A meta-analysis of amputation versus limb salvage in mangled lower limb injuries--the patient perspective

Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study

BACKGROUND

Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England.

METHODS

A retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications.

RESULTS

112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs.

CONCLUSION

Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.

Controversial case: Revascularization of a popliteal vascular injury of poor prognosis

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We need to revaluate and modify our current amputation prediction scores.

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More than 6 h of ischemia does not translate to a bad prognosis.

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There are multiple variables that affect the evolution of the patient.

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It is important to consider revascularization especially in all young patients without significant concomitant injuries and lack of comorbidities.

Introduction

Popliteal injuries are significant health risk that could induce permanent functional impairment, limb loss, and in some cases death. Currently, there is a controversy about the required treatment between amputation and a limb salvage surgery, which in some cases could cause more prominent functional impairment than the amputation. Different indicators help to predict, in some extent, the risk of amputation, however most of them were described two decades ago.

Presentation of case

A patient with a prolonged hot ischemia and in critical conditions, which had no favorable clinical indicators for revascularization is shown and discussed. By means of intraoperative analysis, it was decided to perform a revascularization for limb salvage, progressing with a positive outcome.

Discussion

Advancements in medical and vascular surgery, such as osteovascularized grafts, the use of flaps to cover large defects, the Ilizarov method for bone elongation and stabilization, the use of growth factors, negative pressure therapy, and the use of extracellular matrix, the improvements of intensive care units (ICU), among others, make necessary to revisit and reevaluate these indicators. The accuracy of these indicators has dropped significantly, and currently the medical evaluation cannot longer only depend on them.

Conclusion

Our results suggest the need to revisit and improve the predicting indicators scores for amputation prognosis that should include a preoperative and transoperative analysis.

Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study

INTRODUCTION

Severe lower-limb trauma is a major event in a patient's life, and treatment is a challenge that has not been sufficiently studied. The main objective of the present study was to assess the difference in disability between amputees and patients who kept their leg after severe open lower-limb fracture.

HYPOTHESIS

The study hypothesis was that amputation allows better functional recovery and quality of life, in the same time-frame.

MATERIALS AND METHODS

All male and female patients aged over 18 years admitted to one of the trauma centers of Marseille (France) for major lower-limb trauma with Gustilo IIIb or IIIc fracture were included. Minimum follow-up was 2 years. Two groups were distinguished according to primary treatment: lower-limb salvage, or amputation. Rates of infection and of surgical revision, hospital stay, functional parameters (walking distance, standing, use of canes, running, jumping, driving, and physical and occupational activity) and quality of life (MOS SF-36 score) were compared between groups.

RESULTS

The conservative treatment group comprised 27 patients, and the amputation group 24. Rates of infection and of surgical revision and hospital stay were significantly lower in the amputation group (P<0.02). All functional parameters (except return to work) and overall quality of life were significantly better in the amputation group. There was no significant inter-group difference in MOS mental score.

CONCLUSION

In severe lower-limb trauma, amputation seems to give better functional and quality-of-life results. It did not, however, improve return to work, and was not better accepted psychologically than long and complex conservative management.

LEVEL OF EVIDENCE

IV, retrospective study.

Multiple limb salvage attempts for diabetic foot infections

Aims

Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated.

Patients and Methods

A total of 41 patients who underwent BKA between July 2011 and June 2013 were reviewed. They were divided into primary and creeping (prior multiple salvage procedures) amputations. The Barthel’s Index (BI) and the Reintegration to Normal Living Index (RNLI) were used. A questionnaire was used to identify whether the patient would undergo the same multiple attempts at limb salvage again if faced with the same problem.

Results

All patients had a good mean BI of 14.2 (3 to 20) and RNLI of 73.2 (31 to 100). There was no difference in prosthesis usage, BI and RNLI between both groups. We found that 16 (94.1%) out of 17 patients with creeping amputation would undergo the same multiple salvage procedures if given a similar option. Conversely, only 15 (62.5%) patients with primary amputation would do the same again while the other nine (37.5%) patients choose to do everything possible to save their leg if faced with a similar situation (p = 0.001).

Conclusion

Most patients preferred to undergo multiple procedures to salvage the limb from diabetic foot infection even if it ultimately concluded with a BKA. All the patients had a moderately good functional outcome and ability to return to normal living after BKA. Cite this article: Bone Joint J 2017;99-B:1502–7.

Cost-Utility Analysis of Reconstruction Compared With Primary Amputation for Patients With Severe Lower Limb Trauma in Colombia

BACKGROUND

To establish, from the health system perspective, the cost-utility relationship of limb reconstruction compared with primary amputation for patients older than 32 years with grade IIIB and IIIC severe lower limb trauma in Colombia, S.A.

METHODS

A Markov model was built including different short-term and long-term states that represent the main events that a patient could experience after a lower limb amputation or a reconstruction. A 42-year time horizon was considered for the base case. Transition probabilities were obtained from a systematic review of the clinical literature. The health outcome selected was the quality-adjusted life years. Costs were determined by expert consensus using the standard case methodology, and valuation of resources was conducted with national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted.

RESULTS

In the base case, the reconstruction of the limb compared with primary amputation was a dominant strategy; that is, reconstruction provides more quality-adjusted life years at a lower cost. This result changed only when the time horizon was less than 6 years or when the probability of a secondary amputation was >65%.

CONCLUSIONS

Limb reconstruction is a dominant strategy compared with primary amputation, which is a conclusion that holds in most scenarios this study examined. Therefore, it should be considered in patients who, according to the clinical criteria and the severity and characteristics of their trauma, can benefit from this technique.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

The effectiveness of the bone bridge transtibial amputation technique: A systematic review of high-quality evidence

BACKGROUND

This literature review was undertaken to determine if commonly held views about the benefits of a bone bridge technique are supported by the literature.

METHODS

Four databases were searched for articles pertaining to surgical strategies specific to a bone bridge technique of the transtibial amputee. A total of 35 articles were identified as potential articles. Authors included methodology that was applied to separate topics. Following identification, articles were excluded if they were determined to be low quality evidence or not pertinent.

RESULTS

Nine articles were identified to be pertinent to one of the topics: Perioperative Care, Acute Care, Subjective Analysis and Function. Two articles sorted into multiple topics. Two articles were sorted into the Perioperative Care topic, 4 articles sorted into the Acute Care topic, 2 articles into the Subjective Analysis topic and 5 articles into the Function topic.

DISCUSSION

There are no high quality (level one or two) clinical trials reporting comparisons of the bone bridge technique to traditional methods. There is limited evidence supporting the clinical outcomes of the bone bridge technique. There is no agreement supporting or discouraging the perioperative and acute care aspects of the bone bridge technique. There is no evidence defining an interventional comparison of the bone bridge technique.

CONCLUSION

Current level III evidence supports a bone bridge technique as an equivalent option to the non-bone bridge transtibial amputation technique. Formal level I and II clinical trials will need to be considered in the future to guide clinical practice. Clinical relevance Clinical Practice Guidelines are evidence based. This systematic literature review identifies the highest quality evidence to date which reports a consensus of outcomes agreeing bone bridge is as safe and effective as alternatives. The clinical relevance is understanding bone bridge could additionally provide a mechanistic advantage for the transtibial amputee.

[Limb salvage or amputation after severe trauma to the lower extremities : Evidence from the LEAP Study]

Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military

BACKGROUND

Medical practitioners face difficult decisions over whether to amputate or to salvage a lower limb that has undergone trauma. To our knowledge, there has been little evidence reporting the impact of different surgical decisions on functional and mental health outcomes following intensive rehabilitation that might inform decision-making.

METHODS

This study is a retrospective, independent-group comparison of rehabilitation outcomes from a U.K. military complex trauma rehabilitation center. There were 100 procedures examined: 36 unilateral amputations (11 immediate-below-the-knee amputations, 15 delayed below-the-knee amputations, and 10 immediate above-the-knee amputations), 43 bilateral amputations, and 21 single-limb salvages (including 13 below-the-knee limb salvages); the patients had a mean age (and standard deviation) of 29 ± 6 years and a mean New Injury Severity Score of 34 ± 15 points. The outcome measures at completion of rehabilitation included a 6-minute walk test (6MWT), Defence Medical Rehabilitation Centre mobility and activities of daily living scores, screening for depression (Patient Health Questionnaire [PHQ-9]) and general anxiety disorder (General Anxiety Disorder 7-item scale [GAD-7]), mental health support, and pain scores.

RESULTS

On completion of their rehabilitation, the unilateral amputation group walked significantly farther in 6 minutes (564 ± 92 m) than the limb-salvage group (483 ± 108 m; p < 0.05) and the bilateral amputation group (409 ± 106 m; p < 0.001). The delayed below-the-knee amputation group (595 ± 89 m) walked significantly farther than the group with limb salvage below the knee (472 ± 110 m; p < 0.05), and there was no significant difference between the group with delayed below-the-knee amputation and the group with immediate below-the-knee amputation (598 ± 63 m; p > 0.05). The limb-salvage group was less capable of running independently compared with all amputee groups. No significant differences (p > 0.05) were reported in mean mental health outcomes between the below-the-knee injury groups, and depression and anxiety scores were comparable with population norms. At discharge, 97% of all patients were able to control their pain.

CONCLUSIONS

After completing a U.K. military interdisciplinary rehabilitation program, the unilateral amputation group demonstrated a significant functional advantage over the limb-salvage and bilateral amputation groups. We found that patients electing for delayed amputation below the knee after attempted limb salvage achieved superior functional gains in mobility compared with patients who underwent limb salvage below the knee and experienced no functional disadvantage compared with patients who underwent immediate amputation. The mental health outcomes were comparable with general population norms, optimizing the prospect of full integration back into society.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Fracture Care During War: Opportunities for Research

Reported infection rates following severe open fractures of the lower extremity sustained in combat have varied widely, from 23% to 85%. The infection rates have been either similar to or higher than those reported in the civilian trauma literature. Deployed surgeons have increased the frequency of fasciotomy procedures for limbs with or at risk for clinical compartment syndrome. The long-term sequelae of compartment syndrome and fasciotomies are not clearly defined. The definition of the term late amputation has varied in the literature, and studies have not consistently included information on the causes of the amputations. Preclinical and clinical translational studies on the reduction of the rates of infection and other limb morbidities are needed to address the acute care of combat extremity wounds.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury

OBJECTIVE

Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management.

METHOD

The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method.

RESULTS

Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives."

CONCLUSIONS

Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction

PURPOSE

The purpose of this study was to evaluate the functional and psychological outcomes of patients who underwent delayed lower limb amputation following failed limb salvage surgery.

METHODS

This retrospective, descriptive study evaluated functional outcomes using the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) in 12 patients. Inclusion criteria included patients who underwent limb reconstruction and delayed amputation between July 2006 and December 2014, with an age range between 18 and 80 years of age, the ability to ambulate independently, a time interval between the last salvage procedure and amputation greater than six months, and a minimum follow-up of 24 months. Patients were contacted via telephone by the principal investigator and both the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) were completed. Descriptive analysis (means and standard deviation) was used to determine outcomes for both SIP and SF-36 health profiles.

RESULTS

Ten patients who had amputations following failed reconstruction (2006-2014) with a mean age of 53±10years were interviewed. Six patients had a SIP <5, three patients scored between five and 10 points and one scored >10 points. The main deficit on the SF-36 was in the physical component. The SF-36 scores demonstrated a mean score of 40.8±11.5 for the physical component, and 57.4±7.9 for the mental component. Three patients returned to work after amputation and continued performing their pre-injury duties as farmers. Three other patients returned to work, but were allocated to administrative duties. Two patients were pensioners at the time of their injuries, and the only female patient was a housewife. One patient went into early retirement.

CONCLUSION

The results of this study strongly suggest that delayed amputation following failed limb salvage surgery can still result in good and satisfactory outcomes in the majority of patients and achieves results similar to early amputation and limb reconstruction techniques.

Outcome Assessments of Patients with Posttraumatic "Ultra-Time Vascular Injuries" of the Extremities

The management of posttraumatic vascular injury that presents after 8 h, or “ultra-time vascular injury”, is daunting, and inciting recognition of this injury is vital. We retrospectively analyzed 29 patients with ultra-time vascular injuries to determine the patients’ demographic characteristics and identify the determinants for amputation and disability. The age distribution of the high-risk population was from 18 years to 40 years, which indicated that these patients had plenty of productive life remaining. Injuries to the lower limbs (79.31%) were over four times more common than injuries to the upper limbs (17.24%), and open and blunt injuries occurred most commonly. The overall rate of limb salvage was 82.76% (24/29) and limb function is excellent in 45.83% (11/24) of the patients. The remaining patients experienced different degrees of disability in their limbs, which was determined by the anatomic location of the injury, and the presence of a combined arterial and venous injury, nerve injury, and complex soft tissue injury, as well as the occurrence of compartment syndrome. Hence, we recommend limb-salvage treatment for patients with traumatic ultra-time vascular injuries, particularly for those aged between 18 years and 40 years. Furthermore, we encourage the development of limb-salvage techniques for ultra-time vascular injuries.

Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system

Background

In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scores were developed to establish guidelines for the decision to amputate or not, however in literature there is no consensus about the reliability of this scores.

Methods

The authors focused their attention on the most used score system to provide guidance of the management of a mangled lower limb. The search term used included mangled lower extremity, MESS, PSI, LSI and NISSSA. The inclusion criteria were: studies dealing with mangled lower extremity; articles reporting MESS, PSI, LSI or NISSSA scores; articles published in English in PubMed, Cochrane, Scopus and web of science in the last 30 years, minimum number of cases in study of 15, minimum follow up of 1 year.

Results

According with the criteria described above, we found 134 articles in PubMed, 165 articles in Scopus, 111 articles in the Cochrane Library and 108 articles in Web of Science. The most used score in literature is the MESS. Few results are shown using the other severity scores. There are a lot of controversies in literature about the use of this scale. MESS seems to be more accurate than the LSI in prediction of limb salvage. LSI score shows better results when applied to type III tibial fractures. High sentivity of the PSI score is described when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score. The literature is very poor of articles related to mangled lower extremity in children. Higher sensitivity and specificity are described for these scores in children when compared to adult population.

Conclusion

The mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of succesful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.

Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients

INTRODUCTION

Following severe lower extremity trauma, patients who undergo limb reconstruction and amputations both endure frequent complications and mental health sequelae. The purpose of this study is to assess the extent to which late amputation following a period of limb salvage impacts the evolution of the clinical variables that can affect the patient's perception of his or her limb: ongoing limb associated complications and mental health conditions.

PATIENTS AND METHODS

A case series of US service members who sustained a late major extremity amputation from September 2001 through July 2011 were analysed. Pre- and post-amputation complications, mental health conditions, and reason(s) for desiring amputation were recorded.

RESULTS

Forty-four amputees with detailed demographic, injury and treatment data were identified. The most common reasons for desiring a late amputation were pain and being dissatisfied with the function of the salvage limb. An average of 3.2 (range 1-10) complications were reported per amputee prior to undergoing late amputation and an average of 1.8 (range 0-5) complications reported afterwards. The most common complication prior to and after late amputation was soft tissue infection (24 (17%) and 9 (22%), respectively). Twenty-nine (64%) late amputees were diagnosed with a mental health condition prior to undergoing their amputation and 27 (61%) late amputees were diagnosed with mental conditions after late amputation. Only three of the 15 patients who did not have a mental health condition documented prior to their late amputation remained free of a documented mental health condition after the amputation.

DISCUSSION

Ongoing complications and mental health conditions can affect how a patient perceives and copes with his or her limb following severe trauma. Patient dissatisfaction following limb reconstruction can influence the decision to undergo a late amputation. Patients with a severe, combat related lower extremity injury that are undergoing limb salvage may not have a reduction in their overall complication rate, a resolution of specific complications or an improvement of their mental health after undergoing late amputation.

CONCLUSION

Surgeons caring for limb salvage patients should counsel appropriately when managing expectations for a patient who desires a late amputation.

[Complex reconstruction with internal locking plate fixation for Charcot arthropathy]

BACKGROUND

Osteosynthesis and reposition of the Charcot foot is challenging with respect to choice of a proper implant. There is currently no international consensus regarding the optimal implant.

OBJECTIVES

Locking plates seem to be an innovative and stable method for reconstruction. The aim of this work is to analyze bone fusion, complications, pseudoarthrosis, and patient satisfaction.

METHODS

This paper presents a retrospective analysis of 63 consecutive Charcot feet treated between 2004 and 2014. The mean follow-up time was 2.4 years.

RESULTS

All Charcot feet treated between 2004 and 2014 were Sanders type II or III. A bony fusion was achieved in 50 % of the cases, 26 % had a functional pseudoarthrosis with intact implants and pain-free mobility, and 22 % showed no healing with broken implants. Conclusion Internal fixation with locking plates is superior to screw fixation only with regard to biomechanics. We prefer internal fixation plates to external fixation because of stability even in the case of pseudoathrosis and because of the learning curve.

Limb salvage after vascular reconstruction followed by tissue transfer during the Global War on Terror

BACKGROUND

Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror.

METHODS

Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared.

RESULTS

From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE (P = .69). Secondary patency rates were 100% in the UE and 86% in the LE (P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE (P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain.

CONCLUSIONS

Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm.

Initial injury severity and social factors determine ability to deploy after combat-related amputation

OBJECTIVE

While many recent publications have examined the ability of amputees to return to active duty, it remains largely unknown why few amputees deploy after amputation and many amputees do not. The purpose of this study is to examine what predictor(s) exist for whether or not an amputee will deploy after sustaining a combat-related amputation.

METHODS

All U.S. Service members who sustained major extremity amputations from September 2001 through July 2011 were analysed. Amputation level(s), mechanism of injury, time interval to amputation, age, rank, Physical Evaluation Board (PEB) disposition and ability to deploy after amputation were determined.

RESULTS

Deployment information after amputation was obtained for 953 amputees. There were 47 (5%) amputees who deployed. There were no significant differences amongst service branches for the deployment of amputees (p > 0.2). Amputees who underwent their amputation on the same day of their injury were significantly less likely to deploy after amputation than those who had their amputation on the day of injury (p = .01). Deployed amputees had significantly lower Injury Severity Scores than amputees who did not deploy (15.98 vs 20.87, p < 0.01) and officers were significantly (p < .01) more likely to deploy and the average age of amputees who deployed was significantly higher than those who did not (27.5 vs 25.1, p < .01). Lastly, those amputees who sustained a transtibial amputation were significantly more likely to deploy than all other amputation levels (p < .01). Nine out of 19 (47%) Special Forces amputees were able to deploy.

DISCUSSION

The vast majority of amputees do not able to deploy after undergoing amputation. The main predictors of deploying after sustaining a combat-related amputation appear to be: sustaining a transtibial amputation, being of senior rank or age and being a member of the Special Forces. Many of these factors appear to be non-treatment related and highlight the importance that individual and social factors play in the recovery of severe injuries.

Outcome of percutaneous osseointegrated prostheses for patients with unilateral transfemoral amputation at two-year follow-up

OBJECTIVE

To report outcomes regarding general and specific physical health-related quality of life of treatment with percutaneous osseointegrated prostheses.

DESIGN

Prospective 2-year case-control study.

SETTING

University hospital.

PARTICIPANTS

Individuals (N=39; mean age, 44 ± 12.4 y) with unilateral transfemoral amputation as a result of trauma (n=23), tumor (n=11), or other cause (n=5). At baseline, 33 of the 39 participants used socket-suspended prostheses.

INTERVENTION

Osseointegrated prosthesis.

MAIN OUTCOME MEASURES

Questionnaire for Persons with Transfemoral Amputation (Q-TFA), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning (PF) and physical component summary (PCS), SF-6D, and Physiological Cost Index (PCI).

RESULTS

At 2 years postimplantation, 6 of 7 Q-TFA scores improved (P<.0001) compared with baseline (prosthetic use, mobility, problem, global, capability, walking habits). The walking aid subscore did not improve (P=.327). Of the 39 participants, increased prosthesis use was reported by 26, same amount of use by 11, and less use by 2. Improvement was reported in 16 of the 30 separate problem items (P<.05). Unchanged items included problems regarding phantom limb pain and pain from the back, shoulders, and contralateral limb. The PF, PCS, and SF-6D improved a mean of 24.1 ± 21.4 (P<.0001), 8.5 ± 9.7 (P<.0001), and .039 ± .11 (P=.007) points, respectively. Walking energy cost decreased (mean PCI at baseline, .749; mean PCI at follow-up, .61; P<.0001).

CONCLUSIONS

Two years after intervention, patients with a unilateral TFA treated with an OPRA implant showed important improvements in prosthetic function and physical quality of life. However, walking aids used and the presence of phantom limb pain and pain in other extremities were unchanged. This information is valuable when considering whether percutaneous osseointegrated prostheses are a relevant treatment option.

Doctors' insights into the patient perspective: a qualitative study in the field of chronic pain

Purpose. To strengthen the conceptualization of the patient perspective by identifying aspects that, from doctors' point of view, are important to address during a consultation to build a partnership with patients. Method. Semistructured interviews were conducted with 17 doctors who are experts in the field of chronic pain in Italy. The recordings of the interviews were transcribed verbatim and interpreted using thematic analysis. Results. The participants agreed about the importance of doctors addressing aspects of the patient perspective that can lead to a difference of opinion with patients, namely, patients' views about their health condition (i.e., what they think they have and why and the perceived impact of the health condition on their life) and about treatments (i.e., what they have tried or have heard about and their expectations). Conclusions. Identifying patients' standpoints on their health condition and treatments offers an opportunity for critical discussion of differences of opinions and promotes communication exchange and agreement about the appropriate course of action.

Management of major limb injuries

Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.

A Prospective Study of the Outcome of Patients with Limb Trauma following the Haitian Earthquake in 2010 at One- and Two- Year (The SuTra2 Study)

Background Severe limb trauma is common in earthquake survivors. Overall medium term outcomes and patient-perceived outcomes are poorly documented. Methods and Findings The prospective study SuTra2 assessed the functional and socio-economic status of a cohort of patients undergoing surgery for limb injury resulting in amputation (A) or limb preservation (LP) one year and two years after the 2010 Haiti earthquake. 305 patients [A: n=199 (65%), LP: n=106 (35%)] were evaluated. Their characteristics were: 57% female; mean age 31 years; 74% of principal injuries involved the lower limb; 46% of patients had an additional severe injury; 60% had fractures, of which two-thirds were compound or associated with severe soft tissue damage; 15% of amputations were traumatic. At 2 years, 51% of patients were satisfied with the functional outcome (A: 52%, LP: 49%, ns). Comparison with the 1-year status indicates a worsening of the perceived functional status, significantly more pronounced in amputees, and an increase in pain complaints, mainly in amputees (62% and 80% of pain in overall population at 1- and 2-year respectively). Twenty eight percent (28%) of LP and 66% of A considered themselves as “cured”. 100% of LP and 79% of A would have chosen a conservative approach if an amputation was medically avoidable. Two years after the earthquake, 23·5 % of patients were still living in a tent, 30% were working, and 25·5% needed ongoing surgical management. Conclusions Only half the patients with severe limb injuries, whether managed with amputation or limb preservation, deemed their functional status satisfactory at 2 years. The patients’ perspective, clearly favors limb conservative management whenever possible. Prolonged care and rehabilitation are needed to optimize the outcome for earthquake survivors with limb injuries. Humanitarian respondents to catastrophes have professional and ethical obligations to provide optimal immediate care and ensure scrupulous attention to long-term management. Keywords Haiti earthquake, limb injury, two-year outcome, patients’ perspective, amputation, limb salvage

Management of the mangled extremity

The management of a mangled extremity continues to be a matter of debate. With modern advances in trauma resuscitation, microvascular tissue transfer, and fracture fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. Even if preserving a mangled limb is a technical possibility, the question is often raised whether the end result will also be functional and what treatment would lead to the best patient outcome. The road to salvage is often prolonged with significant morbidity, reoperations, financial costs, and even mortality in some instances. Numerous factors have been implicated in the outcome of these injuries, and a number of scoring systems have been designed in an attempt to help guide the treating surgeon in the acute phase. However, much controversy remains on the ability of these grading systems to predict successful salvage of the mangled extremity. In this review, we discuss the mechanisms of injury, various available scoring systems, initial management, outcome and specific differences between lower and upper extremity trauma injuries.