Abstract
Background:
Preservation of optimal residual limb length following a traumatic amputation can be challenging. The purpose of this study was to determine if acceptable results can be achieved by definitive fixation of a long-bone fracture proximal to a traumatic amputation.
Methods:
We identified thirty-seven active-duty military service members who underwent internal fixation of a long-bone fracture proximal to a traumatic amputation. Functional status was assessed with the Tegner activity level scale and prosthesis use. Secondary outcome measures were the development of nonunion, infection, and heterotopic ossification.
Results:
Twelve patients (32%) underwent amputation and fracture in the same osseous segment. Ten patients (27%) sustained bilateral traumatic amputations, and eight (22%) had a major fracture of the contralateral extremity. The median times to fracture fixation and amputation closure were twelve days and nineteen days, respectively, after the injury. The mean Tegner activity score was 3.32 (range, 1 to 6); patients with isolated extremity injuries had significantly higher Tegner scores than those with severe bilateral injuries (3.59 and 2.38, respectively; p = 0.04). Thirty-three patients (89%) developed an infection requiring surgical debridement. However, all fractures were treated until union occurred, and amputation level salvage was successful in all instances. Heterotopic ossification developed in twenty-eight patients (76%), with operative excision required in eleven patients (39%).
Conclusions:
High complication rates, but acceptable final results, can be achieved with internal fixation of a fracture proximal to a traumatic amputation to preserve functional joint levels or salvage residual limb length.
Level of Evidence:
Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Preservation of optimal residual limb length following a traumatic amputation can be challenging. Ideally, amputations should be performed at the most distal level to maximize function and decrease energy expenditure; however, fractures of the proximal residual limb create a therapeutic dilemma regarding whether to amputate through the fracture site or stabilize the fracture in an attempt to salvage additional residual limb length or joint levels. In contradistinction to the high rate of amputations due to diabetes and dysvascular disease among civilian populations, nearly all extremity amputations in the military are due to trauma1-6. The Global War on Terrorism and the current conflicts in Iraq and Afghanistan have led to >930 amputees with >1100 amputations treated in all U.S. military facilities7. The injuries in this patient cohort are complex, widely contaminated, largely blast-related, and rarely seen in civilian amputees. Further, our study population comprised young individuals in excellent premorbid physical health with a high capacity for healing and long life expectancy8-13.
A previous report from this institution described the successful treatment of two patients with proximal femoral fractures and ipsilateral transfemoral amputations8. In this investigation, we sought to expand that report to include all fractures of long bones with an ipsilateral traumatic amputation in the same extremity. Of particular interest were the outcomes of patients whose fracture fixation and level of traumatic amputation were in the same osseous segment, as a long-bone fracture in such situations is most likely to threaten the ability to successfully salvage the optimal achievable residual limb length.
As a general rule applicable to both the upper and lower extremities, the more distal the level of amputation, the better the results with regard to overall function and more efficient walking8,10-17. For example, upper extremities that retain a longer humerus for transhumeral amputations or relatively longer transradial amputations may have superior prosthetic suspension and better prosthetic options18. Patients who have a lower-extremity amputation that can be maintained at a transtibial level will have more efficient gait and better function compared with those who have a transfemoral amputation19. Therefore, if an adequate soft-tissue envelope permits, it is important to maintain as much skeletal length as practicable to optimize outcomes.
The objective of this investigation was to evaluate the clinical results of internal fixation of long-bone fractures proximal to a traumatic or trauma-related amputation. We hypothesized that these fractures could be treated successfully while maintaining residual limb length in most patients. We further hypothesized that the clinical results would be acceptable with respect to function and prosthetic use and would be similar to those seen in comparable traumatic amputations without proximal fractures.
Study Group
After approval by our institutional review board, the Amputee (prospective) and Surgical Scheduling System (S3) databases were retrospectively reviewed to identify active-duty service men and women with traumatic amputations of an extremity who underwent internal fixation of a long-bone fracture proximal to an amputation at Walter Reed Army Medical Center between January 1, 2003, and September 30, 2008. We included patients who were treated definitively with external fixation proximal to an amputation. A traumatic amputation was defined as either a battlefield injury resulting in the direct loss of the limb or an unreconstructible osseous or soft-tissue injury treated primarily with amputation during the patient's initial hospital admission. Patients who were subsequently treated with amputation on a delayed basis for failed limb salvage were excluded. Thirty-seven patients who met the inclusion criteria for this study formed our study group.
All electronic medical records were reviewed. Abstracted data included age, sex, mechanism of injury, level of amputation, associated fractures of the residual limb, associated orthopaedic injuries including fracture or amputation of the contralateral limb, type and timing of internal fixation, timing of amputation closure, and prosthesis use. Functional status was measured with use of the Tegner activity level scale20. Secondary outcome measures included nonunion, infection, and symptomatic heterotopic ossification requiring excision. Fractures were considered healed when walking or prosthesis use (for upper-extremity fracture-amputations) was possible without pain at the fracture site and when bridging callus was seen on at least three of four cortices on standard orthogonal radiographs.
Treatment
All initial surgical procedures were performed by deployed orthopaedic surgeons in the Iraq or Afghanistan theaters. Fractures were initially stabilized in the theater with external fixation or splints. Open traumatic wounds were aggressively debrided, irrigated, and packed or covered with negative-pressure wound therapy dressings. The service members were subsequently transported to Landstuhl Regional Medical Center, where they typically underwent repeat irrigation and debridements as well as revision external fixation when necessary. On arrival to Walter Reed Army Medical Center, these patients underwent serial irrigation and debridement procedures until the soft-tissue envelope allowed revision amputation and closure. All fractures in the study group were treated with standard fracture fixation techniques and implants, including intramedullary nails, flexible nails, external fixators, and wiring or plate-and-screw constructs (Table I, Figs. 1-A through 1-D).
Statistical Methods
The Tegner score is a continuous variable and is reported with standard deviations. The Student t test was used to analyze subgroup differences in Tegner scores. Associations between categorical variables, such as the development of heterotopic ossification or infection within cohorts, were analyzed with the Fisher exact test. Descriptive statistics (e.g., percentages and/or ranges) are given for all other study data.
Source of Funding
No funding was received to support this study.
Of the thirty-seven study patients, twelve (32%) underwent fracture fixation in the same osseous segment as the amputation. Four patients had upper-extremity amputations, and thirty-three had lower-extremity amputations. Ten patients (27%) sustained bilateral lower-extremity traumatic amputations, and an additional eight patients (22%) had a major fracture of the contralateral lower extremity. Thus, eighteen patients (49%) sustained a severe injury to the contralateral extremity. Including patients with multiple amputations, there were twenty-eight transtibial amputations, six knee disarticulations, eight transfemoral amputations, two transradial amputations, two transhumeral amputations, and one Chopart amputation (Table II). Five amputees with bilateral lower-extremity amputation and three amputees with a unilateral amputation had concomitant upper-extremity fractures.
All four patients with an upper-extremity amputation sustained a humeral fracture. One patient had a comminuted fracture of the proximal one-third of the humerus with a proximal transradial amputation. A second patient had a distal humeral fracture with a midforearm amputation. The third patient had a midshaft humeral fracture with distal transhumeral amputation. The fourth patient sustained a proximal humeral fracture with a midshaft transhumeral amputation.
There were thirty-five men and two women with a median age of twenty-three years (range, twenty to thirty-eight years). The median time to fracture fixation was twelve days (range, two to thirty-six days) after the injury, and the median time to amputation closure was nineteen days (range, six to forty-three days) after the injury. The median length of follow-up was forty-four months (range, ten to 170 months). Patients were followed through their most recent documented therapy or clinical appointment.
Overall, thirty-three patients (89%) developed an infection requiring surgical debridement during their treatment course. Of these infections, eighteen (55%) were at the amputation site and sixteen (48%) occurred at both the amputation and the fracture sites. Despite this high infection rate, all fractures ultimately were treated until union occurred on the basis of radiographic and clinical evidence of healing, and all residual limbs healed and were fitted with prostheses.
Fractures and soft-tissue injuries were stabilized, and nonviable tissue was serially debrided. Split-thickness skin grafts were used to cover superficial defects in fourteen patients. Two latissimus dorsi flaps and a hemisoleus and reverse sural artery flap were used to cover tibial defects in three patients. A latissimus dorsi flap was used to cover a short transradial amputation in a fourth patient. The flap failed and was treated with debridement and a pedicle groin flap. This patient developed a soft-tissue contracture requiring soft-tissue release.
Heterotopic ossification developed in twenty-eight patients (76%). Nineteen patients (68%) had heterotopic ossification at both the amputation and fracture sites; seven (25%), only at the level of amputation; and two (7%), only at the fracture. With the numbers studied, there was no significant difference (p > 0.37 for all) in either the infection or heterotopic ossification rates between the same-segment and proximal-segment fracture subgroups. Eleven patients (30% of the total and 39% of those with heterotopic ossification) required excision of symptomatic heterotopic ossification.
The mean Tegner activity score for all patients was 3.32 (range, 1 to 6), with no significant difference (p = 0.98) noted between the same-segment and proximal-segment cohorts. The mean score was 4.00 (range, 2 to 6) for the upper-extremity cohort and 3.24 (range, 1 to 6) for the lower-extremity cohort. Patients with the injuries limited to a single extremity demonstrated significantly better Tegner scores compared with patients with severe bilateral injuries (3.59 and 2.38, respectively; p = 0.04) (Table III). All patients were successfully fitted with functional prostheses and were capable of walking. Of the patients with an upper-extremity amputation, two used myoelectric prostheses, two used body-powered prostheses, and all used their prostheses in the activities of daily living.
Despite active prosthetic care and rehabilitation training, four patients (11%) at the time of the last follow-up were spending all or most of their time in a wheelchair. Three of them had injuries to both lower extremities. One patient sustained a transtibial amputation with a contralateral tibial and fibular fracture. The second had bilateral transtibial amputations and an inferior pubic ramus fracture. The third sustained bilateral transfemoral amputations. He spent half of his time in a wheelchair to recuperate following athletic activities. In general, the use of a wheelchair appeared to be principally related to the extent of the injuries, subjective reports of pain in clinic notes, and the stage of rehabilitation as of the most recent follow-up evaluations.
Major long-bone fractures proximal to a traumatic or trauma-related amputation may create a dilemma for the treating surgeon as to whether amputation should occur through the proximal fracture or the fracture should be stabilized in an effort to salvage additional residual limb length or levels. We hypothesized that the latter approach would be successful in the majority of patients with regard to fracture-healing, amputation level salvage, and functional outcome as assessed by patient activity level and prosthesis utilization. The injuries in this series were predominantly high-energy blast injuries and, as such, represent particularly complex injuries that are rarely seen in the civilian trauma setting. The management of these patients was further complicated by the severe additional injuries in most patients. Almost half of our study population had either bilateral amputations or bilateral severe injuries with one amputated extremity and the contralateral limb requiring salvage. As Dougherty showed in Vietnam veterans who underwent transtibial amputations, patients with severe injuries to both lower extremities have substantially worse outcomes19.
We identified a trend toward decreased Tegner activity level scores in patients with major bilateral injuries. Although the Tegner scale is used most frequently to assess outcomes after knee or lower-extremity surgery, other authors have used it to assess changes in activity level following spine or upper-extremity surgery21,22. Active-duty military amputees represent a unique group because of their young age, excellent premorbid physical conditioning, generally high level of motivation for rehabilitation, and long life expectancy following amputation. We used the Tegner scale to evaluate the global functionality of these patients during their ongoing rehabilitation. In a study of individuals with normal knees, Briggs et al. found the average Tegner activity scale score for men and women to be 6.0 and 5.4, respectively23, slightly more than 2 points above the mean score in our overall cohort.
The advantages of maintaining optimal functional length of an amputated lower limb are well documented. Greater residual limb length is associated with improved outcomes. This is most objectively demonstrated with improved gait parameters and walking efficiency in patients with transtibial compared with transfemoral amputation levels.
Our approach to maximize the length of the residual limb has been to maintain the residual limb at a level determined by the viability of the soft-tissue envelope, treating any fractures proximal to that level by standard means. This approach is reflected in the United States Emergency War Surgery handbook, which states that, with respect to traumatic amputations, they should "be performed at the lowest viable level of soft tissues, … to preserve as much limb length as possible…?. " and that "fractures, when present proximal to the mangled segment, should not determine amputation level, but must be treated appropriately (cast, external fixator) to preserve maximal length."2 Despite this previously advocated approach, we know of no other report on the results of fracture stabilization proximal to traumatic amputations in this or other patient populations.
Compared with prior conflicts, the current Global War on Terrorism has brought great advances in the speed and efficiency of casualty transport from the front lines to definitive treatment facilities in the United States. Fractures are provisionally stabilized, wounds are treated with irrigation and debridement at each echelon of care en route, and traumatic amputation wounds are kept open and often treated with negative-pressure dressings. The most seriously injured patients arrive in the United States within two to five days after the injury. Concurrently, far-forward deployment of advanced medical resources, combined with modern vehicular and personal body armor, has increased the survivability of previously fatal injuries. Body armor and Kevlar helmets have also further shifted injury patterns to the extremities while providing relative protection to the brain, abdomen, and thorax from penetrating wounds, producing early survivors with up to an 80% rate of extremity involvement.
Rapid aeromedical evacuation to the continental United States avoids many of the barriers to the treatment of fractures proximal to an ipsilateral amputation that were present in the past. In the Vietnam conflict, prolonged in-theater care, high infection risk, limited resources, and time constraints on surgeons during periods of increased demand all precluded the fixation of more proximal fractures in an attempt to increase the ultimate length of a residual limb.
In the current model, external fixation is typically applied in the theater of operations and the open wounds are debrided and irrigated multiple times. On arrival in the United States, the patient has additional irrigation and debridement procedures and cultures are obtained at the first trip to the operating room, with directed antimicrobial therapy prior to the placement of any internal implants. Once the soft-tissue envelope allows, fractures are treated in the standard fashion. Traumatic amputations are sequentially debrided until the wounds are stable and subjectively clean, and they are ultimately closed in a staged fashion.
Despite this methodology, infection remains a problem and this is reflected in the high rate of infection (89%) observed in the current study. Infections are treated with multiple irrigation and debridement procedures, focused antimicrobial therapy, and staged revision amputation, with minimal loss of residual limb length in most cases.
Heterotopic ossification is a well-documented complication of high-energy bone and soft-tissue trauma as well as blast injuries24,25, head injuries, and traumatic amputations24-28. A large percentage of our patients developed heterotopic ossification, but in only approximately one-third of them was it a severe enough clinical problem to warrant surgical excision. This result is consistent with that seen in prior reports in the setting of traumatic, combat-related amputations24.
Limitations of the present study include the absence of validated functional outcome measures, the lack of a control group of amputees without associated proximal fractures, and the retrospective design. Nonetheless, this study represents the first report, to our knowledge, on the use of internal fixation of more proximal fractures to maximize the length of residual limbs resulting from combat-related traumatic amputations.
We believe that these results are comparable with those in patients with a traumatic amputation of an extremity without internal fixation of a more proximal ipsilateral fracture. We observed high rates of both deep infection and heterotopic ossification, which are inherent in the management of high-energy blast injuries. Despite these complications, all fractures were successfully treated to union and amputation level salvage was successful in all patients. Given the severity and complexity of these injuries, the clinical results are encouraging, particularly in the cohort with an isolated extremity injury. In the setting of high-energy blast injuries, we recommend the adoption of standard fracture debridement and fixation techniques in the management of long-bone fractures proximal to ipsilateral traumatic amputations as an approach to salvage the maximal functional skeletal length of the residual limb, including salvage of intervening joint levels when practicable.
Note: The authors thank operative surgeons Lieutenant Colonel Donald A. Gajewski, MD, MC, USA, Colonel Gerald L. Farber, MD, MC, USA, Lieutenant Colonel (R) Harold M. Frisch, MD, MC, USA, Lieutenant Colonel Ronald A. Lehman, MD, MC, USA, Lieutenant Colonel Scott B. Shawen, MD, MC, USA, Lieutenant Colonel (R) John E. Tis, MD, MC, USA, and Lieutenant Colonel (Form) David N. Pressman, MD, MC, USA.
Kirk
NT. Amputations. 1943. Clin Orthop Relat Res.
1989;
243:3-16.
Borden Institute (US). Emergency war surgery. 3rd ed.Washington, DC: US Government Printing Office; 2004.
Burkhalter
WE;
Ballard
A; United States Office of the Surgeon General and Center of Military History, United States Army Medical Dept. Surgery in Vietnam: orthopedic surgery. Washington, DC: Office of the Surgeon General and Center of Military History; 1994.
Coates
J
Jr, . Orthopedic surgery in the European theater of operations. Washington, DC: Department of the Army, Office of the Surgeon General
; 1956.
United States Army Medical Department Historical Unit, Mullins WS. Orthopedic surgery in the Zone of Interior. Washington, DC: Office of the Surgeon General; 1970.
Hampton
OP. Orthopedic surgery in the Mediterranean Theater of Operations. Washington, DC: Department of the Army, Office of the Surgeon General; 1957.
Congressional Research Service. United States Military casualty statistics: Operation Iraqi Freedom and Operation Enduring Freedom. 2009.
Pickard-Gabriel
CJ;
Ledford
CL;
Gajewski
DA;
Granville
RR;
Andersen
RC. Traumatic transfemoral amputation with concomitant ipsilateral proximal femoral fracture. A report of two cases. J Bone Joint Surg Am.
2007;89:2764-8.[PubMed][CrossRef]
Fisher
SV;
Gullickson
G
Jr. Energy cost of ambulation in health and disability: a literature review. Arch Phys Med Rehabil.
1978;59:124-33.[PubMed]
Herndon
JH;
Tolo
VT;
Lanoue
AM;
Deffer
PA. Management of fractured femora in acute amputees. Results of early ambulation in a cast-brace and pylon. J Bone Joint Surg Am.
1973;55:1600-13.[PubMed]
Huang
CT;
Jackson
JR;
Moore
NB;
Fine
PR;
Kuhlemeier
KV;
Traugh
GH;
Saunders
PT. Amputation: energy cost of ambulation. Arch Phys Med Rehabil.
1979;60:18-24.[PubMed]
Waters
RL;
Perry
J;
Antonelli
D;
Hislop
H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am.
1976;58:42-6.[PubMed]
Pohjolainen
T;
Alaranta
H;
Kärkkäinen
M. Prosthetic use and functional and social outcome following major lower limb amputation. Prosthet Orthot Int.
1990;14:75-9.[PubMed]
Crouse
SF;
Lessard
CS;
Rhodes
J;
Lowe
RC. Oxygen consumption and cardiac response of short-leg and long-leg prosthetic ambulation in a patient with bilateral above-knee amputation: comparisons with able-bodied men. Arch Phys Med Rehabil.
1990;71:313-7.[PubMed]
Gonzalez
EG;
Corcoran
PJ;
Reyes
RL. Energy expenditure in below-knee amputees: correlation with stump length. Arch Phys Med Rehabil.
1974;55:111-9.[PubMed]
Pinzur
MS. The metabolic cost of lower extremity amputation. Clin Podiatr Med Surg.
1997;14:599-602.[PubMed]
Antti-Poika
I;
Pohjolainen
T;
Alaranta
H. Severe frostbite of the upper extremities—a psychosocial problem mostly associated with alcohol abuse. Scand J Soc Med.
1990;18:59-61.[PubMed]
Sulzle
H;
Pagliarulo
M;
Rodgers
M;
Jordan
C. Energetics of amputee gait. Orthop Clin North Am.
1978;9:358-62.[PubMed]
Dougherty
PJ. Transtibial amputees from the Vietnam War. Twenty-eight-year follow-up. J Bone Joint Surg Am.
2001;83:383-9.[PubMed]
Tegner
Y;
Lysholm
J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res.
1985;198:43-9.[PubMed]
Paulos
LE;
Evans
IK;
Pinkowski
JL. Anterior labrum reconstruction with mini-capsular shift procedure. Iowa Orthop J.
1994;14:53-64.[PubMed]
Wiese
M;
Krämer
J;
Bernsmann
K;
Ernst Willburger
R. The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon's experience: comparative studies. Spine J.
2004;4:550-6.[PubMed]
Briggs
KK;
Steadman
JR;
Hay
CJ;
Hines
SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med.
2009;37:898-901.[PubMed]
Potter
BK;
Burns
TC;
Lacap
AP;
Granville
RR;
Gajewski
DA. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am.
2007;89:476-86.[PubMed]
McGuigan
FX;
Forsberg
JA;
Andersen
RC. Foot and ankle reconstruction after blast injuries. Foot Ankle Clin.
2006;11:165-82, .[PubMed]
Dudek
NL;
DeHaan
MN;
Marks
MB. Bone overgrowth in the adult traumatic amputee. Am J Phys Med Rehabil.
2003;82:897-900.[PubMed]
Furlong
AJ;
Giannoudis
PV;
Smith
RM. Heterotopic ossification: a comparison between reamed and unreamed femoral nailing. Injury.
1997;28:9-14.[PubMed]
Steinberg
GG;
Hubbard
C. Heterotopic ossification after femoral intramedullary rodding. J Orthop Trauma.
1993;7:536-42.[PubMed]