Amputees Adjust To Limb Loss

Truck driver John-Guy Foisy was headed to a delivery in Atlanta in September 2019 when another driver cut him off, forcing his truck to flip over. His left arm, dangling out the open driver’s side window, took the brunt of the impact. He was rushed to the local hospital with major arm, hand and wrist injuries.

“I lost my entire palm and all the nerves, blood vessels, arteries and anything that was connected to my palm was severed down to the bone,” said Foisy, who lives in Perkasie, Bucks County.

Emergency surgery at a Virginia hospital near the site of the accident stopped the bleeding and set his broken fingers, but his pinkie had to be amputated. That was the first of 14 surgeries Foisy would endure to create a new palm, increase the range of motion in his fingers and hand, and graft nerves to give him feeling.

After a month, his healing wasn’t progressing, so he was sent to Penn Musculoskeletal Center in University City. A team led by L. Scott Levin, chair of the department of orthopedic surgery and professor of surgery in the division of plastic surgery at Penn Medicine, took over.

Foisy, who is lefthanded, had no movement in his hand, fingers, or wrist. An avid guitarist, he was determined to regain the use of his limb.

“Guitar was my passion,” said Foisy, 30. “The doctors were straightforward with me that I’d be lucky to be able to write again and turn a doorknob. They told me the goal was to get my fingers to work enough to have some quality of life with my dominant hand.”

Levin used his experience in limb salvage, microvascular surgery and hand surgery to address the significant loss of skin, subcutaneous tissue, muscle and nerves in Foisy’s hand.

Advanced techniques in those specialties have allowed doctors to do more to salvage damaged limbs. Where amputation was once considered the only option, many more patients are regaining near full function after life-altering accidents or diseases.

Unlike skin grafting, which transfers a portion of the skin without its blood supply to a wound, Levin used flaps of living tissue from Foisy’s upper arm and moved them to reconnect the blood supply to his hand. While a skin graft may be successful for a more superficial injury where there is still blood flow in the area, flaps, which include their own blood supply, work best in more complex injuries, such as deeper wounds or joint injuries where there is limited or no blood flow.

“We have the ability to transfer tissue from one place in the body to another on its blood vessels,” Levin said.

Using an operating microscope and tiny sutures, surgeons hook up the vessels so the tissue can survive.

In Foisy’s case, “that resurfaced his palm, opened up his thumb index web space, and allowed us to do some reconstructive work on his nerve,” Levin said.

Foisy worked hard in physical therapy, three times a week over eight months through excruciating pain, to gain movement in his fingers, hand, and wrist. Throughout the whole process, he was reteaching himself how to play the guitar.

“He’s very talented at the guitar and none of that function would have been possible without microvascular and complex hand surgery,” Levin said.

The use of flaps has about a 98% success rate, Levin said, with the possibility of transferring multiple types of tissue, such as bone and skin together, or living muscles that can re-create limb function. For example, someone who tore their shoulder in an accident might lose function in their arm or hand.

“We have ways to restore nerves, muscles and even transplant muscles into the arm to give grasp or elbow flexion,” Levin said. “It’s called a functional muscle transfer.”

Advancements in microvascular and limb salvage surgery have allowed for hand transplants and even uterine transplants. So far, Penn Medicine has completed four bilateral hand transplants. For women who had been unable to conceive, a uterine transplant from another woman has led to the delivery of two healthy babies.

“We’ve gone from just being able to transfer tissue to being very sophisticated in terms of what we transfer, and even have gone as far now as to procure tissue from other humans, similar to a heart or lung or kidney,” Levin said.

For many patients such as Foisy, “not only are these patients given hope, they are given solutions that make them functional again,” said Levin.

Not every patient is a candidate for limb salvage. After being hit by a drunken driver five years ago, Lynael Keeler had severe pain in her right leg. She had a half-dozen surgeries to try to save her leg, but the agony continued. In March, Keeler, 43, opted for amputation below the knee and is finally pain-free.

“I couldn’t take the pain,” said Keeler, who lives in Berlin, Camden County. Before the surgery, she spent much of her time in bed. She couldn’t walk her dog around the block, drive, or garden. “I was more than ready for an amputation.”

Keeler then had targeted muscle reinnervation (TMR) surgery to reconnect the leg nerves into her muscle to decrease phantom limb pain, in which nerve endings at the site of the amputation continue to send pain signals to the brain.

Through physical therapy, Keeler is learning to adapt to her prosthetic.

“I finally see light at the end of the tunnel and I can’t wait to get back to just walking around the development,” she said. “They are telling me I’ll be able to shoot basketball hoops with my son Ethan. I can’t wait for that day.”

She has a tattoo on her arm that says “Just Keep Swimming,” a line from the Pixar movie Finding Nemo that has been the mantra for Keeler and Ethan, 11, since her accident. Keeler said she sees progress every day and is glad she made the decision to amputate.

“There are certain disease extents where, despite our sophisticated capabilities, they’re not applicable,” said Levin. “If the limb that we attempt to reconstruct will not function better than a prostheses, we advise amputation.”

For Foisy, life is getting closer to his old normal. “It’s been a long and painful process, but I did the work and the doctors said I made a miraculous recovery,” he said. “Nobody expected me to get to where I am now.”

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