Where Are We Now? Hippocrates said, “If you want to learn surgery, go to war.” He was right. Major advances in civilian trauma care have come from wartime experience over the last century. Along with our allies, the United States has endured two decades of conflict resulting in our military physicians and allied health personnel providing advanced extremity care for soldiers who survive their combat-related trauma injuries, like high-energy blast injuries resulting in Grade 3B and Grade 3C open fractures. High rates of survival for combat-related trauma injuries can be attributed to advances in body armor, tourniquet usage, the early placement of vascular shunts, forward surgical units, improved understanding of treatment of hemorrhagic shock, rapid transport to high echelons of care, and as Hoyt et al. [4] describe in their study on flap-based limb salvage surgery, high levels of institutional experience and willing collaboration between orthopaedic and plastic surgeons. In the current study, the authors performed a retrospective analysis of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System’s National Capital Region between January 1, 2003 and December 31, 2012. A total of 330 flap procedures were performed on 307 patients over the course of a decade. The authors found that 12% of the flaps failed, with no differences between free tissue transfers and pedicled flaps [4]. This high likelihood of success could be attributed to a strong multidisciplinary application of the orthoplastic approach (comanagement between orthopaedic surgeons and plastic surgeons) to care for patients with injured limbs [5, 6]. The largest remaining problem, as I see it, is the delay in timely referral for definitive soft tissue management of open fractures. The improper use of negative pressure devices, skin substitutes, and ill-conceived local or regional flaps contribute to patient morbidity, delay of bone healing, increased cost of care, prolonged time to return to function, and late amputations. Data from an NIH-sponsored Lower Extremity Assessment Project study concluded that each case must be evaluated individually in terms of salvage versus amputation [3]. There is inherent bias against limb salvage in patients with Grade 3B and Grade 3C injuries by some orthopaedic traumatologists, perhaps caused by a lack of microsurgical support in their hospitals [7]. And, of course, another problem is that flaps performed by well-intentioned but less experienced surgeons are more likely to lead to poor outcomes. Here’s what we know: Limb salvage is possible in a high proportion of patients, but training, experience, technical ability, and orthoplastic approach must be the guiding principles of care. Where Do We Need To Go? In 1996, I organized a conference in Seattle, WA, USA dedicated to limb salvage and reconstruction. The orthoplastic concept was in its early stages, but the participants still emphasized the need for specialty collaboration and understanding of what each specialty can bring to the table regarding limb salvage. Approximately 25 years later, we are still questioning limb salvage versus amputation. Although we have a better understanding that “early treatment is better than late treatment,” particularly regarding soft tissue coverage and early rehabilitation, few orthopaedic surgeons pursue reconstructive microsurgery training programs, and even fewer practice routine microsurgical reconstruction. I believe it is time to bring several disciplines (orthopaedic surgeons, reconstructive plastic surgeons, rehabilitation specialists, prosthetists, and pain management specialists) back to the table once again to revisit limb salvage and reconstruction. There are several questions we still need to answer, such as: What are the advances that have been made over the last quarter century and what problems have yet to be solved? What have 20 years of Operation Enduring Freedom/Operation Iraqi Freedom taught us? What have been the outcomes of Congressionally Directed Medical Research Programs grants dedicated to care of the wounded warrior? We need answers to these questions. Additionally, organizations such as the American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, American Orthopaedic Foot & Ankle Society, Residency Review Committee for orthopaedic surgery, American Orthopaedic Association, and the AO Foundation should recognize that there is a major knowledge gap of orthopaedic surgeons regarding their knowledge of soft tissue reconstruction. More fundamental is the lack of teaching of techniques for proper soft tissue handling to residents. These basic but vital competencies have never been measured or emphasized. Improvements in these skills would help avoid iatrogenic morbidity in fracture care. How Do We Get There? Guidelines have been established for timely referral to limb salvage centers. The Lower Extremity Guidelines for Salvage protocol provides clear indications for the transfer of injured extremities resulting from a variety of mechanisms that require advanced techniques for salvage. The principles are similar to those used for transfer of patients to Level 1 trauma centers or burn centers based on established criteria. The same now applies for salvage of the traumatized extremity [1]. Disseminating these guidelines to emergency rooms, physicians, and emergency medical technicians would improve extremity trauma care. Orthopaedic residencies should develop fellowship training programs in orthoplastic surgery. A formal curriculum should include training in microvascular surgery, reconstructive plastic surgery, major nerve injury treatment including brachial plexus, and the management of osteomyelitis, nonunion, and deformity. Educational modules that teach residents and established practitioners about angiosomes, debridement principles, and atraumatic techniques for handling tissues should be developed to address our soft tissue reconstruction knowledge gaps. The NIH should convene a panel on limb salvage and reconstruction, and a consensus conference should be held with military and civilian surgeons to define best practices and sustainability of orthoplastic centers and support of personnel trained in orthoplastic techniques [2]. Maintaining military preparedness during peacetime is critical for providing state-of-the-art care during future conflicts. Military medicine must recognize that future world conflicts, battlefield injuries, and terrorism are inevitable. Preparation of dedicated military microsurgeons like two authors of the current study (SMT, JMS) are essential for military readiness. Partnering with civilians dedicated to military medicine and creation of an alliance led by the American College of Surgeons and other surgical societies will create a new collaborative effort to research the future of limb salvage. Research in limb salvage and reconstruction should center on workforce needs, cost-effective care, disease teams, and treatment pathways that improve treatment and improve functional outcomes for patients who choose limb salvage surgery. For example, creating a national registry of patients treated in orthoplastic limb salvage centers and following this cohort for prolonged periods would provide knowledge on long-term outcomes of limb salvage. Similar to burn centers, hand trauma centers, and Level 1 trauma centers, orthoplastic centers for limb salvage should be formalized. Such a center already exists at the University of Pennsylvania (Penn Orthoplastic Limb Salvage Center). Certification of such centers could be done by the American College of Surgeons (Committee on Trauma) and the OTA. Finally, the creation of an NIH study section dedicated to research in limb salvage (translational and clinical research) would provide funding to address additional gaps in knowledge for limb salvage.
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Feb 14, 2024
Amber El-Amin + 6
Open Access