The Mangled Extremity

1
The Mangled Extremity

• Steven Ogden, M.D.
• LSU Shreveport Orthopaedics
• Case Presentation 8/1/2006

2
History

• 22 y.o. male roughneck, smoker with good family
  support sustained R Gr IIIC open distal 1/3
  tibial shaft fracture from on-the-job injury
  offshore. Metal pipe crushed R leg. Immediately
  transported via Lifeair to nearest ED and then to
  LSU. Taken emergently by vascular to OR,
  orthopaedics consulted intra-op.

3
Physical Exam

• Vital signs without evidence of hypotension
• Right leg with near circumferential soft tissue
  injury with small 3 cm anterior skin bridge
• Complete laceration through anterior and lateral
  compartments of leg
• Cool pulseless extremity lt 6 hours until flow
  restored
• Neurological exam indeterminate
• Posterior tibial nerve in continuity
• Gross contamination noted

4
X-rays
5
MESS

• Limb ischemia 2
• Pulseless, diminished cap refill lt 6 hours
• Skeletal/soft tissue 4
• Very high energy with gross contamination
• Shock 0
• SBP always gt 90
• Age 0
• lt 30
• Total 6

6
History

• Time of injury/ischemia time
• Comorbidities
• Smoking
• DM
• Concomitant injuries
• Social support

7
Physical Exam

• Given subcutaneous nature of tibia, deformity and
  open wound usually readily apparent
• Circumferential inspection
• Lacerations
• Ecchymosis
• Swelling
• Tissue turgidity

8
Physical Exam

• Neurologic and vascular exam
• Ankle-Brachial Index if needed
• Grading of wound done at time of surgical
  debridement
• Cover wound, avoid multiple exams

-Mills, J. Trauma 2004
9
Gustilo and Anderson Classification

• Type I - skin opening of 1cm or less, minimal
  muscle contusion, usually inside out mechanism
• Type II - skin laceration 1-10cm, extensive soft
  tissue damage
• Type IIIA - extensive soft tissue
  laceration(10cm) but adequate bone coverage
• Type IIIB - extensive soft tissue injury with
  requiring flap advancement or free flap
• Type IIIC - vascular injury requiring repair

Gustilo, JBJS 1976
10
Tscherne Classification of Soft Tissue Injury

• Grade 0- negligible soft tissue injury
• Grade 1- superficial abrasion or contusion
• Grade 2- deep contusion from direct trauma
• Grade 3- Extensive contusion and crush injury
  with possible severe muscle injury, compartment
  syndrome

11
Compartment Syndrome

• Diagnosis same as in closed tibial fractures
• Common with high energy tibia fractures
• Treatment is 4 compartment fasciotomies

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Mangled Extremity Severity Index
MESI gt 20 amputation Lower extremity trauma Not
all info present at time of injury Sensitivity
6 Specificity 90 to 100
Gregory et al J Trauma 1985 Roessler et al Arch
Surg 1991
13
Mangled Extremity Severity Score
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MESS

• Combined orthopaedic and vascular injuries
• Validated by prospective trial
• MESS lt 7 predicted salvage with 100 accuracy in
  both trials
• MESS lt 4 100 salvage gt 7 100 amputation
  McNamara 1994
• Bonanni et al Sens 22 Spec 53

Johansen et al J Trauma 1990
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Predictive Salvage Index

• Combined orthopaedic and vascular injuries
• Salvage if PSI lt 8
• Sensitivity 33 to 78
• Specificity 70 to 100
• All information not available in ED

Howe 1987 Bonanni 1993
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LSI

• Limb trauma and vascular injury
• LSI lt 6 salvage
• Sensitivity 56-78
• Specificity 79-100
• Extensive surgery required for scoring
• Definitive outcome needed for scoring skin

Russell 1991, Bosse 2001 Bonanni 1993
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NISSSA

• Modification of MESS
• Open tibial fractures
• Salvage lt 11
• Splits Skeletal and soft tissue components
• Adds nerve injury
• 1 retrospective study more sensitive and specific
  than MESS

McNamara JOT 1994
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What does all that mean?

• 100 sensitive for amputation ( threshold)
• Predicts amputation need
• Only small number of unsalvagable limbs salvaged
  with high sensitivity
• 100 specific for salvage (lt threshold)
• Predicts salvage potential
• Only small number of salvageable limbs amputated
  with high specificity

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Indications for Amputation of Grade IIIC Open
Tibial Fractures

• Absolute
• Anatomically complete disruption of Posterior
  tibial nerve in adult
• Crush injury with warm ischemia gt6 hours
• Relative
• Serious associated polytrauma
• Severe ipsilateral foot trauma
• Anticipated protracted course to obtain
  soft-tissue coverage and tibial reconstruction

Lange, RH J trauma 1985
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Does the insensate foot amputation?

• Tibial nerve dysfunction on physical exam not
  equivalent to nerve disruption
• 67 of insensate feet had normal sensation at 2
  years
• Insensate limb at initial presentation not
  predictive of outcome

Bosse JBJS 2005
21
Limb Salvage vs. Amputation

• Saving a functional
• limb versus saving
• the patient

22
Treatment Objectives

• Prevent Infection
• Soft tissue coverage
• Union
• Function
• Often requires staged treatment over several
  months

23
Limb Salvage vs. Amputation

• Host factors
• Type A healthy
• Type B minimal comorbidities
• Type C Multiple comorbidites, tobacco use, poor
  social support

• The four Ds
• Disabled
• Destitute
• Drunk
• Divorced

24
Bilateral Injuries

• Bilateral amputation group best initial scores
• All three groups equalized over 1 yr
• Bilateral salvage group had best
  outcomes/improvement at 2 years
• Rec salvage limb unless absolute indication for
  amputation

Smith, Joel J, et. al 2003 LEAP symp
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Initial Treatment

• ER superficial evaluation
• Sterile dressing
• Reduction splint
• Tetanus prophylaxis
• Antibiotics
• I cefazolin
• II, III Add Aminoglycoside
• Soil contaminant add PCN
• Antibiotic spectrum changing based on local
  bacterial spectrum

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Treatment of Soft Tissue Injury

• Meticulous debridement
• Explore/Extend wound
• Deliver bone ends for full exposure
• Excise all foreign material, necrotic muscle,
  unattached bone fragments, exposed fat and fascia
• Infection 21 vs 9 w/ improved debridement
• Fasciotomy as indicated

-Edwards, CORR 1988 -Patzakis, JAAOS 2003
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Role of Irrigation

• D I Debridement Irrigation
• No consensus on volume required
• Pulse lavage
• May remove debris vs. harmful to osteoblasts
• Antibiotics vs. Soap

-Anglen, JBJS 2005
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Timing of Surgical Debridement

• Controversial issue
• Classically lt6hrs
• Currently urgent, not emergent
• Early antibiotics may be more critical
• More wound contamination requires more urgency
  and more frequency

-Bosse, JAAOS, 2002 -Skaggs, JBJS 2005
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Timing of Treatment Versus Infection

• Injury until debridement
• Infected 11.5 hours
• Not infected 11.4 hours
• Admission to debridement
• Infected 6.5 hours
• Not infected 8.0 hours
• Injury until trauma center admission
• Infected 5.2 hours
• Not infected 3.5 hours (plt0.01)

Pollak, AN 2003 LEAP symp
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Fracture Stabilization

• Reduces risk of infection
• External Fixation
• uniplane vs. multiplane
• provisional vs. definitive tx
• Intramedullary nail
• Plate fixation

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Advantages of External Fixator

• Can be applied quickly in polytrauma patient
• Allows easy monitoring of soft tissues and
  compartments

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Outcomes of External Fixation

• 95 union rate for group of closed and open tibia
  fractures
• 20 malunion rate
• Loss of reduction associated with removing frame
  prior to union
• Risk of pin track infection

Anderson et al. Clin Orthop 1974 Edge and Denham
JBJSBr 1981
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Reamed vs. Nonreamed Nails

• Reamings (osteogenic)
• Larger Nails ( locking bolts)
• Hardware failure rare w/ newer nail designs
• Damage to endosteal blood supply?
• Clinically proven safe even in open fx

Finkemeier, et.al. JOT 2000 Forster, et.al.
Injury Mar 2005 Bhandari, et.al., JOT 2000
34
Unreamed IM Nail

• Laboratory benefit of improved cortical perfusion
• Good results
• 9 delayed union
• 5 deep infection in Type III fractures

-Schemitsch, J. Trauma 1998 -Gaebler, JOT 2001
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Reamed Tibial Nailing

• Good results in Open Fx
• time to union 26wks
• deep infection rate 3.5
• Complications increased with Type IIIB fractures
• time to union 50 weeks
• infection rate 23

-Court-Brown JBJS 1991
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Blachut JBJS 79A
Reamed vs. Nonreamed Nails

• Reamed Non-Reamed
• pts. 73 63
• Nonunion 4 11
• Malunion 4 3
• Broken Bolts 3 16

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Outcome

• Early amputation
• All returned to work within 6 months
• Better functional scores and quality of life
• Delayed amputation
• Return to work at mean of 36 months
• Salvage
• Return to work at mean of 18 months

Fairhurst CORR 1994 Grade III tibia fx
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Outcome

• Limb salvage with free flap
• 16/20 successful
• More surgery, higher cost, more complications and
  longer hospital stay
• 3/16 returned to work
• 12 considered themselves too disabled to work
• Primary amputation
• 18 patients
• 9 returned to work full time
• 4 considered themselves too disabled to work

Georgiadis JBJS 1993
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LEAP Study

• Multicenter observational prospective trial
• 569 patients
• LEISS not predictive of amputation
• Low scores do predict limb salvage potential
• At 2 years 7 years F/U no difference in outcome
  scores (SIP) or return to work
• Limb reconstruction more likely to require
  rehospitalization for revision procedures.

-Bosse, et.al.
40
Cost analysis

• Primary amputation (lt24 hours)
• 1.6 surgeries
• 22 inpatient days
• 29,000
• No deaths
• Delayed amputation (gt24)
• 7 surgical procedures
• 53 inpatient days
• 53,000
• 21 death rate

Bondurant J trauma 1988
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True cost analysis

• Amputation
• 30,148
• Lifetime prosthetic cost 21,960-151,000
  (2,196)(5,695)(4,218)
• Salvage
• 59,214

Williams CORR 1994
42
Conclusions

• Outcome most affected by severity of soft tissue
  and neurovascular injury
• Aggressive, staged treatment improves results
• Most studies show major change in results between
  Type IIIA and IIIB/C fractures
• Early soft tissue coverage improves results
• 72 hours to 1 week should be goal

43
Conclusions

• LEISSS are classically designed for injuries
  below the knee
• LEISSS have limited usefulness and cannot be used
  as sole criterion for which amputation decisions
  are made

44
Treatment Course

• Patient stopped smoking day of injury
• Treated with serial Lavage and debridement
  external fixator stabilization and 2 vessel
  vascular repair.
• Over next 2 weeks, most of anterior and lateral
  compartment debrided, and had revision of graft
• Skin grafts placed when no necrotic tissue
  present at debridement (approx 2 -3 weeks out)
• Pt sought second opinion, decided on salvage
• Conversion to Nail 8 weeks out
• Bone grafted 3 months later, ICBG and BMP

45
Conversion to IMN
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3 Months After IMN
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Latest Radiographs pod 20