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Chapter 2A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles The Choice Between Limb Salvage and Amputation: Overview
John H. Bowker, M.D.
Because of the finality of amputation, both in a physical and psychological sense, it seems appropriate to present, in a book on amputations and prosthetics, current thought and available options regarding limb salvage as an alternative to amputation. The patient and certainly the surgeon should be constantly looking for such options to ensure that the best result in terms of function and disease eradication is achieved.
Whenever a patient presents to a physician regarding a serious injury or disease of a limb, the first inevitable question is "Can it be saved?" The initial physician, if not a surgeon, will be asked by the patient and family for a referral to a surgeon whom the primary doctor feels will give every consideration to saving the limb. A thorough evaluation of each situation will include appropriate consultation with other specialists to assure the patient and the family as well as the amputation surgeon that all reasonable avenues have been explored. Consultations may be sought from a vascular surgeon both in peripheral vascular disease and in limb trauma involving major vessels. Since most cases of major foot infection occur in diabetics, a diabetologist as well as an infectious disease specialist has much to offer in helping to manage the patient preoperatively and postoperatively. In tumor cases, consultation with a surgical oncologist, preferably prior to biopsy, is suggested.
While in years past there were often no alternatives to amputation other than palliation, this is no longer true in many instances. In trauma cases, improved methods of fracture fixation and vessel and nerve repair, along with the selective use of vascularized distant muscle and skin flaps, have provided many opportunities for limb salvage in cases destined for amputation prior to development of these techniques. This approach to limb salvage involves the skills of several specialists during multiple surgical procedures, often followed by prolonged rehabilitation. To ensure cost-effectiveness, trauma rating scales based on the probability of a good functional outcome should be applied.
In peripheral vascular occlusive disease, if immediate surgery is not required, as in dry gangrene limited to the forefoot, a vascular surgeon should be consulted if limb blood flow to that area is critically diminished. Advantage should be taken of the major advances that have been made in recanalization and reconstruction of vessels. Restoration of flow to the foot by in situ and reverse vein grafting may result in salvage of most or all of the foot.
In cases of infection, prior to procedures based on abscess drainage with or without limited distal amputation, limb blood flow should be evaluated to give the surgeon and patient reasonable assurance that the resulting wound will heal. Infected feet, mostly related to diabetes mellitus, can often be drained adequately with resultant salvage of most or all of the foot. By using the method of Kritter, most feet with low-grade infection can be loosely closed following thorough debridement, thus sparing the patient considerable morbidity.
In the past, tumors of the limbs were routinely treated with early amputation as the best hope for cure. Powerful new chemotherapeutic agents, often combined with radiation and selective excision of solitary metastatic deposits, have made tumor control possible in many instances. The current limb salvage approach combines ablation of the tumor with reconstruction using an allograft, endoprosthesis, or a combination.
Many of these advances in treatment concepts and procedures have occurred in the decade since the first edition of this book was conceived. The tremendous increase in a patient's expectation of a good outcome based on technological advances is offset by the cost of many of the more advanced procedures. While this dichotomy cannot be ignored, the fact remains that prosthetic replacement following amputation falls far short in restoration of motor and sensory function. Until this situation changes, limb salvage rather than amputation should be the goal, provided that the salvaged limb is functionally better than its prosthetic counterpart.
Chapter 2A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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