After a trauma that threatens the life of a limb, physicians’ first instinct is to save as much as they can. When the patient is stabilized and healed to a certain degree, a conversation begins on how aggressively to try and salvage the bone.
Accidents, disasters and also progressive conditions like diabetes and cancer can present a decision between limb salvage and amputation. Physicians can cut out a part of bone that is infected, dead or unable to heal (due to, for example, blood vessel or muscle damage that reduces blood flow to an injured area). A limb lengthening specialist then breaks the bone above or below the gap and moves the healthy bone up or down. Healthy bone grows to fill the spaces where bone was removed and where the surgeon made a break.
“Determining if limb salvage is possible considers the injury and wound, but also a patient’s overall health and ability to comply with an intensive surgical and rehabilitation plan,” says Dr. Austin Fragomen, orthopedic surgeon and skeletal reconstruction specialist. “We have to decide if we can overcome their problem and get the bone to heal. It’s more an art than a science.”
Limb salvage takes at least three surgeries (taking bad bone out and putting an external fixator on, breaking the healthy bone, removing the fixator) and from four-six months to a year to complete, Fragomen says. While a commitment, the results can be outstanding, and limb salvage has brought countless patients back to their pre-injury or disease status.
For some patients, though, limb salvage may not be the answer. Those who suffer from chronic pain or debilitating arthritis or those who have nerve damage and limited function, may opt to amputate a limb. Many are not given a choice.
However, patients with prostheses do have options. “You can have a prosthetic leg that you can run in, swim in, mountain climb in, do just about anything in,” says Glenn Garrison, director of Prosthetics and Orthotics.
Prostheses for everyday life have evolved, too. A limb with a computerized knee allows the patient to lift the leg to a 90-degree angle, improving gait and range of motion. A new ankle prosthesis mimics natural movement, too. “It’s a huge improvement over older style leg prosthetics, which are essentially hinged springs incapable of sensing subtle shifts in movement,” Fragomen told ABC News. The new replacement “senses changes in incline and decline and makes adjustments accordingly.”
Garrison comments that getting a patient into an advanced prosthesis like those takes time. First a patient gets what Garrison compares to “a bike with training wheels on it.” The patient must learn to trust the prosthesis and to receive, process and respond to biofeedback from the device. It takes 15-40 percent more energy consumption to walk with a below-the-knee prosthesis and 30-75 percent with an above the knee device, Garrison says.
Adding to the difficulty are changes in anatomy during the first year after an amputation. As muscle atrophies and skin responds to new pressure, the prosthesis is modified. Amputation after a traumatic event can bring more challenges as scarred skin is not as flexible and more fragile. After about a year the limb stabilizes and the patient gets a prosthesis with all the “bells and whistles,” says Garrison.
Those bells and whistles and the functionality they afford are impressive. “It is a remarkable time now. Rehabilitation has improved tremendously. The components have improved tremendously, and they continue to improve,” Garrison says.
Fragomen echoes that sentiment and says the same of his specialty. “Whichever way you go, the end result is getting better. Techniques for limb salvage are getting better, and so are prostheses,” he says.
Dr. Austin Fragomen is an assistant attending of orthopedic surgery. He co-created the Limb Lengthening and Complex Reconstruction Service (LLRCS) at HSS with Dr. S. Robert Rozbruch. Dr. Fragomen also helped create the fellowship in Limb Lengthening & Reconstruction Surgery. He serves as fellowship director, director of education, and director of the LLRCS Clinic. He is dedicated to clinical and biomechanical research and enjoys his busy clinical practice.
Glenn Garrison, CPO, is director of Prosthetics and Orthotics. He is a certified prosthetist orthotist by the American Board for Certification in Orthotics, Prosthetics and Pedorthics.