Surgical Options in Mgmt of Acquired and Congenital Limb Deficiencies

Question 1

Amputation as General Surgical Option

Answer 1

Skeletal immaturity and future growth are important factors to consider

Physes should be preserved when possible

• UE most growth occurs at physes around shoulder and wrist
• LE most growth occurs at physes around the knee
• If amputation results in significant LLD should use limb sparing techniques

Amputation in long bones may result in terminal overgrowth is important to consider

• overgrowth can be painful and impact ability to WB and wear prosthesis
• can result in spikelike overgrowth d/t osteogenic activity in the periosteum
• occurs most frequently in humerus and fibula
• may require surgical revision or bone capping

Wound healing is rarely a concern in children

Question 2

Amp to revise congenital limb deficiencies to improve fxn

Answer 2

Amp rarely necessary with ue limb deficiencies

Children with bilateral PFFD may be more functional with surgery

Unilateral PFFD- if has stable hip/foot and have significant portion of normal femur–leg lengthening procedure may be appropriate, must have 60% of femur length

• if do not have enough femur left can do knee arthrodesis and foot amputation
• –Syme (removal of the foot including calcaneus) or Boyd (arthrodesis of calcaneus and tibia which adds length to the limb) amputation at foot is recommended

Amp may be option for children with longitudinal or fibular total deficiency in which a significant LLD exists with a foot deformity

• foot is frequently in equinovarus or valgus with absent rays
• if tibia is completely absent– knee disarticulation with prosthesis = very functional
• if LLD is too significant for limb lengthening techniques a Syme or boyd amputation may lead to more functional LE with addition of a prosthesis for a child with partial absence of fibula

Question 3

Amp in mgmt of traumatic injury and malignant tumors

Answer 3

May result in a short residual limb if child has significant growth remaining

• • specifically seen in AKA
• • lengthening of the short residual limb may increase efficiency of gait and promote better prosthetic fit

Malignant bone tumors- traditional approach is to amputate limb where tumor was found, surgical margin for amputation is 6-7 cm above most proximal medullary extent of the tumor
- local recurrence rate using this level of margins is 5%

Tumor sites that are proximal in the humerus or femur–amp results in significant loss in function

• most surgeons elect not to perform amp if possible for tumors in the UE
• limb sparing procedures may result in more functional extremity than a proximal amputation without decreased the expected rate of survival

Question 4

Rotationplasty

Answer 4

Typical option fro congenital limb deficiencies (PFFD or tumor)

Ankle functions as knee joint- PF extends knee, DF flexes knee

Advantages: increased limb length, improved prosthetic function, improved WB capacity, elimination of issues for terminal overgrowth and pain from neuromas or phantom limb sensations, allows for growth of the leg (can run, jump, and play with peers with appropriate prosthetic)

Disadvantages: cosmesis, derotation of foot

When performed in young children derotation of the foot can occur, requiring re-rotation surgery of the limb

Question 5

Limb Sparing procedures

Answer 5

Alternative to amp in children with malignant bone tumors

Involves resection of tumor and reconstruction of the limb to preserve function without amp
– reconstruction may include excision of bone without replacement or replacement with allograft or endoprosthetic implant

Most important goal is to remove all of the tumor

Contraindicated if tumor has invaded soft tissue to a large extent, involves neurovascular supply, or if tumor invaded intramedullary cavity

May result in LLD in skeletally immature

Autograft not appropriate
Use cadaver allograft and osteoarticular allografts may be used to preserve growth plates
Grafts are very stable and do not loosen overtime
Greatest complication seen in children receiving chemo at the same time

High impact activities limited for a child with osteoarticular allograft

Endoprosthetic devices- similar to joint arthroplasty procedures- potential problems = infection or mechanical issues, may not be appropriate for young children due to limited growth of devices
- can incorporate telescoping devices to account for growth- problems = loosening of the device, need for repeat surgeries, infection following lengthening, mechanical failure, fracture

Limb sparing may result in increased complications including reduced ROM (specifically in procedures involving knee), decreased timed up/down stairs, TUG, and 9 min walk/run test

Question 6

Comparison of surgical options

Answer 6

Functional mobility assessment (FMA)- measure pn, TUG, timed up/down stairs, use of amb supports, satisfaction of walking quality, participation in work/sports, endurance

Adolescents with femur limb sparing surgery scored significantly higher on FMA assessment than those who had an AKA
BKA scored higher in QOL

Question 7

Limb replantation

Answer 7

option for traumatic amputations

goal to preserve limb and restore pain free function of the extremity

UE replantation successful if: have function of elbow/hand and distal sensation
LE replantation successful if: painless, sensate extremity capable of WB during normal activities

Distal ue replantation has more favorable outcomes than proximal
- proximal associated with violent MOI that results in damage to nerves, vessels, and mm
UE replantation has better outcomes than le replantation

PT indicated for: wound care, edema control, joint ROM, strengthening, gait training, self care

Question 8

Osseointegration

Answer 8

direct attachment of a prosthesis to the end of the bone of a residual limb

long process, requires multiple surgeries
First procedure = implantation of threaded cylinder
6m later = metal abutment threaded onto cylinder
Final- WB loads on abutment are gradually increased through use of temp/perm prostheses—stage can take over a year

Advantages- elimination of socket, preservation of sensation
Disadvantages- problems associate with poor fitting sockets and suspension models

Not indicated for skeletally immature

Question 9

Phantom limb sensations

Answer 9

fewer reports in children vs adults

decreased complaints in children

incidence of phantom sensations increases with age
- all children 8 y or older reported some sort of phantom sensation

most report perceived ability to move limb rather than pain

phantom limb sensations/pain can be intense in adolescents and it may become debilitating and impact ability to complete daily activities