Functional salvage of a severely injured extremity is a challenge for the patient and the treating surgeon. We report a case of a woman presenting with severely injured lower limb and bone loss, which was managed using a custom-made endoprosthetic replacement for successful functional outcome. Despite being complicated by bone loss, nerve injury and infection; a planned staged surgical treatment and rehabilitation have resulted in satisfactory outcome. At 3-year follow-up, the functional score according to the Musculoskeletal Tumor Society-International Symposium on Limb Salvage System was 70% and the Toronto Extremity Salvage Score was 62%. Endoprosthetic replacements may have a limited role in managing selected patients with mangled extremity and can lead to a good functional outcome to these patients

Abudu, Adesegun

Baloch, Khalid

Mohammed, Riazuddin

Peart, Francis

English

PubMed

Springer - Publisher Connector

CASE REPORT
Functional salvage of a mangled lower limb using custom-made
endoprosthetic replacement
Riazuddin Mohammed Æ Khalid Baloch Æ
Francis Peart Æ Adesegun Abudu
Received: 29 December 2008 / Accepted: 31 August 2009 / Published online: 24 September 2009
 Springer-Verlag 2009
Abstract Functional salvage of a severely injured
extremity is a challenge for the patient and the treating
surgeon. We report a case of a woman presenting with
severely injured lower limb and bone loss, which was
managed using a custom-made endoprosthetic replacement
for successful functional outcome. Despite being compli-
cated by bone loss, nerve injury and infection; a planned
staged surgical treatment and rehabilitation have resulted in
satisfactory outcome. At 3-year follow-up, the functional
score according to the Musculoskeletal Tumor Society-
International Symposium on Limb Salvage System was
70% and the Toronto Extremity Salvage Score was 62%.
Endoprosthetic replacements may have a limited role in
managing selected patients with mangled extremity and
can lead to a good functional outcome to these patients.
Keywords Mangled extremity  Functional salvage 
Endoprosthetic replacement
Introduction
A severely injured extremity poses difficult decisions for
the patient and the treating surgeon. The degree of soft
tissue injury, neurovascular damage, bone loss, presence of
other injuries, patients’ general physical and psychological
condition are all important factors in decision-making. The
majority of the patients were previously treated by ampu-
tation. However, with advances in surgical methods of
fracture stabilization, soft tissue reconstruction and
microsurgical techniques, some mangled limbs can now be
salvaged.
Adequate soft tissue reconstruction is of utmost impor-
tance. Various treatment options have been suggested for
managing the associated bone loss. These include internal
fixation with bone grafting, distraction osteogenesis
through circular external fixators; primary shortening
followed by staged lengthening and allografts. However,
these are associated with very prolonged recovery and the
functional outcomes are unpredictable. We report a case of
a woman presenting with severely injured lower limb and
bone loss which was managed using a custom-made
endoprosthetic replacement for successful functional
outcome.
Case report
A 52-year-old woman sustained a severe crushing injury to
her left lower limb having been trapped between a wall and
a rapidly reversing car. She was conscious, coherent and
haemodynamically stable. Her other injuries included a
deformed right ankle and some bruising over the right
cheek. There was no other major system injury. She was
resuscitated according to the advanced trauma life support
R. Mohammed  K. Baloch
Department of Trauma and Orthopaedics, University Hospital
of Birmingham NHS Trust, Birmingham B29 6JD, UK
F. Peart
Department of Plastics and Reconstructive Surgery,
Royal Orthopaedic Hospital NHS Trust,
Birmingham B31 2AP, UK
A. Abudu
Department of Orthopaedics and Musculoskeletal Oncology,
Royal Orthopaedic Hospital NHS Trust,
Birmingham B31 2AP, UK
R. Mohammed (&)
16 Bayliss Close, Birmingham B31 2XP, UK
e-mail: riaz22@hotmail.co.uk
123
Strat Traum Limb Recon (2009) 4:145–149
DOI 10.1007/s11751-009-0068-x
protocol and the bleeding from the leg was attended to.
After she was clinically stabilized, a secondary survey was
conducted to asses the limb status. Extensive soft tissue
injury with degloving of skin and muscle damage from
mid-thigh to lower calf was noted.
There was a significant comminution of the lower end of
femur with loose fracture fragments visible. Distal pulses
were palpable. Neurological assessment was found to be
difficult at this stage. The mangled extremity severity score
(MESS) was calculated to be 6 (3 for high energy injury,
1 for transient hypotension and 2 for age) and was utilised
to asses the suitability for limb salvage. There was no
significant past medical history or medication and allergy
history of note.
The wound was covered with sterile dressings and the
limb was splinted. Antibiotic and tetanus prophylaxis were
administered. Adequate analgesia was provided. The right
ankle and foot were found to be swollen, bruised, but with
intact skin and were extremely tender. Trauma series
radiographs and limb radiographs confirmed a comminuted
distal end left femur fracture with bone loss (Fig. 1), a right
ankle bi-malleolar fracture and an undisplaced base of right
first metatarsal fracture.
An emergency debridement and stabilization of the
femur fracture were obtained using a bridging Hoffman
uniaxial external fixator (Fig. 2). The devitalized bone
fragments were debrided. Operative findings included
loose femur fragments with contamination from fragments
of plastic material, partially intact lateral gastrocnemius,
partially detached iliotibial band and an avulsed biceps.
The knee extensor mechanism and the neurovascular
bundle were found to be intact. The right ankle fracture
was also internally fixed on the same day.
At this stage, the patient was referred to us due to
extensive soft tissue defect and a 12 cm femur bone loss.
The aim was to reconstruct these defects using an endo-
prosthetic replacement. Option of an amputation and limb
preservation was discussed with the patient. The patient
preferred limb salvage. The plastic surgeon was also
involved in the decision-making process and the patient
was informed of the treatment plan. Over the next few
days, a relook debridement was done and was followed by
repeat debridement. The vascular status of the limb was
normal, but there was a foot drop on clinical assessment.
The wound exploration revealed that the common peroneal
nerve was found to be intact, but had been stretched.
A cement spacer to allow for the bone loss and a lateral
gastrocnemius flap were harvested with input from the
plastic surgeons. Unfortunately, this got infected with
bacillus species. The wound was debrided, an across knee
intramedullary rod and cement spacer was used to achieve
stability. The infection was controlled by intravenous
vancomycin.
In view of the ongoing infection and soft tissue prob-
lems, it was necessary to pursue on a cautious note. The
next few weeks involved multiple wound washouts in the
operating theatre to control infection. The wound swabs
grew Acinetobacter Baumannii sensitive to the antibiotic
merapenem. About 5 weeks after the initial injury, the leg
was re-debrided and the cement spacer was revised. A left
latismus dorsi free-flap was used for soft tissue recon-
struction. The wound was assessed and redressed a few
times in the operating theatre subsequently. With continued
Fig. 1 Soft tissue wound depicting the stretched common peroneal
nerve
Fig. 2 Plain radiograph confirming a comminuted distal end fracture
of left femur with bone loss
146 Strat Traum Limb Recon (2009) 4:145–149
123
antibiotic treatment for 4 months, the infection was under
control and repeated aspirated from the knee were
negative.
The leg wound had healed well. However, the knee had
only a jog of movement. A distal femur endoprosthetic
replacement was planned for about 11 months from the
initial injury (Figs. 3, 4). A custom-made distal femoral
endoprosthesis, the SMILES implant (Stanmore Modular
Individualised Lower Extremity System), Stanmore
Implants Worldwide, UK, was used for reconstruction.
Quadricepsplasty was needed to achieve sufficient access
and the range of movement on table was 0–60.
The patient underwent staged physiotherapy and gradual
rehabilitation. The range of knee movement was of some
concern and a manipulation under anaesthesia was per-
formed 6 months after the reconstructive arthroplasty.
Current status
The patient is now 3 years from the endoprosthetic
reconstruction. She is independently mobile and able to
drive a car without limitations. The knee flexion remained
limited to 0–30 only. There is no evidence of infection.
The prosthesis remained stable and well cemented. The
limb is now 4 cm short. Functional score according to the
Musculoskeletal Tumor Society-International Symposium
on Limb Salvage System [1] was 70% (21 out of a possible
30 points) and the Toronto Extremity Salvage Score [2]
was 62% (93 out of a possible 150 points). Figure 5 shows
the latest radiographs at 3 years after surgery.
Discussion
Mangled limbs with severe bone and soft tissue loss
present a clinical challenge in terms of reconstructive
surgery, prolonged rehabilitation, physical and psycholog-
ical demands on the patient, and with no guarantee of a
successful outcome. A question of primary amputation or
limb reconstruction is a difficult one. Various scoring
systems are available to asses the suitability for limb sal-
vage in such situations such as the MESS; the limb salvage
index; the predictive salvage index; the nerve injury,
ischaemia, soft tissue injury, skeletal injury, shock and the
age of patient score; and the Hannover fracture scale-97.
Although a recent prospective study questions the clinical
usefulness of any of these scores [3], the most commonly
Fig. 3 Long leg radiographs for preoperative planning for the
endoprosthetic replacement
Fig. 4 Manufacturer’s proof of the custom-made distal femoral
endoprosthesis
Strat Traum Limb Recon (2009) 4:145–149 147
123
used in the MESS system. Helfet et al. [4] have reported
that an MESS score of greater than or equal to 7 had a
100% predictable value for amputation.
The extents of soft tissue damage and neurovascular
status are the important local factors in making the correct
initial decision. Hence, significant experience with man-
aging such patients and input from other relevant special-
ists are essential from the onset.
The goal of limb salvage surgery in such extremity
injuries is to provide adequate soft tissue cover, skeletal
stabilization, restore adequate length and alignment and
most importantly, result in a functioning limb. Although
various treatment modalities have been advocated in the
management of limb injuries with bone loss, the common
element in all these are the multiple reconstructive proce-
dures, long term to recovery and the less than satisfactory
functional results. Acute shortening followed by progres-
sive lengthening [5, 6], bone transport using Ilizarov
technique [7], allografts to replace bone defects [8, 9] and
free vascularised bone grafts [10] have all been advocated
for the reconstruction of the defects. However, the com-
plications are many and the success limited. The major
advantage of cemented endoprosthesis is early stabilization
and recovery of function.
We have reconstructed a mangled extremity with 12 cm
bone loss in the femur using a custom-made distal femoral
endoprosthetic replacement. To our knowledge, this has so
far not been reported in literature. Traditionally, endo-
prosthetic replacements are used for managing skeletal and
soft tissue defects following the tumour resection and have
had good long-term results [11]. However, there seem to be
additional applications afforded by these systems. Failed
internal fixations of fracture, severe fractures with bone
defects, failed joint arthroplasty with insufficient bone
stock are the non-tumour indications for endoprosthesis’
[12]. The advantages with endoprosthetic replacement are
the ability to reconstruct massive skeletal and soft tissue
defects, ready availability and are relatively inexpensive
[13]. The patients can recover rapidly and weight bear
early [14, 15]. The major complications are infection,
aseptic loosening, mechanical failure and fracture. Many of
the complications can be readily addressed, provided the
patient is regularly followed up. Also the surgeon needs to
be fully acquainted with the prosthesis and be fully aware
of the limitations and dangers of the procedure.
Endoprosthetic replacement for the management of
trauma may have a limited, but a defined role in addressing
skeletal defects. However, the principles of managing an
acute open fracture with bone loss remain the same,
whatever the final choice of reconstruction. The initial
sequence of management is resuscitation, wound debride-
ment and skeletal stabilization. Appropriate soft tissue
cover must be obtained early and any infection be ade-
quately controlled. Only then can secondary osseous
reconstruction proceed. This process may take many
months, especially if complicated by infection. The limb
although having survived the initial trauma can become
stiff and functionless. Endoprosthetic replacement with
adequate soft tissue procedures can aim to provide a more
functional limb that is stable, pain free and has satisfactory
range of movements. All through the treatment plan, the
patient needs to be fully informed and involved in the
process. The treating surgeon and the patient must be able
to evaluate the progress, the treatment and change the
course of treatment when necessary.
Patients suffer from both physical and emotional con-
sequences following the severe extremity trauma. The goal
of limb salvage is to provide a satisfactory limb function at
the end of the arduous treatment journey. Endoprosthetic
replacements may have a limited role in managing selected
patients with mangled extremity and can lead to a good
functional outcome to these patients. We recommend that
this type of treatment be performed only by specialist
teams consisting of surgeons experienced with endopros-
thetic surgery, plastic surgeons, specialist microbiologists,
wound care nurses, physiotherapists and occupational
therapists.
References
1. Enneking WF, Dunham W, Gebhardt MC, Malawer M, Pritchard
DJ (1993) A system for the functional evaluation of
Fig. 5 Plain radiograph of the endoprosthetic replacement at 3 years
follow-up
148 Strat Traum Limb Recon (2009) 4:145–149
123
reconstructive procedures after surgical treatment of tumors of
the musculoskeletal system. Clin Orthop 286:241–246
2. Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A,
Bell RS (1996) Development of a measure of physical function
for patients with bone and soft tissue sarcoma. Qual Life Res
5(5):508–516
3. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX,
Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP,
Patterson BM, McCarthy ML, Cyril JK (2001) A prospective
evaluation of the clinical utility of the lower-extremity injury-
severity scores. J Bone Joint Surg [Am] 83-A:3–14
4. Helfet DL, Howey T, Sanders R, Johansen K (1990) Limb sal-
vage versus amputation: preliminary results of the mangled
extremity severity score. Clin Orthop Relat Res 256:80–86
5. Lerner A, Fodo L, Soudry M, Peled IJ, Herer D, Ullmann Y
(2004) Acute shortening: modular treatment modality for severe
combined bone and soft tissue loss of the extremities. J Trauma
57(3):603–608
6. Saleh M, Rees A (1995) Bifocal surgery for deformity and bone
loss after lower-limb fractures: comparison of bone-transport and
compression–distraction methods. J Bone Joint Surg [Br]
77-B:429–434
7. Mekhail A, Abraham E, Gruber B, Gonzalez M (2004) Bone
transport in the management of posttraumatic bone defects in the
lower extremity. J Trauma 56(2):368–378
8. Beaver RJ, Mahomed M, Backstein D, Davis A, Zukor DJ, Gross
AE (1992) Fresh osteochondral allografts for post-traumatic
defects in the knee: a survivorship analysis. J Bone Joint Surg
[Br] 74-B:105–110
9. Salai M, Horoszowski H, Pritsch M, Amit Y (1999) Primary
reconstruction of traumatic bony defects using allografts. Arch
Orthop Trauma Surg 119:435–439
10. Allende C, Allende BT (2004) Posttraumatic one-bone forearm
reconstruction: a report of seven cases. J Bone Joint Surg [Am]
86-A:364–369
11. Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ (2007)
Endoprosthetic replacement of the distal femur for bone tumours:
long-term results. J Bone Joint Surg [Br] 89(4):521–526
12. Freedman EL, Eckardt JJ (1997) A modular endoprosthetic
system for tumor and non-tumor reconstruction: preliminary
experience. Orthopedics 20(1):27–36
13. Grimer RJ, Carter SR, Tillman RM, Sneath RS, Walker PS,
Unwin PS, Shewell PC (1999) Endoprosthetic replacement of the
proximal tibia. J Bone Joint Surg [Br] 81(3):488–494
14. Unwin PS, Cobb JP, Walker PS (1993) Distal femoral arthro-
plasty using custom-made prostheses: the first 218 cases.
J Arthroplasty 8(3):259–268
15. Bradish CF, Kemp HB, Scales JT, Wilson JN (1987) Distal femoral
replacement by custom-made prostheses: clinical follow-up and
survivorship analysis. J Bone Joint Surg [Br] 69(2):276–284
Strat Traum Limb Recon (2009) 4:145–149 149
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Functional salvage of a mangled lower limb using custom-made endoprosthetic replacement

Riazuddin Mohammed

Khalid Baloch

Francis Peart

Adesegun Abudu

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A system for the functional evaluation of

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Functional salvage of a mangled lower limb using custom-made endoprosthetic replacement

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