Transcription:
Updates in Complex Limb Reconstruction

Melanie: Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole and I invite you to listen as we discuss complex limb reconstruction. Joining me is Dr. Bennet Butler. He's an Assistant Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Butler, it's a pleasure to have you join us today. Tell us a little bit about complex limb reconstruction. When is it recommended over amputation?

Dr Bennet Butler: So complex reconstruction is kind of a varied term and when it's recommended over amputation depends on a lot of things. It depends on the injury. Depends on the patient. It depends on the surgeon. So for me, I'll embark on complex reconstructions if I have a patient who is willing to go down that road, because these things can take years and many, many surgeries. And then of course, if it's an injury that, can be salvaged in the first place, but it's hard to give exact, indications for it, because again, there's a lot of different factors that play in.

Melanie: Well as we're talking about that and the clinical indications for this, are there some situations you can describe where the limb would be salvageable?

Dr Bennet Butler: Yeah, certainly I think any limb that has blood supply is basically salvageable. And so with reconstruction, it's always a multi-disciplinary, situation between an orthopedic surgeon, a vascular surgeon, a plastic surgeon. And oftentimes other surgeons as well, but as long as we can get the blood flow reconnected, most limbs are ultimately salvageable with enough work.

Melanie: And as you mentioned in the first question, Dr. Butler, that you can't always pinpoint when it would be recommended. Can you tell us about patient selection for this type? You mentioned that it could be many procedures over many years. What's important to note when you're talking about patient selection criteria.

Dr Bennet Butler: I think, it's really a conversation between the patient and the surgeon. Both have to sort of decide that it's worth going down that road. I think, for me, the patients have to be motivated, and have to be willing to undergo all that work and willing to do the rehab that comes with it. And I think it's important that they also have a good understanding that, not only is it a long road, but it's a long road that often has setbacks. And so they have to mentally prepare themselves for that. And so I think it's important to me to see that they understand that, which again is a long conversation often. But as long as they have the appropriate mindset. That's really the most important thing to me. All the other physiologic and medical parameters aren't as important I think as the mental component of it. Just having a patient who understands what they're getting themselves into and is willing to make those sacrifices in order to keep their limb.

Melanie: What a great point, because I would imagine there's a lot of emotional and psychosocial work that goes involved. And before we talk about latest techniques and such, why don't you reiterate about the multidisciplinary approach that's necessary for these patients to have a successful outcome?

Dr Bennet Butler: So I think the first step, as I said, was getting blood flow to the limb. Without that there's really nothing you can do. And so it's important to have a good relationship with the vascular surgeons, which we do here at Northwestern, fortunately. And as long as the blood flow is reconnected, then usually the next steps are to get soft tissue coverage for the limb. And so for that, it's usually combined debridement’s with the plastic surgery service close at hand. And ultimately, they're the ones who often will have to place flaps or skin grafts in order to get the wounds closed. And then from there, it's really avoidance of infection and reconstruction of the bony defects. So in a lot of ways, even though I, as an orthopedic surgeon, am involved in the entire process, my part is often sort of the third phase or the phase that's after the vascular and plastic surgeons have done a lot of work.

Melanie: Do you have any preferred methods for limb reconstruction that you'd like other providers to know about? Speak about any techniques or technical considerations that you would like other providers to know?

Dr Bennet Butler: I think it’s very variable just depending on the injury. I think for me, the most challenging ones and the ones that I think make me think the most are cases where you have large losses of bone, especially in the long bones, like your femur or your tibia, or even your humerus, because that just won't heal without you figuring out a way to fill in that bone defect. And for me, the technique that I tend to go with the most is called a bone transport where you take bone that's healthy from a distance site, you osteomize it, and then you slowly move it into the bone defect at a rate of a millimeter a day. And over time that bone, that you're shuttling either downward or upward fills the gap. And because you're only moving in a millimeter a day, bone fills in behind it. And so you can take humongous bone defects, 15, 20 centimeters sometimes and fill them. But again, it takes a lot of patience, just a millimeter a day, but that is a big go-to for me, with some of the more complex limb reconstruction surgeries I do.

Melanie: So as we're discussing limb function restoration, tell us some of the effects of radiation and excision surgery after cancer treatment dr. Butler. What have you seen happen as a result?

Dr Bennet Butler: I think in cancer reconstruction, there's definitely a lot of complicating factors. I think radiation is a really big one. A lot of our options for reconstruction require pretty good, healing capacity for the patient. And radiation can really damage that. So, yeah, I think that those kinds of reconstructions, when you compare them to reconstructions in people who have been traumatized and are otherwise younger and healthier and haven't had radiation or chemo can be a lot more challenging and sometimes impossible.

Melanie: So then tell us a little bit about your success rate of limb reconstruction. Does Northwestern have a higher success rate than other hospitals? Tell us about your outcomes.

Dr Bennet Butler: It's hard again to pin down outcomes. Because what you define as success really depends on a lot of things. And I always go back to the patient. What do they define as success? Because sometimes the amputation is a success. If they have a prosthesis that they're able to use comfortably and allows them to function as they'd like to. And so in some ways, that's how I more define my success is at the end of the day, whether my patients are happy and satisfied with the function that we've been able to give them. And sometimes that is through limb reconstruction, but sometimes it's not. Like I said, sometimes it's through amputation. But either way I would put our success rate up against anyone's. So I think we have, again, it's a multi-disciplinary approach and we have incredibly talented surgeons, nurses, physical therapists, social workers, a whole team of people able to really, save limbs that I think at a lot of places could not be saved.

Melanie: As we wrap up Dr. Butler, what advice do you have for other orthopedic surgeons looking to improve their outcomes? Give us some of your thoughts on the future of limb reconstruction and any research that you're working on that would impact this future.

Dr Bennet Butler: So I think, the advice that I'd give other orthopedic surgeons is, again, I think it's important to keep hammering home this point that, first and foremost, it's about the patient because these are very varied injuries. And the people who sustain them are very different people. And so it's all about tailoring what you're doing and what your approach is, to the actual patient and not getting lost in their injury, but keeping in mind what they want, what they need and making sure that you're doing the best things for them from that end.

I think the future, there's a couple interesting directions and because it's multidisciplinary, I think there's a lot of different fields that are advancing at the same time with respect to limb reconstruction. I think I've been impressed, over the past few years by the improvements in I would say flap technologies, what the plastic surgeons are able to do. It's really amazing. The kind of defects that they can reconstruct. From an orthopedic perspective, I think while bone transport remains the gold standard for filling large defects, there's definitely room for improvement in that process because as I described, sometimes it can be an extremely long, extremely complex process. And so I think there's a lot of interest in terms of being able to potentially build cages in which we can fill a bone graft and keep it stable there and actually get it to heal, which could be an interesting new direction if it works.

But certainly those are things that I'm going to be looking at and taking my research in that direction hopefully. But yeah, I think there's a lot of interesting stuff on the horizon with it, and I should also note that, concurrently with improvements in limb reconstruction technology, there also have been dramatic improvements in prosthetic technology. So even while our reconstructive capabilities get better, I think we're also able to deliver really good outcomes for patients, even if their limb is not reconstructible or if they decide not to undergo reconstruction and go for an amputation. So I think both remain now and into the future, very viable options for our patients.

Melanie: Well thank you so much Dr. Butler for joining us today and sharing your expertise. What an interesting topic. Thank you again. And to refer your patient or for more information, please visit our website@nm.org /ortho to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.