Moderatorsʼ Summary: Amputee Care

摘要

In this session, the Armed Forces Amputee Patient Care Program (AFAPCP) is reviewed; the nature of the injuries sustained by the combat amputee is delineated; heterotopic ossification is identified as a difficult sequela in the military amputee; current research efforts that are bringing the skeletally attached, neurally integrated robotic prosthesis closer to reality are outlined; and the outcome of civilian traumatic amputation is explained, with comparisons made to the military patient population. Gajewski and Granville review the AFAPCP from the time of wounding through advanced rehabilitation. The rationale behind the creation of amputee patient care centers in order to concentrate amputee care and expertise and enable patients and their families to provide mutual support to one another is discussed. The improved survival of the wounded, with resulting increased severity of extremity wounds, is hypothesized as being secondary to several factors, including better ballistic body armor, the increased use of tourniquets and hemostatic dressings, improved medic and corpsman training, far-forward “damage control” surgery, and the capability to evacuate unstable patients to tertiary care facilities in the continental United States (CONUS). The current unified approach to catastrophic extremity injury is outlined. Resuscitation is begun at the point of injury, with tourniquets applied to prevent exsanguinating hemorrhage. Advanced Trauma Life Support principles are used to identify and treat life-threatening associated injuries. Broad-spectrum antibiotics are administered. Débridement of all contaminated and devitalized tissues is performed through longitudinal, extensile incisions, recognizing that contamination is driven far up fascial planes in blast injuries. Fasciotomies are performed liberally because the patient will have long periods during evacuation when no intervention is possible. All viable soft tissues are retained to maximize the reconstructive options at the definitive treatment facility. Guillotine circular amputations are discouraged because the prolonged skin traction required to achieve closure of these amputations slows rehabilitation and isolates the patient. The short evacuation times of the current conflict eliminate skin retraction as a clinically significant entity. Fractures are stabilized by splinting or external fixation. The soft-tissue injury, not the bony injury, dictates the level of amputation. All wounds are left open. Negativepressure dressings are used frequently but current field methods are not air worthy, so they are removed before air evacuation. Initial surgery is limited, with care being taken to avoid hypothermia, acidosis, and coagulopathy. Resuscitation is continued postoperatively, and repeat surgeries are planned with consideration of the physiologic state of the patient. Usually débridements are performed every 48 to 72 hours through the evacuation chain and are continued at the tertiary care facility until a clean wound with viable tissues allows closure. On arrival in CONUS, each patient is evaluated by a multidisciplinary team. Dressings are changed under adequate anesthesia. Patients with wounds with significant drainage or other wound conditions of concern are taken immediately to the operating room; the remainder are scheduled for surgery the following day. Once adequate débridement is achieved, myodesis is performed. Myodesis, as well as skin closure, frequently requires surgical creativity because nonstandard flaps are necessary for length-preserving amputation. Wound closure is achieved by the simplest means compatible with the maximum preservation of length. At times, this may involve rotational flaps or free tissue transfer. The authors have found that modern prosthetic advances such as anatomic socket design and silicone gel liners allow successful fitting over split-thickness skin graft and insensate flaps. Fracture fixation is performed as soon as the soft-tissue enve