Your peri-operative experience with limb reconstruction
The necessity for limb lengthening, for correction of congenital and acquired deformities of the upper and lower limbs or for reconstruction of a post-traumatic limb defect may bring you to this page.
May this information and perspective empower you to be an active participant in your recovery process and may it reduce the discomfort and anxiety associated with the unexpected.
Orthopaedic Trauma Care
Management of the mangled extremity is one of the most challenging tasks in orthopaedic trauma care. Deciding if an amputation or reconstruction is best for an individual patient is most of the time a difficult and complex decision. Many factors including patient and injury variables must be considered in the assessment of a treatment strategy aimed at the best possible outcome. The instinctive desire on both the patient and physician’s part to save a limb at all costs must be tempered by the expected long-term functional result. Once the patient has been stabilized in the emergency setting and concomitant life-threatening injuries managed, attention can be directed to the injured limb.
Your orthopaedic surgeon plays a central role in the diagnosis and individualised treatment and rehabilitation plan for your specific injury. Hereafter he involves a multidisciplinary team to put this plan into action. Besides the orthopaedic surgeon, the team consists of an anesthesiologist, physician or intensivist, physiotherapist, nurses and occupational health worker. Each highly skilled member is dedicated to implementing their specific part for a successful outcome.
Be assured that each member of this team has your best interest at heart and is committed to providing you with the highest quality of healthcare. We wish you a safe and comfortable perioperative experience and are dedicated to walking the path towards your recovery with you.
Before you go to theatre the anaesthesiologist will do a preoperative examination and risk analysis with or without consultation of the attending physician. Apart from managing a patient’s pre-existing medical conditions during anaesthesia and the basic necessity of safety during the operation, the injury itself and the specific surgical procedure provide unique challenges for the anaesthesiologist. Certain special investigations and treatments may be necessary preoperatively to prepare the patient for his/her anaesthetic. Your anaesthesiologist will then discuss the intra-operative anaesthetic plan as well as the postoperative pain-control protocol that will be best suitable for your situation. Your anaesthetic will most of the time be a general anaesthetic coupled with some type of local anaesthetic technique (local infiltration, peripheral block, spinal or epidural). This multimodal pain strategy provides a more comfortable patient and staff experience, reduces the general anaesthetic requirements of the patient, improves his/her anaesthetic stability and generally improves patient morbidity and mortality. Multimodal techniques reduce the dose of each individual drug which, in turn, reduces the potential for adverse drug effects. Intervening before the pain system becomes sensitised is an absolute necessity when your goal is to attenuate the pain associated with the surgery and to give optimal patient benefit.
While most patients experience some level of anxiety about their injured limb, it is sometimes the prospect of an anaesthetic with it’s accompanying fears about awareness, not waking up, excruciating postoperative pain and extreme vomiting that overshadows all else. Please feel free to discuss any concern that you may have with your anaesthesiologist.
Unfortunately, every drug has the potential to cause side-effects and depending on the patient’s genetic make-up, age, pre-existing conditions and chronic medication, each patient displays an individualised susceptibility towards the multiple potential adverse effects. The most common dichotomy seen is the excellent pain relief versus the sometimes overwhelming side-effect of nausea and vomiting caused by the opiates. Side-effects may be the first sign of a need to discontinue the mode of treatment, change the dosage or switch to a different drug. Fortunately, there are superb drug options on the market today that can manage most of these side-effects.
For the extensive surgical interventions, we prefer to send the patient to a high care facility postoperatively with a Patient Controlled Pain Pump (PCA). These devices are connected to your IV line and deliver a pre-programmed dosage of analgesic (calculated on your body weight) whenever you press the pain button. If solely handled by the patient this modality is extremely efficient and safe with a built-in lockout time to prevent overdose. This intense acute-pain-control-method is usually only necessary for the first postoperative day where after the pain protocol is continued in the ward with a combination of injections, infusions and pills until discharge.
In special situations, a need for chronic pain management arises for instance for phantom limb pain after limb amputation where the classic analgesics are combined with antidepressants, anticonvulsants and/or neuroleptics.
Another special concern with limb reconstruction surgery apart from pain control is the prevention of deep venous thrombosis. This is a potential problem because multiple surgeries and limited mobilization predispose certain high-risk patients to thrombosis. These patients will be identified preoperatively and pharmacological and mechanical preventative measures will be implemented.
In the treatment of severely injured limbs, the use of flaps may be necessary to close open parts of the wound. Flaps are simply layers of tissue with an intact pre-existing blood supply that are moved to cover an adjacent wound. In this instance, a Plastic Surgeon joins the team and performs the surgery in collaboration with your Orthopaedic Surgeon. There are special anaesthetic considerations with flap surgery and more invasive monitoring methods like a central venous line and an arterial line is usually indicated.