% rate of revision of the amputated limbs in their series of 149 patients.6 Most importantly, however, they highlighted that a large percentage of these patients will remain severely disabled.7 Potter summed up the reality of amputation surgery when he commented that amputations are “…often viewed as a simple procedure with predictable outcomes, and therefore, frequently relegated to junior trainees…In reality, the procedures are anything but simple, the technique nuanced and fraught with complications.2”
The experience of the military amputee centers has shown somewhat different results from the LEAP study with respect to value of rehabilitation and specialized centers and has also allowed for the quantification of the major surgical complications which lead to reoperation among our amputees. The Military Extremity Traumatic Amputation versus Limb Salvage (METALS) study, a retrospective cohort of 324 lower limb amputees from military conflict with behavioral and rehabilitation interventions (not present in the LEAP series) examined comparative function, vigorous activity, and posttraumatic stress disorder (PTSD) in single and double limb amputees and limb salvage patients. In all domains of the Short Musculoskeletal Functional Assessment, outcomes of amputees were significantly less poor than limb salvage, but all were worse than noninjured norms. The authors found improved outcomes related to the rehabilitation centers that provided focused intensive rehabilitation to amputees. In a retrospective analysis of 300 major lower extremity amputees from Operations Iraqi and Enduring Freedom (OIF/OEF) with a mean follow-up of 23 months, there was a 53% reoperation rate. Among these 156 limbs that underwent reoperation, there were a total of 261 distinct indications leading to 465 additional surgical procedures. Repeat surgery was performed urgently for wound infection or wound dehiscence (31%). Revision amputations were also performed in persistently symptomatic residual limbs for heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). After these revision surgeries, there was a significant increase in ambulatory status and a decreased dependence upon pain medications suggesting that, despite the high rates of revision surgery, patient outcomes could be improved through operative intervention.8
Recent studies from Operations Iraqi and Enduring Freedom have indicated that the return to duty rate in a volunteer military for US amputees was 11%–16.5%.9–11 When Stinner et al10 compared the rate of return of amputees to active duty from the 1980's, they found an increase from 2.3% to 16.5% and attributed this change to advancements in combat casualty care and the establishment of centralized amputee centers. One of the most unique findings from the return to duty studies indicated that the United States Army Special Forces amputees were significantly more likely to return to active duty (58%, P = 0.0022) than all other specialties. Interestingly, none of these Special Forces soldiers were found to suffer from PTSD as a disabling condition. The authors concluded that a lack of PTSD may be a contributing factor to their increased rate of return to duty.9
When a similar cohort of 100 upper extremity amputees was reviewed from the war, the reoperation rate was 42% leading to a total of 103 repeat surgical interventions. Indications for reoperation were wound infection or dehiscence (19%), heterotopic ossification excision (19%), neuroma excision (9%), scar revision (5%), and contracture release (4%).12 Again the results of this study demonstrated that patients were dramatically improved with surgical intervention for these anatomic complications. The prosthesis use was significantly increased from 19% before surgery to 87% after revision surgery.12
Despite the promising improvements in upper extremity prosthesis use, Krueger et al revealed that of 173 upper extremity amputees, none were found fit for duty, 12 (8.3%) were allowed to continue on active duty, and more upper extremity amputees were retired than lower extremity amputees (82% vs. 74%). These upper extremity amputees were much more likely to have disability from PTSD (13% vs. 8%) and nerve dysfunction (11% vs. 6%).13 Again PTSD seems to be an important factor in the ability of a soldier to return to duty.
Although more amputees have returned to duty during recent conflicts, improvements in surgical technique are constantly sought to improve the prospect of returning warriors to the battlefield.10 Controversy has surrounded the concept of osteomyoplasty, and multiple studies have been performed evaluating the utility of the bone-bridging procedures. Currently, the evidence and indications for performing a bone-bridging procedure remain conflicting and frequently debated.14 Gwinn et al15 demonstrated safety of these amputations in a perioperative study of bone-bridging amputations compared with standard transtibial amputations. Tintle et al compared the complication rates of 100 standard Burgess style transtibial amputations to 37 bone-bridging amputations and found that reoperations were performed at a significantly greater rate both overall and for noninfectious complications in the bone-bridging cohort. Specifically, they noted that bone-bridge complications were found in 32% of that cohort. Delayed union or nonunion of the synostosis (11%) and implant-related complications (27%) were common. Ultimately 3 bone bridges were removed, and the authors concluded that detailed counseling and patient selection were necessary in the absence of convincing functional benefit of the procedure.16
Functional data on the procedure have been mixed. In a 2008 study by Pinzur et al17 in the United States, the authors were unable to demonstrate an advantage of the bone-bridging technique over a standard amputation technique. This was in contradistinction to his previous 2006 study, performed in Brazil, in which patient-perceived functional outcomes were improved in the bone-bridge cohort.18 A military study also demonstrated equivalence between bridge synostosis and non–bone-bridging groups retrospectively with no difference noted between Short Form-36 domains or Prosthesis Evaluation Questionnaires.19 In contrast, a recent database study, comparing all Burgess (400) to osteomyoplasty amputees (72) from 2001 to 2011 in the Department of Defense, demonstrated no significant differences in disability ratings, or ability to deploy; however, bone-bridge amputees remained on active duty at a higher rate (P = 0.021), suggesting the possibility of a functional advantage, although potential selection bias for this procedure remains a difficult confounding factor.
Regarding ambulation, a recent pilot study comparing 7 standard Burgess to bone-bridged amputees was performed in the military.20 Although no specifying superiority was determined, the study did suggest that the bone-bridge amputees may have had improved loading of their residual limbs at higher walking speeds. Additional civilian data have also supported the benefit of the bone-bridging amputations. Two civilian retrospective comparisons have recently evaluated the bone-bridging amputations, with both suggesting improved outcomes in the bone-bridge cohorts.21,22
Clearly, conflicting data are present in the literature, and the selection bias inherent in the performance of these procedures may always confound finding the true optimal surgical technique. The majority of literature on this subject remains level III to V evidence and, as a result, the Department of Defense has funded the Major Extremity Trauma Research Consortium to compare these amputations prospectively14 and, it is hoped that, definitively answer this question.
The osseointegration of implants for prosthetic wear has been in clinical practice for over 2 decades now for both transfemoral and transhumeral amputees.23 The concept of osseointegration arose due to the persistently low prostheses use rates and attempts to avoid the frequently reported problems with stability, comfort, excessive sweating, and irritation from conventional sockets.24–26 Although the concept of a bone-anchored implant conflating the outside world to the bone has been met with critical skepticism, studies reporting low rates of deep infections and implant removal and improved outcomes mandate that this surgery be a consideration for select amputees.23,24,27,28
A prospective nonrandomized study of osseointegrated prostheses for 51 patients with 55 transfemoral amputations found a 92% 2-year survival, improved prosthetic use, mobility, global situation, and fewer problems (P < 0.001). The SF-36 physical function scores were also improved. Despite a high rate of superficial infection (54.9%), most infections were able to be treated with oral antibiotics alone. The implant was removed from 3 patients for aseptic loosening and one infection.24
This same group also recently published outcomes of osseointegrated humeral prostheses. Very reasonable results with 83% 2-year and 80% 5-year survival were achieved. These were, however, lower than the 92% achieved by the transfemoral implants, and the authors believe that the causes for this were the increased experience of the surgical team at the transfemoral level and the use of custom implants which they believe allowed for better primary stability of the implant immediately after surgery.23 The 2-year superficial infection rate was 19% and at 5 years was 38%. Nonoperative or minor skin revisions were adequate to treat these infections and there was only one deep infection, which occurred 3.5 years after surgery. The authors concluded that osseointegrated arm prostheses should be considered an acceptable alternative to conventional socket prostheses.
The recent results of these studies on osseointegrated implants and the ongoing research efforts directed toward improving the skin/implant interface portend a promising future of this technology, and the Department of Defense has recently endorsed and funded a large-scale project to prospectively study this technology in our wounded warriors.
TARGETED MUSCLE REINNERVATION
Most surgeons with an interest and familiarity with amputation surgery would support the statement that targeted muscle reinnervation (TMR) is one of the great recent advancements in amputation surgery. What began as a surgery designed to increase upper extremity prostheses wear may also prove to have substantial benefits for amputation neuroma pain.29,30 Upper extremity prostheses rejection rates are frequently reported to be greater than 30%, and the rates may be substantially higher if cosmetic devices are excluded.31–34 TMR was developed by Kuiken and Dumanian to improve the control of myoelectric prostheses, originally in the proximal level upper extremity amputee.35–37 TMR uses the transected nerves that formerly innervated muscles in the distal limb through a set of novel nerve transfers to reinnervate portions of the remaining muscles. There is no functional loss, as the transected nerves were not going to any remaining muscle. Upon reinnervation of the remaining muscle segments, the muscles act like transducers of the transferred nerves' original function. Electromyography signals are produced, and intuitive control of a myoelectric prosthesis is created.31 TMR has proven beneficial in small case series in terms of improving both objective and subjective outcome measures.30,38
Fortuitously, surgeons performing TMR surgery recognized that an added benefit of these nerve transfers was the subsequent absence of previously existing neuroma pain. Souza et al retrospectively studied 26 patients who were treated with TMR for the primary purpose of improving myoelectric prosthesis control in the upper extremity. They demonstrated in this review that all but 1 of the 15 patients that presented with preoperative neuroma pain experienced complete neuroma pain relief postoperatively, and the other patient reported partial relief.29 Pet et al simultaneously published their data on what they termed targeted nerve implantation in which they reviewed 35 primary amputation or neuroma pain patients. They found that 11 of the 12 (92%) of the primary amputee patients, and 20 of the 23 (87%) neuroma pain patients were free of palpation-induced neuroma pain at the time of final follow-up. They concluded that targeted nerve implantation may offer an effective primary prevention and treatment of neuroma pain in the amputee. Notably, 16 of the 35 (46%) patients in this study were lower extremity amputees.39
Currently, TMR surgery continues to be performed for improved intuitive function and prosthesis control in coordination with advanced pattern recognition algorithms. TMR surgery is also being performed for the primary prevention and the secondary treatment of amputation neuromas in both the upper and lower extremities. A randomized Department of Defense–funded study to prospectively evaluate this technique for neuroma management is underway.
TO FEEL AGAIN
Although the ability to restore painless prehensile function in a wearable prosthesis has been the goal of surgeons, prosthetists, and rehabilitative specialists, the biotechnological advancements suggest that amputees may have the capacity to feel again. This seemingly less important feat should not be underestimated in importance in terms of both function and limb or prosthesis “ownership” by persons with limb loss. Currently, multiple unique approaches including targeted sensory reinnervation, haptics, and vascularized composite allotransplantation all offer the possibilities to improve or restore the ability to feel again.
Haptics is commonly defined as the sense of touch including vibration, textures, slip, temperature, pain, force, and proprioceptive sensations.40 This field takes advantage of the skin sensing ability to relay tactile feedback (vibration, pressure, and stretch) from the prosthesis to the brain through afferent nerve fibers. The goal of haptics is to replace or augment the deficits inherent to an amputee and serve as an alternative to the lost native sensory and proprioceptive functions. Currently, prosthetic users gain feedback about their environment visually (77%), listening (67%), and residual limb sensations (57%).40,41 Multiple haptics studies have demonstrated clear benefit of wearable haptic feedback systems for upper limb prostheses.42,43 Although most studies focus on restoring one function i.e. (slip or pressure), as the miniaturization and simplification of bulky haptic machines progresses, multisensation restoration will lead to more restorative normal function of a prosthetic wearer.40
Recently, haptics technology has been combined with the field of targeted reinnervation to provide promising results that more accurately is capable of restoring sensation to a particular region of the brain to better replace what has been lost.44,45 In synonymous fashion to targeted muscle reinnervation, sensory afferents are redirected to the skin overlying specific transfer sites, creating specific sensory expression in distinct regions of the missing limb. This allows for sensory afferents that once innervated the hand to reinnervate more proximal areas of the amputation site which could then be used by the prosthesis to relay more natural hand sensation.45,46
In attempts to truly restore rather than replace, the field of vascularized composite allotransplantation has developed. High rates of prosthetic rejection and the lack of adequately reproducible prehensile function and touch have driven this field of study. The need for lifelong immunosuppression tempers the excitement and promising future of this field of transplantation. Although hand transplantation is being performed with increasing frequency, obstacles do remain, including continued funding, immunology, candidate selection, long-term outcome studies, and refinement of the indications.47 Today, the most common hand transplants are performed for bilateral upper extremity amputees, and this is the most widely accepted indication for transplant.48–50 In these situations, meticulous considerations of the amputee's future is necessary, and surgical techniques should be modified as necessary so as not to complicate future transplantation opportunities. Maximizing length of the extremity and nervous structures needs to be weighted against the optimal amputation lengths and the attempt to prevent symptomatic neuromas.
TRAUMA-RELATED CIVILIAN AMPUTATIONS AND CONCLUSIONS
Recent global terrorism events and natural disasters continue to reinforce the notion that orthopaedic surgeons who care for trauma patients require fundamental familiarity with and competence in amputee care and amputation surgery. The majority of the amputations that are performed in the United States occur in the civilian setting. Recent military experience brings a large number of amputations performed at a few select centers permitting study and standardization of amputation techniques, postoperative care, and rehabilitation. Additionally, the study of the complications, outcomes, and return to duty has identified best practices which translate to civilian life (Table 1). The optimal care of these patients dictates that an amputation is not performed in isolation. Multidisciplinary teams addressing all aspects of the patient's life to include psychology and psychiatry are imperative for optimal outcomes. Close long-term follow-up of these patients will likely allow for persistently symptomatic limbs to be addressed and treated, which will lead to increased prostheses use and overall improved outcomes.
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