What Can Doctors Do to Save a Leg from Amputation?

The Atlantic Wire
 What Can Doctors Do to Save a Leg from Amputation?
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What Can Doctors Do to Save a Leg from Amputation?

The doctors fighting to save the lives — and limbs — of those wounded in the Monday's bombing will have the benefit of recent major advances, many of them results of medical experience during the Iraq and Afghanistan wars, in what is called limb salvaging. The latest casualty figure has 183 injured in the attack (fortunately, 89 have now been released), and at least 10 of them have had a limb amputated, according to CNN. More will probably be added to that toll: at least nine of the 28 people sent to the Brigham and Women's Hospital  have "limb threatening" wounds, according to a hospital spokesman.

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"In general due to the advances of microsurgery, it is possible to replant extremities," Dr. Linda Cendales, an assistant professor at Emory told The Atlantic Wire. That is the good news. The bad news is that the procedures can take a very long time and might not be worth it for some. This is how that works:

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If the right conditions are met—a big if—then the patient undergoes replantation surgery. First and foremost the patient has to be stabilized. ("Life over limb," Cendales repeated more than once.) At that point, the doctor evaluates the state of the amputated segment, the limb, the type of damage, and the injury. If it's the damage the doctors think they can fix, the patient then undergoes hours worth of surgery, in which surgeons mend bones with plates and screws and reconnect tendons, nerves, vessels, and skin. Afterwards, for precision, doctors will then mend those tissues under a microscope.

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And that may just be the first of many surgeries in the process. Time's Nate Rawlings wrote about a veteran of Afghanistan who underwent 23 surgeries and six months of painful bone stretching to save his leg. Cendales said that his would be an extreme case. One of her patients who suffered a grenade explosion incident went through three surgeries, she said.

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No matter the number of procedures, there is still a lengthy rehab period. The actual time depends on a number of factors, but Cendales says the healing process of the bones and muscles alone takes months. "The nerves could take up to a couple of years as well to regenerate," she says. All through the process, there's a chance that the limb may still never function again.

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Preserving a limb involves a lot of specific care, soon after the injury. The general guidelines are as follows, per Cendales:

Take that segment or that part and then wrap it with a moist cloth. Then place it on a plastic bag and seal the plastic bag and then submerge it in either ice or cold ice and bring it to the emergency room along with the patient. 

Dr. Kent Sepkowitz over at The Daily Beast is pessimistic about those conditions being met in Monday's bombing. "As for the reattachment of missing limbs and fingers, unfortunately the chaos that ensued after the explosions makes this just about impossible," he writes. "Even the basic task of matching the correct limb to the patient was not assured," he writes. 

Given the risks and costs of limb salvaging, prosthetics might be a better choice for some patients, who might not want to go through the invasive surgery and rehabilitation to possibly never walk again. Prosthetics may actually deliver a better outcome. A recent study found that patients who got replacements had better "overall function" than those who went through rehabilitation. The Brooke Army Medical Center, saw more "late" amputations from veterans starting in 2009 because patients were having trouble walking. "I met several limb salvage patients at BAMC who could barely walk 10 feet on a carpeted floor," writes Rawlings.

For those who don't qualify for limb reattachment, there have been huge advancements in prosthetics as well. The Intrepid Dynamic Exoskeletal Orthosis (pictured right) was designed by Lieut. Co. Joe Hsu, an orthopedic surgeon; Ryan Blanck, a prosthetist; and Johnny Owens, a physical therapist. It has helped hundreds of veterans since its invention a year ago. It looks and works a lot like a prosthetic, but it fits over the re-attached limb. "The way it works is very much like a runner’s prosthetic," Blanck explains. "As the warrior steps on it and moves forward, the energy of the foot piece is transferred to the back of the foot piece with a spring motion." Soldiers who once limped following limb rehabilitation were back in their original units.