The Penn Orthoplastic Limb Salvage Center (POLSC) is among a handful of programs in the nation combining the principles and practices of orthopaedic surgery and plastic surgery to encompass the preservation and practical restoration of the limbs, hands and feet.
Functional reconstruction, a unique area of specialization at the Center, is devoted to restoration of range of movement, weight-bearing capacity, sensation and strength in the limbs and lost to missing or damaged tissue/muscle and aberrant healing (scarring, nonunion, malunion) as a result of trauma, or cancer and its treatment.
“These are extremely complicated cases,” says Stephen J. Kovach III, MD, who with fellow co-directors L. Scott Levin, MD, Chair of Penn Orthopaedic Surgery, and Samir Mehta, MD, Chief of Orthopaedic Trauma, plans and performs limb reconstruction procedures at the Center.
“What’s unique about patients seeking functional reconstruction is that their injuries can’t be resolved by any single surgical specialty,” says Dr. Kovach. “Our advantage is having the expertise not only to address these issues in a single location, but often as one-stage procedures, which means faster recovery and better outcomes for our patients.”
Repairing the Damage Done
Whatever the cause, the goal of limb function therapy at the Penn Orthoplastic Limb Salvage Center is to restore the patient’s limb to optimal functional status. To achieve this objective, specialists at the center use sophisticated surgical techniques and innovations facilitated by the practical experience, research, advanced training and interdisciplinary collaboration available at Penn Medicine.
Microsurgery is a foundational modality of orthoplastic surgery. Writing in the year 2000, Dr. Levin, who was among the first to use the term orthoplastics to define the combination of both orthopaedic and plastic disciplines, observed that “microsurgery and creative thinking have now combined to address limb function and aesthetics.”[1]
“Our skills and teamwork set us apart,” says Dr. Levin. “On any given day, our surgeons are collaborating to perform complex microsurgical procedures, bone reconstruction surgeries and combined approaches unrivaled in the nation.”
Soft Tissue Injuries
Patients with soft tissue deficiencies lack adequate muscle, fascia and skin coverage to permit extension or control of the extremities or flexion of the hands and feet. For this population, the Center offers microvascular perforator flap surgery, free functional muscle transfers and microsurgical reconstruction of soft tissues of the affected limb. These procedures transfer healthy tissue, blood vessels and nerves from other areas of the body to the extremities to restore function, form and tensile strength to the limb.
“These are extremely complicated cases,” — Stephen J. Kovach III, MD
“Typically, microsurgery at the Center involves reconstruction with fasciocutaneous perforator flaps,” Dr. Kovach says. To maximize recovery, minimize the effects of procuring soft tissue, and better ensure flap survival, POLSC surgeons assess the patient prior to surgery to determine the best available donor site for the flap. The nature of the injury will determine the type and extent of microsurgical intervention; the volume and surface area of tissue deficiency will determine the type of flap to be selected. The microsurgeons at the Center have the ability to move not only soft tissue, but bone and functional muscle.
Nerve Damage
Nerve damage from cancer surgery or trauma manifests as chronic pain, loss of sensation and motor function in the limb.
By applying microsurgical techniques, orthoplastic microsurgeons at Penn can reconstruct nerves by connecting functioning nerves to the damaged nerve in the limb (neurorrhaphy), or by autogenous nerve transfer, wherein functioning nerves are transferred from other regions of the body to replace nonfunctioning nervous structures. Patients with extremity nerve damage caused by avulsion, laceration or contusion are candidates for these microsurgical nerve grafting and nerve transfer techniques to restore function and alleviate pain of the limbs.
When motor nerves are affected, the potential for irreversible atrophy in the limb exists if not restored within six to nine months of injury. For injuries exceeding six to nine months from onset, the center is able to use gracilis functional free muscle transfer (FFMT) in coordination with Penn Neurosurgery. Nerve reconstruction surgery is often used in reanimation surgeries.
Limb Function Restoration After Treatment for Cancer
Cancer treatment is a common precedent for limb function therapy at the Penn Orthoplastic Limb Salvage Center, particularly for patients experiencing the post-treatment effects of radiation and excision surgery for sarcoma and soft tissue tumors. Treatment of these tumors may involve radiation as well as resection of muscle, bone, nerves or soft tissue.
In the immediate aftermath of sarcoma excision, soft tissue coverage and bone reconstruction are essential to address the significant tissue loss that attends the surgery. Treatment of sarcomas and soft tissue tumors commonly need adjuvant radiation therapy for optimal treatment. Unfortunately, the effects of radiation can result in a number of persistent defects, including chronic contracture, a permanent scar-induced shortening of muscle and its surrounding tissue, and soft tissue compromise in the irradiated limb. Lingering wounds, moreover, are associated with pain in the extremity and potential soft tissue breakdown that can be addressed with microsurgical reconstruction.
Although restoration of limb function following preoperative radiotherapy and wide resection of sarcoma remains a challenge, POLSC surgeons have had excellent outcomes with microsurgical and pedicled flap reconstruction.
“Many times, radiation changes are lifelong,” says Dr. Kovach. “But once we remove the radiated soft tissue and replace it with a nonradiated, supple microvascular or pedicled soft-tissue flaps, patients can put these wounds behind them and go on with their lives.”
Referring to the Center for Limb Function Reconstruction
“Far too many of our patients arrive here in the delayed setting with a poorly functioning limb from surgery or trauma-related extremity injury that hasn’t healed correctly after previous provisional surgeries or inadequate stabilization,” says Dr. Kovach. “While we can do amazing things here, options can become limited as time goes on.”
The key to referring patients to the Penn Orthoplastic Limb Salvage Center for limb function therapy is timeliness. To refer a patient to the Center, call 215-615-6978. You will be connected with a Penn Orthoplastic Limb Salvage Center surgeon to discuss the case. For non-emergent patient referrals, please call Penn Orthoplastic Limb Salvage Center at 215-294-9625. A Penn service representative will coordinate your patient’s care.
Reference
- [1. Seminars in Surgical Oncology 2000; 19:272–281]