>> Hi. This is Dr. Rob Rosworth [assumed spelling] from Hospital for Special Surgery,
and I wanted to spend some time on the topic of when to amputate
and when to reconstruct a limb at risk.
This is an excerpt from a previous recent lecture that I gave in Dallas, Texas.
All the patients who's identity is shown have given consent.
And there is graphic detail of surgery contained in this lecture.
There is a time for everything.
That is a common philosophy and idea that is present, and I think it does apply to the idea
of limb salvage versus amputation.
There's a time for limb salvage.
There's a time for amputation.
But the decision making process about what is the best approach
for each individual patient can be quite complex.
It involves a variety of factors that lead to the decision making,
and these include the extent of the injury, the surgeon's ability to deal
with a particular situation, the expected functional outcome, and very importantly,
the patient's emotional state and where they are in the recovery
and reconstruction of the particular injury.
And when you weigh all of these factors, it is helpful in making the decision
between limb salvage and amputation reconstruction.
It is a personal decision.
We have a lot of positive experience with limb salvage for limbs at risk,
both clinically -- we've published on this.
Here's an example.
Gabriel had a very extensive injury, which lead to the loss of her talus bone.
Initially treated with a talus implant.
But over time, this eroded into the tibia and into the talus,
and this was no longer a viable option for her.
This is a complex limb salvage problem, because there is bone loss
of five centimeters or 50 millimeters.
Limb salvage approach was taken, and this entailed a combination of ankle arthrodesis
or a tibial calcaneal fusion, after removal of the talus implant.
And then a proximal osteotomy for lengthening of the tibia, to make up for the bone loss.
So, you see, it's a bifocal approach.
There are two areas that are being worked on, the ankle arthrodesis and the lengthening.
The patient is allowed to stand and walk during the treatment.
And at the end of a successful treatment, there is fusion of the tibia to the calcaneus,
and also the lengthening site of the tibia, with the internal lengthening rod.
The functional outcome was great.
She had equal leg lengths, no deformity and was able to walk quite well.
In contrast, a similar patient of similar age presented also
after a total talus bone that had been placed.
This patient was not doing well.
You can see the talus implant is very unstable.
She was unable to work.
She had develop CRPS, chronic regional pain syndrome.
You can see the discoloration and the changes in the bone, at that time.
This too was a limb at risk, and we presented the patient with two options.
One was a tibial calcaneal fusion, with stage lengthening,
similar to what I showed you in the previous case.
The second was a [inaudible] amputation, with immediate osteo integration.
This patient had been dealing with this for a long time and desired a fast recovery,
and the patient desired and opted
for the amputation reconstruction, with osteo integration.
For this patient, this was a good option.
The integration planning is done off of the x-ray.
The amputation level is planned.
The length and the diameter is planned, off of the CT scan.
During the surgery, a press fit titanium [inaudible] coded implant is inserted,
and at the same time, targeted muscle reinnervation was done,
to treat and prevent nerve pain and phantom nerve pain.
Post-operatively, a progressive loading protocol was implemented, starting with 20 pounds
and increasing with five pounds every other day.
The prosthetic leg was attached at 10 weeks.
Here, you can see the patient walking independently and without assistance
at four months after the date of surgery.
Another example of osteo integration
for [inaudible] amputation is illustrated here with Jesse.
He is showing the process of removing and reapplying the prosthetic leg.
There is no socket that is necessary.
And at one year, his functional level has improved dramatically,
and he is showing the ascension of a hill in Central Park.
So, in conclusion, limb salvage versus amputation reconstruction is a complex decision
that is individualized for each patient.
It depends on the extent of the injury, the surgeon's ability to deal
with that injury and reconstruction.
The expected functional outcome, and the patient's emotional state.
And all of this is taken into account.
Discussion between the surgeon and the patient is had,
and an individualized treatment plan is created for that particular patient.
Thank you for your attention.