KANSAS CITY, Kan. — University of Kansas Hospital surgeons performed a unique procedure Tuesday on a 19-year-old man from southwest Missouri who had bone cancer in his left arm.
The 10-hour procedure involved amputating the cancerous limb and then saving as many nerves as possible to use with a prosthesis.
Surgeons said that, by saving the nerves and implanting them in his chest muscles, he should be able to use the prosthesis more easily and do more with it.
Only 35 of these procedures, called targeted muscle reinnervation, have been done worldwide since 2001 and the surgery at KU Hospital was the first to be performed on a cancer patient — not a trauma patient. It also was the first to be done on such a high level of amputation.
Todd Kuiken, director at the Neural Engineering Center for Artificial Limbs at the Rehabilitation Institute of Chicago, developed the procedure and witnessed the operation.
"This surgery will greatly enable what his options are for controlling an artificial arm," Kuiken said. "He's a young man who's going to have a lot of opportunities with the improvements in time."
Kim Templeton, the chief surgeon and an orthopedic oncologist, said her patient's surgery consisted mainly of two processes.
The first was amputating the man's arm, collar bone and shoulder blade — a procedure that Templeton said she does a few times a year for a variety of reasons.
For patients with bone cancer, doctors typically salvage the limbs by removing the cancer and reconstructing the limbs, Templeton said. But his bone broke just below the shoulder and the cancer cells spread. Without amputation, his survival rate would have been very poor, if not close to zero.
The patient had chemotherapy before the surgery and tests revealed the cancer had not spread outside the area that was amputated. He will undergo more chemotherapy after the surgery to make sure any cancer that might not have been detected doesn't appear. It's another measure to improve his survival.
"When we are dealing with cancer patients, the first thing obviously is to get rid of the cancer and to try to do our best to keep people alive," Templeton said. "After that you worry about function and what will they be able to do."
Most artificial limbs are controlled by remaining muscles — usually between two and four — near the amputation. To use the prosthesis, it requires effort and thought. To open a hand, for example, a person has to move a chest muscle.
During Tuesday's surgery, Templeton cut through the mass of nerves up in the armpit — called a brachial plexus — and separated them based on what part of the arm they would have gone to. Then, the nerves were implanted into the muscles in his chest. She was able to save six nerves.
She was assisted by Bruce Toby, chairman of the Department of Orthopedic Surgery at KU Hospital.
"What we are hoping for is that those nerves will trigger electrodes in the (artificial) arm to actually get the arm or hand movement that those nerves would have generated with his own arm," Templeton said.
She said that if the patient is thinking about opening his hand, it will automatically do that.
"It will be more intuitive," she said of the prosthetic arm. "The hope of this is that it will make his function faster. If research continues and we can get a prosthesis that has a functional shoulder — which is currently being worked on — then, eventually, this patient will qualify for that, too."
Typically, a person is fitted for a prosthesis in six to eight weeks after the swelling goes down, but this patient will have to wait about six months until the nerves mature in the muscle and become functional.
"So, perhaps, it could be a year before we know exactly what his function is going to be," Templeton said.
The patient and his family have been working with Matt Luetke, a certified prosthetist of Hanger Orthopedic Group,which has partnered with the University of Kansas Hospital.
Luetke said once the patient is healed and he is able to move the muscles, they will start the process of fitting the prosthesis, which cost about $80,000. He said each prosthesis is custom made by scanning the body with a laser and creating a 3D image with a computer. They will align each electrode with the appropriate muscles to make the limb function. He said having more nerves connected in the chest muscles will allow for more electrodes and ultimately, more functions.
The surgery should allow the patient to do things, like pick up a cup and put it down, two and half times faster.
Luetke said the process will require lots of therapy that will begin soon after the surgery. The patient will need to be thinking about opening and closing his hand and straightening his elbow.
"There is a tendency when you lose a limb to forget about it because you aren't using it," he said.
Luetke said he develops close relationships with the patients because he is there for each step of their journey — one that is not easy to endure.
"It's just an amazing testament to the human spirit," Luetke said. "In general, losing any limb — whether it's your leg or arm — if you talk to psychologists, you go through the same grief and the same mourning as losing a sibling. It's on the exact same level as losing a brother or a sister. So, this is not an easy thing to deal with."
Templeton described this patient as amazing.
"He and his family have excellent attitudes with this," she said. "Their primary goal, and I would say solo goal, is to cure his cancer and get him back home and have a normal lifespan.
"For him, the function is important, but he really doesn't want to talk about that much now. He just wants to get the cancer gone, finish his chemotherapy and survive all of this. That is really the perfect attitude to have for this."