Revision surgery improves upper limb amputation outcome

By Lynda Williams, Senior medwireNews Reporter

Revision surgery can significantly reduce pain and increases prosthesis use in veterans who undergo combat-related major upper-extremity amputation, US research demonstrates.

The study showed that patients significantly benefited from reoperation for factors affecting the residual limb following high-energy trauma, such as heterotopic ossification, infection, and neuroma excision.

"The surgical treatment of these complications in this patient cohort improved prosthesis acceptance and appears to lead to outcomes equivalent to those experienced by amputees who did not have a complication," say Benjamin Potter (Walter Reed National Military Medical Center, Bethesda, Maryland) and co-authors.

The researchers followed up 96 wounded patients, aged a median of 26 years, who received explosive blast injury (87%), high-velocity gunshot wounds (8%), or other trauma during Operation Iraqi Freedom and Operation Enduring Freedom.

This included 11 wrist disarticulations, 47 transradial amputations, two elbow disarticulations, 36 transhumeral amputations, and four shoulder disarticulations. Four patients underwent bilateral upper-extremity amputation and 18% of patients also sustained lower-limb amputations.

A total of 103 revision procedures were performed on 42 limbs, half of which were irrigation and debridement to treat deep infection, and the remainder to treat heterotopic ossification, symptomatic neuroma, scar revision, or contracture release.

Just 19% of patients who underwent revision surgery reported regular prosthesis use before reoperation, compared with 87% after revision surgery, a significant difference.

Furthermore, at last follow up, at a median of 20.1 months, there was no significant difference in residual limb pain or phantom limb pain, use of neuropathic pain medications, or rates of return to duty after rehabilitation between patients who did and did not require revision surgery.

Although level of amputation did not predict pain, opioid use, or return to duty, the researchers found patients who sustained transradial amputation were 4.7 times more likely to experience phantom limb pain and 2.8 times more likely to use neuropathic pain medication than other amputation patients.

"Potential explanations for the higher rates of pain medication use and neuropathic pain are the higher rate of prosthesis use among the transradial amputees as well as the possibility of unshielded residual-limb use in activities of daily living, which is likely more common with transradial amputees because of the increased length of the residual limb and the presence of the elbow," Potter et al suggest.

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