IC47-R: Upper Extremity Amputations: Lessons Learned from Combat Injuries Moderator(s): Peter C. Rhee, DO, MS Faculty: Mark R. Bagg, MD, Jason A. Nydick, DO, Kenneth F. Taylor, MD, and Scott M. Tintle, MD Session Handouts 75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. 8/24/2020 Jason A. Nydick, DO Consulting Fees: Axogen, Trimed, Checkpoint Surgical, Conmed Contracted Research: Axogen 1 Factors in Determining Limb Salvage Versus Amputation IC47-R Program Jason Nydick, DO 2 Factors in Determining Limb Salvage Versus Amputation • Injury mechanism / Type of injury / Level of injury • Timing of injury • Age • Tobacco • Medical hx • Associated injuries 3 1 8/24/2020 Factors in Determining Limb Salvage Versus Amputation CONTRAINDICATIONS • Severely crushed or mangled parts • Multiple-level amputations • Patients with multiple trauma or severe medical problems (relative contraindication) • Completely degloved (avulsions) • Self inflicted 4 Factors in Determining Limb Salvage Versus Amputation SURGICAL GOALS • Successful restoration of function. • Simply returning circulation to an amputated part does not in itself define success. • Replantation of a part that will not perform useful activity should be avoided 5 Factors in Determining Limb Salvage Versus Amputation • Single fingers distal to the FDS insertion usually function well • Hands proximal to the mid-palm also usually function well • Replanted thumb is almost always useful, even if it functions as a post for opposition 6 2 8/24/2020 Factors in Determining Limb Salvage Versus Amputation • Single fingers distal to the FDS insertion usually function well • Hands proximal to the mid-palm also usually function well • Replanted thumb is almost always useful, even if it functions as a post for opposition 7 Factors in Determining Limb Salvage Versus Amputation • 57% success rate • Radial sided injury, no tobacco use predictors of success • Team approach • Need to evaluate current benchmarks and clinical settings for replants 8 Factors in Determining Limb Salvage Versus Amputation • 15 yr old table saw 9 3 8/24/2020 Factors in Determining Limb Salvage Versus Amputation • Replantation performed • Success • Enrolled in Military 10 Factors in Determining Limb Salvage Versus Amputation • 80 yr old female • Dog leash avulsion 11 Factors in Determining Limb Salvage Versus Amputation • Vein graft artery repair • 2 veins • FPL, EPL • Nerves with severe avulsion too distal to repair Functional Thumb…. Success 12 4 8/24/2020 Factors in Determining Limb Salvage Versus Amputation • Forearm amputation • Crush injury • Revision amputation & TMR 13 Factors in Determining Limb Salvage Versus Amputation • Limb salvage • - Nerves intact / good chance to recovery & function • Amputation (Reconstruction / TMR) • -myoelectric • Future directions in prosthetics / TMR/ RPNI although slow, may lead to better reconstruction outcomes 14 THANK YOU Factors in Determining Limb Salvage Versus Amputation IC47-R Program Jason Nydick, DO 15 5 8/24/2020 SURGICAL TECHNIQUE FOR DIGITAL AND METACARPAL AMPUTATIONS: TIPS AND PEARLS MARK R. BAGG, MD HAND CENTER OF SAN ANTONIO 1 DISCLOSURES Mark R. Bagg, MD Speakers Bureau: ExsoMed 2 WHEN REPLANTATION IS NOT AN OPTION INITIAL MANAGEMENT OF BATTLEFIELD AMPUTATIONS OF THE FINGERS AND HAND DEBRIDEMENT LEAVE WOUNDS OPEN LOOSE DRESSING PREVENT WOUND RETRACTION 3 1 8/24/2020 WHEN REPLANTATION IS NOT AN OPTION INITIAL MANAGEMENT OF BATTLEFIELD AMPUTATIONS OF THE FINGERS AND HAND DEBRIDEMENT LEAVE WOUNDS OPEN LOOSE DRESSING PREVENT WOUND RETRACTION PRESERVE “SPARE PARTS” TO FACILITATE COVERAGE 4 GOALS OF TREATMENT • Non-tender stump • Short period of disability • Good cosmesis 5 FINGERTIP AMPUTATIONS 6 2 8/24/2020 FINGERTIP AMPUTATIONS • PRIMARY CLOSURE Best way…… if you have the tissue to close Trim dog ears 7 FINGERTIP AMPUTATIONS • STSG/ FTSG Poor choice Bad color match Doesn’t add bulk Usually tender 8 FINGERTIP AMPUTATIONS • LOCAL Flaps V-Y flaps/other local flaps Hypersensitivity Kutler -- 1947 Atasoy et al -- 1970 9 3 8/24/2020 FINGERTIP AMPUTATIONS • Cross-finger flap Adds bulk to finger tip PIPJ contractures Donor scar 10 FINGERTIP AMPUTATIONS • Thenar Flap Few indications PIPJ contractures Bulk to fingertip 11 FINGERTIP AMPUTATIONS • Moberg Flap Best reserved for THUMB Coverage of less than 2cm defect 12 4 8/24/2020 FINGERTIP AMPUTATIONS • Microsurgical reconstruction Rarely indicated Best restoration of the pulp 13 FINGERTIP AMPUTATIONS SECONDARY INTENTION BEFORE AFTER “THE BEST WAY” 14 TREATMENT IN ER • Digital block • Minimal debridement--trim ragged edges • Trim the bone to just below the level of the soft tissue • Bulky dressing MB1 • Pain medication Six weeks later 15 5 Slide 15 MB1 Mark Bagg, 8/22/2020 8/24/2020 IN THE OFFICE 48 HR. LATER • Remove the dressing • Xeroform/ Coban • Instructions to air-dry wound as much as possible 16 BEFORE 17 AFTER 18 6 8/24/2020 THE PROBLEM: NAILHORNS Excise all visible nail bed tissue Curette dorsal cortex vigorously Don’t forget the matrix on the underneath side of the proximal nail fold 19 AT OR NEAR PIP LEVEL 20 PIP & DIP DISARTICULATIONS • Round off the volar and lateral flares of the phalanx • May add some grip strength but poor cosmesis 21 7 8/24/2020 MP OR SHORT PROXIMAL PHALANX Poor cosmesis Functional impairment Consider Ray Amputation 22 RAY AMPUTATION • All remaining fingers work in the same plane of motion • Excellent cosmesis • Good function • Probably slight loss of grip strength 23 RAY AMPUTATION • MOST SERIOUS COMPLICATION • Amputation neuroma • JF Murray et al • J.Hand Surgery • 2:471, 1977 24 8 8/24/2020 PREVENTION OF NERVE PROBLEMS • Avoid excessive tension on the digital nerves • Leave them long (PIP level) • Bury the nerves within the periosteal tube under NO TENSION 25 RAY AMPUTATIONS • SPECIAL CONSIDERATIONS OF THE MIDDLE FINGER AND RING FINGER MORE DIFFICULT THAN THE BORDER INDEX AND SMALL FINGER TRANSPOSITION RARELY INDICATED HIGH COMPLICATION RATE COSMESIS NOT ANY BETTER 26 LONG/RING RAY WITHOUT TRANSPOSITION • MUCH BETTER WAY • LESS COMPLICATIONS • THREE KEYS TO GOOD COSMESIS OSTEOTOMY AT THE FLARE OF MC PRECISE WEB DESIGN SUTURE DTML 27 9 8/24/2020 Leave one web intact EXCISE the other 28 Digital nerve 29 30 10 8/24/2020 THUMB: SPECIAL CONSIDERATIONS • SAVE ALL LENGTH MP joint is the critical point • PARTICULARLY THE PROXIMAL PHALANX Save every mm of proximal phalanx 31 THUMB: SPECIAL CONSIDERATIONS Functional Thumb No reconstruction needed 32 THUMB: SPECIAL CONSIDERATIONS No thumb Needs reconstruction 33 11 8/24/2020 Peter C. Rhee, DO, MS Consulting Fees: TriMed Inc., Integra LifeSciences 1 45M – Auger Injury ©2017 MFMER | slide-2 2 Surgical Techniques: Tips and Pearls for Trans-Radial Amputation Peter Charles Rhee, DO, MS Program Director, Hand Surgery Fellowship Associate Professor of Orthopedic Surgery Department of Orthopedic Surgery Mayo Clinic, Rochester, MN ©2017 MFMER | slide-3 3 1 8/24/2020 Factors to Consider in Determining Amputation Level Pain-free, sensate, and stable hand/residual limb is more functional than a textbook amputation. An amputee will utilize the residual limb with or without a prosthesis. With increased length and preservation of each joint, the person becomes exponentially more capable in interacting with the environment. (Tintle et al. JBJS Am, 2010) ©2017 MFMER | slide-4 4 Amputation Goals • Preserve as much length as possible • Even free-tissue transfer (Baccarani et al. Plast Reconstr Surg, 2007) • Functional outcome • Cosmesis Preserve length while taking into account: Size, shape, durability, and appearance of the residual limb. Affects ultimate patient satisfaction ©2017 MFMER | slide-5 5 UE Prosthesis Function • Cosmetic (passive) • Functional Components Body Powered (cable controlled) • Socket with suspension • Joint (if applicable) • Terminal device (Behrend et al. JHS Am 2011) Externally Powered (myoelectric) ©2017 MFMER | slide-6 6 2 8/24/2020 Socket Suspension • Requires robust soft tissue envelope • Able to acquire stable suspension • Soft tissue • Bone (Branemark et al. JBJS Br, 2014) (Marchessalt et al. JHS Am 2011) www.prostheticrehabclinic.co.za ©2017 MFMER | slide-7 7 Adaptive Terminal Devices Advanced Arm Dynamics (Behrend et al. JHS©2017 Am, MFMER 2011) | slide-8 8 Transradial Amputation Advantages • Preserved ability to rotate the forearm • Stable lever arm for prosthetic • Able to weight bear through the stump (especially if crutches/walker) • Most variety in prosthetics while maintaining equal limb length Disadvantages • Radio-ulnar impingement • Elbow flexion contracture (if proximal amputation) ©2017 MFMER | slide-9 9 3 8/24/2020 Surgical Technique: Trans-Radial Amputation ©2017 MFMER | slide-10 10 Transradial Amputation: Technical Pearls Volar Dorsal ©2017 MFMER | slide-11 11 How Much Length is Needed/Ideal? - Proximal = ~6 cm of proximal ulna - At most = ~3-5 inches of distal radius Enagage a Prosthetist Early Pre-op ©2017 MFMER | slide-12 12 4 8/24/2020 Expected Supination/Pronation (Fitzgibbons et al. JAAOS, 2015) ©2017 MFMER | slide-13 13 Engage Prosthetists Pre-op ©2017 MFMER | slide-14 14 Transradial Amputation Pronator Quadratus Flap ©2017 MFMER | slide-15 15 5 8/24/2020 Transradial Amputation Osteotomy