The Mangled Extremity: It s NOT Just a Flesh Wound. William Hakeos, MD September 22, 2017
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1 The Mangled Extremity: It s NOT Just a Flesh Wound William Hakeos, MD September 22, 2017
2 Disclosures: Financial I tried to find somebody to pay me to give this talk, but couldn t
3 Disclosures: Intellectual I tried to find somebody to give me all the answers to this problem, but couldn t
4 The Mangled Extremity:Definition Severe, limb threatening, extremity trauma MVCs, peds v. auto, industrial accidents, crush injuries, GSWs Open fractures with extensive soft tissue damage I know it when I see it!
5 The Mangled Extremity
6 Limb Salvage vs. Amputation Difficult decision to make Chaotic environment of trauma bay/or Pt may not be able to participate in decision Hesitation by family members Emotional attachment
7 Outline 1. Scoring systems 2. LEAP study 3. Practical Advice
8 Objectives 1. Understand the anticipated functional outcomes of limb salvage v amputation 2. Recognize important steps in initial management 3. Learn simple decision making tips and tricks
9 28 y.o. laborer s/p GSW
10
11 He s got problems Gun shot wound (GSW) W34.00XA Anemia due to acute blood loss D62 Open fracture of shaft of right tibia S82.201B Injury of muscle T14.90 Nerve damage of right foot G57.91 Walking troubles R26.2 Out of work Z56.0
12 You Make The Call!! OR for amputation OR for salvage procedure Transfer Am I on call??
13 Open Fracture Classification: Gustilo & Anderson Type 1: minimum soft tissue stripping, <1 cm open wound Type 2: moderate soft tissue stripping, 1-10 cm open wound Type 3A: extensive soft tissue stripping; wound amenable to primary closure Type 3B: requires flap coverage Type 3C: associated vascular injury
14 Scoring Systems MESI MESS PSI LSI NISSSA
15 Mangled Extremity Syndrome Index (MESI) >20 = amputation 6% sensitivity 90% specificity
16 Mangled Extremity Severity Score (MESS) < 7 equals salvage 22% Sensitivity 53% Specificity
17 Predictive Salvage Index (PSI) > 8 equals amputation 33% sensitivity 70% specificity
18 Limb Salvage Index (LSI) >6 equals amputation Sensitivity 61% Specificity 43%
19 NISSSA
20 Scoring Systems Summary Based on retrospective studies Salvage was viable extremity Level of function not studied
21 -Did not validate clinical utility of any of the injury severity scores -High specificity: low scores can predict salvage potential -Low sensitivity: high scores do not accurately predict need for amputation
22 Lower Extremity Assessment Project Prospective, multicenter, observational Compared amputation to limb salvage Primary measure: Sickness Impact Profile (SIP) Secondary measures: limb status, complications, rehospitalization
23 LEAP Subjects Exclusion criteria GCS < 3 weeks Spinal cord injury 3 rd degree burns Transfer > 24 hours after injury Non english/spanish speakers Psych illness Military personnel Demographics 77% male 72% white 71% between ages % graduated high school 25% below poverty line 38% (20%) uninsured 2x incidence of heavy drinkers
24 LEAP: Injuries High energy trauma below the distal femur Open fractures: IIIB &C Dysvascular limbs: knee dislocations, penetrating vascular injuries Major soft tissue degloving or crushing Severe foot and ankle fractures
25
26 Sickness Impact Profile Self reported multidimensional health status questionaire Scores Average score 2-3 Score > 10 represents sig disability
27 No significant difference in functional outcomes between amputation and reconstruction at 2 years Similar return to work rates at 2 years Reconstruction group more likely to require rehospitalization Neither group did well
28
29 LEAP: Other Results Smoking is really bad 2x risk of infection, 4x risk of severe complication
30 LEAP: Other Results Smoking is really bad 2x risk of infection, 4x risk of severe complication Plantar sensation NOT indication for amputation ½ returned within 2 years No functional differences
31 LEAP: Other Results Lifetime cost of amputation higher AKA and BKA did similar Through knee was much worse
32 LEAP: Other Results Patient factors such as self efficacy, personal, economic, and social resources were more predictive of outcome than salvage/amputation Psychologic issues are very common 2 years 20% receive treatment
33 OK, so what do I do?
34 Remember the basics A B C D E F
35 Remember. Ancef Bones Casts Debridement Expletives Fractures
36 Initial Management Stop the Bleeding! Clamps Tourniquets Compressive dressings
37 Initial Management Stop the Bleeding! Clamps Tourniquets Compressive dressings
38 Initial Management - Remove Gross Stuff
39 Initial Management - Remove Gross Stuff
40 Initial Management - Remove Gross Stuff - Give antibiotics Cephalosporin, gent, PCN (??)
41 Initial Management - Remove Gross Stuff - Give antibiotics Cephalosporin, gent, PCN (??) - Take a picture!
42 Initial Management - Remove Gross Stuff - Give antibiotics Cephalosporin, gent, PCN (??) - Take a picture! - Dressing & splint
43 Surgical Planning Huddle Up! Trauma surg, plastics, vascular, neurosurg, ortho Know all injuries Skin, nerves, vessels, bones, etc. Life before Limb
44 Talk to the Patient Have you seen your leg? Do you know anyone with an amputation?
45
46 Talk to the Patient Have you seen your leg? Do you know anyone with an amputation? Prosthetic consultation
47 Talk to the Patient Have you seen your leg? Do you know anyone with an amputation? Prosthetic consultation We will evaluate your leg carefully in the operating room and save it if we can, but an amputation may be necessary
48 OR Decision Making Do what you feel is right on the first night! Do not delay an inevitable amputation!
49 OR Decision Making: Amputation Leave no contamination behind Soft tissue coverage is more important than bone length Staged procedure: save final bone cuts until definitive surgery Try to save the knee Skin grafts, free flaps, etc High BKA better than AKA, knee disartic
50 OR Decision Making: Salvage Leave no contamination behind Debride early Debride often Stabilize the bone Ex fix Provisional ORIF Soft tissue coverage is most important
51 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
52 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
53 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
54 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
55 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
56 Salvage Techniques Bone Ex Fix ORIF IM nail Bone Graft Soft Tissue Wound Vac Skin grafts Free flaps
57 Back to Our Guy ER: gross debride, antibiotics, splint, dressing OR: I&D (x3), ex fix, ORIF, cement spacer Free flap Delayed bone 3 months Begin weight 6 months
58 Beautiful on the Outside
59 And on the Inside!!
60 Mangled Limb Summary Bad injuries, bad outcomes Salvage = more surgeries, more hospital Amputation = more expensive & permanent Function is the same! Team approach Don t forget the patient s feelings!
61 Men go abroad to wonder at the height of mountains, at the huge waves of the sea, at the long courses of the rivers, at the vast compass of the ocean, at the circular motion of the stars; and they pass by themselves without wondering. -Saint Augustine Thank You
62 References 1. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. Bosse et al. NEJM Dec 12;347(24): Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). MacKenzie EJ. JAAOS. 2006; 14(10 Spec No.):S Demographic, social, and economic variables that affect lower extremity inury outcomes. Cannada LK. Injury Dec; 37(12): Complications following limb-threatening lower extremity trauma. Harris et al. J Orthop Trauma Jan; 23(1): Complex limb salvage or early amputation for severe lower-limb injury: a metaanalysis of observational studies. Busse et al. J Orthop Trauma Jan; 21(1): Early predictors of long-term work disability after major limb trauma. MacKenzie et al. J Trauma Sep; 61(3): Long term outcomes after lower extremity trauma. Butcher et al. J Trauma Jul; 41(1): Long-term persistence of disability following severe lower-limb trauma. Results of a seven year follow up. MacKenzie et al. JBJS Aug; 87(8): Open fractures: evaluation and management. Zalavras CG. JAAOS 2003;11: A prospective evaluation of the clinical utility of the lower-extremity injury severity scores. Bosse et al. JBJS Jan; 83-A(1):3-14
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