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Written on 9th July 2020 by

Claire Roantree recently interviewed Matija Krkovic, an orthopaedic and trauma surgeon at Addenbrookes Hospital in Cambridge, where they talked about limb salvage and amputation.

We typically see clients who have been involved in major trauma, or people who have experienced a nasty crush injury to the lower leg, and who have limb conserving treatment. Can you please tell us about the type of patients that you see as part of your everyday practice? 

The vast majority of my acute practice involves patients who have sustained significant injuries to their limbs, predominantly their lower limbs. The injuries can be either open fractures with or without soft tissue defects (missing skin and muscles) or they might be complex articular fractures (with a brake inside the joint).

All of the above injuries are often accompanied by bone loss, either minimal (small part of bone missing not involving the whole circumference of the bone) or segmental (whole circumference of bone is missing) which can be in the length of several cm. A bone defect in the length of 10cms or even longer is not unusual. Without restoring the bone, patients cannot use their limbs and require amputation.

The non-acute part of my practice covers non-union work (not healed fractures of bones) and treatment of infections post fractures or knee replacement surgery.

What type of operations do you carry out involving limb salvage?

Limb salvage/reconstruction surgery from an Orthopaedic perspective involves predominantly techniques of growing new bone to heal the bone defects and healing fractures. 

Growing new bone is done utilising so called callus distraction or osteogenesis principles. In these cases we break the bone with the defect in its healthy part and then pull the new break apart with speed of 1mm/day. Usually this is done in 4 daily increments of 0.25mm each time. The smaller the step and the more steps we do, the more reliable the bone regeneration is that we get. 

These procedure can be either done using external fixator or using internal fixation. 

All these methods can be also used in non-union surgery depending on the type of non-union and also in cases of infection, again depending of the type of infection and soft tissue quality.

Can you give us some examples of the type of complex orthopaedic injuries you see?

I regularly see open fractures of the lower limb, involving the femur and tibia with or without missing bone or soft tissues. The higher the energy which caused the accident the more comminution of the bone we can expect. This is usually accompanied with soft tissue defects requiring multiple procedure in collaboration with plastic surgeons who provide soft tissue cover of the exposed bone or bone defect. If the bone is not covered with a good quality soft tissue (usually muscle or fascio-cutaneous flaps) the fracture will not likely heal. In fact the chances of getting an infection in the exposed bone are extremely high. For these reasons we put a lot of efforts into timely but appropriate management of those injuries.

What is meant by limb salvage? 

If the structurally important bone is missing in a limb, that limb cannot be functional. 

As soon as the muscles contract, the limb will shorten, and with fingers for example, will not move. For muscles to work effectively they need to be spanned over a certain distance. Bones are offering just that. 

If a significant proportion of the bone is missing the limb cannot be functional and represents more or less a dead weight. The only option is an amputation. This is still quite often the outcome if we cannot manage the bone loss or soft tissue loss. 

Limb salvage covers all the procedures required to restore the limb’s function close to where it was prior to the accident. It is almost impossible to restore the full function after a significant injury of a limb. It is important to bear in mind that the limb reconstruction process is a very time consuming and labour-intensive process for the medical team and very difficult time for patient. 

There are many complications during the treatment with the duration of a treatment on average one year or more. Patients really need to be motivated and get all support they can get from hospital, community and their families. It does happen that patients lose their patience and motivation during the treatment and demand an amputation as they see it as a quick solution for their problems. This is not usually the case though and we do spend a lot of time to re-convince them that what we are doing is in their best interest.

What can be the benefits of limb salvage?

The main benefit from limb reconstruction surgery is that people keep their limbs and don’t need to use a prosthetic limb or even a wheelchair. It is now widely expected that on average the expected function from reconstructed limb will be comparable to the prosthetic limb. This is probably not completely true for elderly patients as the relative energy requirement for walking with a prosthetic leg increases directly with the height of the amputation and patients’ age. If patients were borderline coping with walking before the accident it is not likely they will be able to walk with a prosthetic leg, either below or above knee, but they may be able to walkork with their reconstructed leg. 

Another important reason to salvage limbs is that patients keep their limbs and they don’t have to put them on and off at the beginning or end of the day. If the reconstructed limb gives people reasonable function and the pain is controlled, the reconstructed leg will on average perform better than any prosthetic leg available on the market.

What are the consequences of limb salvage and the problems that these patients often face?  

Patients with limb reconstruction are faced initially with lengthy treatment which is very painful and full of complications. The majority of the complications we can predict, but not all. Pain is certainly a very important part. At the moment we have a strategy to give patients painkillers as possible, which allows them to participate in physiotherapy and exercises. On average we expect that patients who do not exercise regularly require double the length of the treatment.

Appropriate pain relief is paramount resulting in better function of the limb during and at the end of the treatment. Inadequate pain relief can also lead to chronic pain after the completion of the treatment. 

The majority of the patients will develop stiffness of certain joints. This can be as a result of either the accident and the procedure itself or can be as a result of non-compliance with exercising. We work very hard to convince patients to exercise as much as possible to maintain their level of activities, but some patients simply cannot comply. 

Nerve pain is not often present in the limb reconstruction patients unless they had severe nerve damage at the time of the accident. In these cases our options are limited. General pain in the limb post limb reconstructions is present in the majority of the patients. From my experience this is the pain majority of patients are happy to accept for a period of time.

We know that although limb salvage might be an option for someone who has sustained a traumatic injury, sometimes amputation is recommended by the treating clinician. In what circumstances would amputation be recommended instead of limb salvage? At what point with a limb salvage patient do the clinicians look towards amputation instead of further salvage treatment? 

I would personally offer an amputation in certain conditions: 

  • If the foot is mangled and we don’t expect to get any reasonable function from the foot. In these cases even for example if we reconstruct the whole tibia or femur, patients still won’t be able to put their foot on the floor because of the extremely painful and non-functional foot.
  • If the soft tissue cover of the bone is not possible for different reasons or if the soft tissue is simply too big to reconstruct. In these cases the limb needs to be amputated as the bone fractures will otherwise not heal.
  • If there is a significant neurological and vascular compromise of the limb.
  • If we don’t expect patient to be able to participate in the lengthy treatment of limb reconstruction and
  • If the patient refuses to have it reconstructed.

For someone who wants to regain a functional limb, is the better option limb salvage or amputation? 

In my opinion salvage is a better option as at the end patients are left with their own limb which does not need to be attached and detached, does not need to be replaced every few years and certainly requires less energy to mobilise comparing to the prosthetic leg. Limb reconstruction will on average take 1 year +/- a few months. The average time required to get a definitive prosthesis is in my understanding around 9 months, at least this is the amount of time required for the stump to mature. Amputation patients have on average around 50% risk to develop phantom pain, when limb reconstruction patients don’t. From a financial perspective limb reconstruction is cheaper than amputation in the long term. Amputation is really only an advantage for people who want to go back to their work as soon as possible, particularly if they do predominantly sedentary work.

What can be the benefits of amputation over limb salvage? 

Amputation is a quick solution for a complex problem and results in fast discharge from hospital with low outpatient treatment requirement. There is also a short term advantage for people wanting to back to their work as soon as possible, or for the patients who cannot comply with prolonged treatment and prolonged periods of pain.

What type of MDT involvement is needed for limb salvage and how does this change in respect of amputation? 

Usually limb salvage or amputation is decided on the day of accident or shortly after between senior orthopaedic and plastic surgeon with experience in the field. If they are not available we tend to err towards temporary salvage particularly if the condition of the limb is ambiguous or if we know either from the patients or relatives that the amputation is not what is expected.