Functional Limb Restoration Through Amputation: Minimizing Pain and Optimizing Function With the Use of Advanced Amputation Techniques

Abstract

Objective: To demonstrate the role of advanced orthoplastic techniques in harnessing the full potential of elective amputation as a functionally restorative procedure. Summary of Background Data: Once considered the unfortunate consequence of failed reconstructive efforts, recent outcomes studies have prompted a re-evaluation of the role of amputation in the management of complex extremity trauma. However, even as amputation is appropriately afforded greater consideration as part of the reconstructive algorithm, reconstructive techniques that are commonly utilized in pursuit of limb salvage are rarely applied to amputation. Methods: The following case demonstrates the successful application of orthoplastic reconstructive techniques to achieve optimal pain and functional outcomes in a 41-year-old active duty soldier who underwent an elective transtibial amputation after prolonged, limb salvage. Results: The patient presented with a large osteocutaneous proximal tibial defect secondary to trauma and subsequent osteomyelitis. The patient underwent a free scapular-parascapular fasciocutaneous flap to provide soft tissue coverage and facilitate the skeletal reconstruction necessary for either continued limb salvage or amputation. Due to tibial allodynia and severely limited ankle function, the patient subsequently elected for amputation in favor of continued limb salvage. Thus, a transtibial amputation was performed concurrently with a pedicled vascularized fibula to address the proximal tibial defect. A modified agonist-antagonist myoneural interface procedure was used to maximize post-amputation function, with creation of regenerative peripheral nerve interface constructs to prophylax against neurogenic pain. After the operation, the patient achieved improved function of the extremity with the use of a prosthesis and reported substantially improved pain while remaining on active duty in a warfighting military occupational specialty. Conclusions: By addressing all of the reconstructive components commonly considered in limb salvage, an orthoplastic approach to amputation surgery can minimize pain and maximize the rehabilitative potential of the amputee.

What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury?

“…Pain was not included as an attribute as significant pain has been reported in patients who have had limb salvage or amputation and is difficult to predict. 3,4,[8][9][10] The total number of attributes and levels produced 1280 possible profiles and 818,560 two-option comparisons. As such, we used the Choice Design Platform in JMP, Version 16 (SAS Institute Inc., Cary, NC) to assemble 16 hypothetical comparisons of 2 unique profiles that effectively balanced practical (number of choice sets) and quality (D-efficiency) considerations.…”

Editorial: Advances in rehabilitation intervention after limb amputation

“…Efforts to incorporate newer technical developments in amputation surgery and reconstruction demonstrate a shift toward an outcomes-oriented approach in amputee care ( 10 – 13 ). Surgical training in advanced and modified techniques for amputations has expanded to include osteomyoplasty and osseo-integration, agonist-antagonist myoneural interfaces (AAMIs), tibia-turnup plasty, rotationplasty, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs).…”

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

“…5) and dramatically improve prosthesis control. [49][50][51] Patient and system factors are potentially more pronounced with amputation. Patients without the ability to receive regular prosthetic care may comparatively benefit from "heroic" attempts at limb salvage.…”