37.3 Separation of components in re-amputation surgery: applying basic surgical tenants to maximize outcome        

            JC Lantis, MD; C. Gendics, RN; G. Todd, MD; St. Luke's, Roosevelt Hospital Center, New York, NY

Introduction: Patient seek below the knee re-amputation for poor function, pain and/or poor match to prosthesis. We believe the best technical outcomes require identification of all the constituent portions of the limb prior to reconstruction; we identify and separate the tibia and fibula, muscles and neurovascular bundles of the 4 compartments of the lower leg and the subcutaneous, skin and nerve tissue of the envelope.

Methods: Ten patients over a 30-month period underwent re-amputation. The pre-operative and post-operative pain assessment, time to return to function, narcotic requirement, and quality of life was assessed. The patients all had undergone unilateral traumatic lower extremity injuries, and were less than 50 years old, 8 men and 2 women, and had undergone initial amputation 17 ( ± 31) days after their injury. All patients underwent complete preoperative trigger point mapping, x-ray evaluation and physical exam. They then underwent surgical revision; consisting of complete separation of components, resection of all scar noted not be identifiable as one of the components, including bone remodeling and primary closure. Four of 10 had Ertl procedures, 60% had (I)mmediate (P)ost (O)perative (P)rosthesis placement, and 3 of 10 underwent immediate post-operative radiation therapy to the surgical site.

Results: The average return to independent ambulation with crutches was 30 days, without crutches 48 days. The patients pain scale decreased from an 8 to a 2, and the 90% of patients stopped all narcotics within 45 days. There were an average or 4 neuromas identified and removed per patient.

Discussion: The complete separation of components prior to revision of the lower limb amputation appears to facilitate very fast recovery with identification of previously unrecognized technical problems as the primary reason for the techniques effectiveness. In addition adjuncts such as IPOP and radiation appear to have a positive effect on outcomes.