Orthopedist to fracture patient in the ER: “Your tibia will just have to be a bit disfigured…oh, and there’s some dead bone in there, but it shouldn’t cause any problems. There may be a plastic surgeon available at another local hospital, but it’s just too complicated to try and find one.”
An orthopedist would surely never utter such words to a patient. But the reality “on the ground, ” say our experts, is that orthopedic patients whose limbs are in danger haven’t always had the full complement of care they need—including appropriate plastic surgery services. In some areas of the country, however, things are improving.
Dr. L. Scott Levin, Chairman of the Department of Orthopaedic Surgery at the University of Pennsylvania and Professor of Plastic Surgery, is both an orthopedist and a plastic surgeon. When Dr. Levin joined “Penn” in 2009 he brought with him a vision of a seamless, multidisciplinary center for limb salvage and reconstruction. Now, the plans for The Penn Extremity Reconstructive Center (PERC) are complete and the doors are set to open soon.
Dr. Levin states, “Traditionally, there have been stand-alone wound centers, trauma centers, and the occasional limb salvage center. In most cases they are run by a single service like hyperbaric medicine or vascular surgery. Our center will be jointly administered by the Department of Orthopaedic Surgery and the Division of Plastic Surgery.”
“What we are creating is a true multidisciplinary center built on the marriage of orthopedics and plastic surgery—“orthoplastic.” It has been my dream to create this type of entity within an academic institution so that we can offer patients immediate access to orthopedics, vascular care, pain management, hyperbaric care, infection control, oncology, and imaging. I am proud to say it is the first such entity in the Northeastern United States.”
PERC will focus on the treatment of acquired and congenital deformities of the upper and lower extremity, debilitating conditions that may result in loss of work, limb function, and chronic pain. Dr. Levin: “The sequelae of prior extremity injuries including nonunion and malunion also remains a formidable problem for many patients. These patients are best served in a multidisciplinary setting where they would benefit from staged reconstruction. Infections of the musculoskeletal system including osteomyelitis require aggressive treatment and ultimately many patients require bony and soft tissue reconstruction for optimal outcome.”
So how will they ensure that there is a certain specialist available when needed? Dr. Levin notes, “The upside is that patients won’t have to wait for hours, and can see multiple specialists at the same visit (or two visits if it is a particularly complex case). We will take care to have enough open ‘PERC’ slots in each of the specialists’ schedules. For example, a patient with chronic osteomyelitis who needs imaging, an arteriogram, an orthopedic surgery consult, and an infectious disease specialist, can see all these people in one day, and have a coordinated treatment plan developed along the way.”
When creating a symphony, however, there are sometimes discordant notes.
This effort requires mature individuals who know what they don’t know. An orthopedist has to be able to say, ‘I don’t know what antibiotics to give this person, ’ and then call in a specialist.
“Tamping down the ego is always necessary in order to do the best for one’s patient. In effect, these multidisciplinary centers should be run by people who are doing this type of work all the time. And like any team, as long as you don’t care who gets the credit then the work will get done.”
A Multidisciplinary Approach Saves the Day
With regard to the delicate issue of limb salvage versus amputation, says Dr. Levin, a multidisciplinary approach can save the day. “The joint decision may be that instead of salvaging the limb, we need to amputate because it has been functioning so poorly for so long.
While the consensus is fairly uniform, there are times when one physician says, ‘This limb can’t be saved’—but then they don’t know what I have in my toolbox as a plastic surgeon.
“We take care to continually educate our team as to what each person/department has to offer this type of patient.”
The most complex cases require a particularly methodical approach, says Dr. Levin. “In someone with polytrauma, a staged reconstruction is the most appropriate treatment. For example, a multiply injured patient comes in who requires vascular reconstruction to get blood flowing into his leg. This would be followed by a microvascular tissue transfer procedure that may or may not be done at the same time. So if the vascular repair is done well, then that sets the stage for the remainder of the efforts to save the limb.”
And how will this novel program be evaluated? “We will be performing outcome studies with some patients as historic controls (those who have not had a multidisciplinary approach). Then we will look at the incidence of amputation. We will use quality of life indicators and outcome research methodology to continually evaluate the success and failure of limb salvage and drill down on whether salvage or amputation improves quality of life under multiple conditions (oncologic reconstruction/acute trauma/chronic infection).”
Dr. Stephen Kovach, Co-Director of The Penn Extremity Reconstructive Center, is a plastic surgeon. He adds, “Our typical patient is a younger person with acute lower extremity trauma; we can offer these individuals exceptional orthopedic care, along with plastic surgery treatment for the soft tissue defect in a timely manner. We also see patients whose fractures have been treated elsewhere and have recalcitrant nonunions…in those cases we can offer these patients advanced microsurgical techniques for limb salvage. These techniques are also useful when it comes to salvaging limb length. Many of our patients with extremity injuries require the integrated care of multiple services to afford them the best care and chance of salvage of the function and appearance of the traumatized limb. The Center would offer them that chance. Overall, our hope is that in five years The Penn Extremity Reconstructive Center will be treating patients from all over the world.”
Dr. Randy Sherman, Vice Chair of the Department of Surgery at Cedars-Sinai Medical Center, is a plastic surgeon who is a past president of the American Society of Reconstructive Microsurgery. He states, “Cedars-Sinai is a level one trauma center in which the plastic surgery unit is integrated for early response, stabilization, and early reconstruction. When someone comes in we immediately perform a complete evaluation of the extremity, including imaging, neurological testing, and vascular imaging—all so that we can assess how best to stabilize someone and get him or her ambulating as quickly as possible. This process also helps us gain a realistic understanding as to whether the patient is capable of undergoing a reconstruction.”
“For example, take someone with a multiple segmental fracture whose knee and ankle are destroyed; this person also has neurological damage to the extremity. Together, these things mean that the patient may never actually be ambulatory again; in that case it is not in the best interest of the patient to put them through 12 months of complex reconstructive surgeries. If we select patients correctly then we can move them rapidly toward fixation and wound cover at the same time.”
“The unique thing that we bring to the table as a plastic surgery service is the ability to not have orthopedic reconstruction be comprised by a marginal or inadequate soft tissue envelope. If an orthopedic surgeon performs a sophisticated operation but the plates get infected then the result will be osteomylitis or a nonunion. But if a free tissue transfer was done as well then the patient may be able to go on to healing without infection, with an earlier discharge, and with earlier bone healing.”
“To achieve this streamlined approach, however, means that plastic surgeons must be dedicated to responding quickly to orthopedic surgeons.”
Convinced that plastic surgery is no longer just a pretty face, Dr. Sherman says, “My message to orthopedists is, ‘Recognize tissue deficiency early and don’t be afraid to involve a plastic surgeon from day one.’ If I’m delivering this message to an audience of orthopedists, this is the point when three-fourths of them say, ‘But I can’t find a plastic surgeon who will do this work.’ Things are changing, though, and I am pleased to see that plastic surgery is evolving towards a greater commitment to orthopedics. Previously, the economics of plastic surgery were such that there were enormous advantages to performing cosmetic surgery. Conversely, there were numerous disadvantages to performing reconstructive surgery, including poor reimbursement, sick patients, etc.”
Sometimes the drumbeat of progress takes awhile to hear. In this case, says Dr. Sherman, it’s been about 40 decades.
The need for plastic surgery expertise in orthopedics has appeared in the literature for many years. And the issue is not that my orthopedic colleagues don’t want to do the right thing; often, however, the logistics and the availability of plastic surgeons have gotten in the way.
And then there are just times when the orthopedist isn’t aware of what a plastic surgeon can offer. “The classic example—and the one that causes the most problems—is that of open tibial fractures, the most common type of fracture in the lower extremity. The problem with the lower leg is that the front side is thin skin over bone and the back is a lot of muscle. With a fracture, the bone protrudes and there is a significant amount of soft tissue damage. The orthopedist fixes the fracture, recloses the skin and puts plates in (which adds volume). You are also stripping the blood supply, and, because the skin is open, microbes have gotten in. The solution is to add soft tissue to that area using a muscle flap, a piece of muscle that has been rotated around from the back to the front or set free from abdomen and reapplied using a microvascular procedure.”
When saving a limb is at issue, time is of the essence. In such cases, an all-out approach with in-house expertise is the best we can offer patients.
