Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

Abstract

In the setting of near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Current Concepts in Upper-Extremity Amputation

“…Diaphyseal humeral shortening, performed in conjunction with elbow disarticulation, can improve prosthetic fit and rotational control while preserving adequate space for the prosthesis. 9,10 Much the same way that a long-arm cast is difficult to keep on a child without a good supracondylar mold, prosthetic suspension can be particularly challenging in short residual limbs without a distal condylar flare. The benefit of retained humeral condyles can be simulated in long transhumeral amputees with an angulation osteotomy (humeral flexion osteotomy).…”

Novel Approach of Femur Shortening With Insertion of Expandable Rod to Achieve End-to-End Repair of Sciatic Nerve Laceration

“…Few studies have reported the use of shortening osteotomies in the upper extremity for primary repair 17 and to facilitate nerve transfer without the need for an interpositional graft. 18-21 Lower extremity osteotomies for this purpose, however, have historically been avoided because of concern of functional limitations from leg length discrepancies. 17…”

Wrist fusion using an induced membrane technique for forearm salvage in a patient with an infected open injury with segmental bone loss: A case report

“…Acute shortening and fusion can be achieved provided the bone defect is <2-3 cm [7] . Greater shortening increases the risk of vascular compromise due to vessel kinking [8] and alters tendon excursion leading to flexor/extensor imbalance and reduced active range of motion. In this case, as vascular reconstruction was required, vessel kinking was less of a concern.…”