Salvage Operation

Salvage. If you’re a retired naval officer, the word might conjure up images of a superannuated battleship about to be reduced to a pile of scrap metal and spare parts. If you’re an orthopaedic surgeon, you might envision a desperate patient sporting a checkerboard of surgical scars. Neither prospect is very enticing, but the goal is to make the best of a bad situation, to recoup some value from an otherwise hopeless case. I had an opportunity to contemplate the meaning of salvage last June, when I had the honor to serve as one of two guest speakers at the University of New Mexico Alumni Conference, an annual occasion scheduled to coincide with festivities for the graduating residents and fellows. It’s always fulfilling to take part in such an event, and witness the intelligence and promise of the young graduates who are the future of orthopaedic surgical care. As expected, the trainees were uniformly inspiring, but it was my fellow guest speaker who left me with the most indelible impression. Joe Hsu is an orthopaedic trauma specialist who recently left the US Army. Joe’s expertise is the salvage of severely mangled limbs, and he’s seen a lot of them in recent years. According to the Joint Theater Trauma Registry, over 80% of combat-related fractures are classified as open wounds, most commonly caused by explosions, gun shots, and mortar attacks. Although these mechanisms of injury will seem foreign to most sports traumatologists, the patient population will not: ‘‘They are accustomed to being incredibly physically fit and being able to participate in a large variety of high demand athletic and recreational activities. ’’ In the past, such injuries routinely led to acute amputation, but current treatment protocols enhance the possibility of limb retention. On site, these severe wounds are aggressively treated with stabilization, vascular repair, and necessary debridement; the stabilized patients are then conveyed to specialized treatment centers for definitive care. At the conference, Dr Hsu recounted his experience at one of these centers in San Antonio, Texas. The injuries are often severely contaminated, involve loss of muscle and vascular and neurologic damage, and are associated with numerous other physical and psychological wounds. Nevertheless, with liberal use of circular fixators, creative surgery, and intensive rehabilitation, Joe and his team were often able to salvage remarkably serviceable limbs from the mutilated wreckage. Imagine his frustration and sadness when some of the beneficiaries of his expert handiwork came to him requesting amputation of their restored extremities. Having observed the rapid improvement of comrades with amputations, some reconstruction patients in the midst of their treatment had become discouraged at their relatively glacial rate of progress. Others who had completed their recovery process were frustrated because they weren’t able to achieve the high level of function required for sports or return to full active duty. Although these requests were based upon the patients’ personal experiences and anecdotal observations, they in fact reflected the results of multiple clinical investigations. A multicentric study published in 2002 reviewed 569 patients with severe lower limb injuries treated with reconstruction or amputation. After 2 years of treatment, about half the patients in each group had been able to return to work, but those who had undergone reconstruction were more likely to have required rehospitalization than the amputees. A 2007 meta-analysis of 9 observational studies confirmed these findings and went on to report equivalent function up to 7 years post-injury. Both reconstruction and amputation patients remained severely disabled in comparison with an uninjured population. Dr Hsu’s reaction to these requests for amputation was to develop an action plan to achieve better outcomes for his limb salvage patients. The result was a multidisciplinary clinical pathway, dubbed Return to Run, supported by the departments of orthopaedic surgery, physical therapy, and prosthetics and orthotics. Key elements of this pathway included an aggressive rehabilitation program, developed by Johnny Owens, MPT, and an innovative orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), invented by Ryan Blanck, LCPO. Joe’s team modeled their program after the rehabilitation routines of the most elite athletes, because in fact that was exactly whom they were treating. In order to minimize the inevitable debilitation that follows these extensive injuries, the rehabilitation began while the patients were still wearing circular external fixators. The program’s components will sound familiar to the orthopaedic sports medicine audience: Strength training including squats, lunges, and dead lifts; plyometric exercise involving progressive horizontal and vertical jumping, bounding, and hopping; agility drills to develop footwork and maneuverability. Patients in early stages of recovery were rehabilitated alongside ‘‘teammates’’ who were further along, to provide inspiration, encouragement, and competition. Each patient was fitted with an IDEO that was custom made to match their altered anatomy and motor function. During surgery, positioning of their compromised ankles was adjusted with the ultimate fitting of the orthosis in Editorial