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Farrelly E, Tarapore R, Lindsey S, Wieland MD. Management of the Mangled Extremity. Surg Clin North Am 2024; 104:385-404. [PMID: 38453309 DOI: 10.1016/j.suc.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.
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Affiliation(s)
- Erin Farrelly
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA.
| | - Rae Tarapore
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Sierra Lindsey
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Mark D Wieland
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
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Ataya J, Daaboul R, Alhomsi H, Issa H, Elewee A. Lower limb preservation in pediatric trauma: a case study of Gustilo grade IIIC fracture in a 7-year-old. J Surg Case Rep 2024; 2024:rjae016. [PMID: 38283407 PMCID: PMC10810729 DOI: 10.1093/jscr/rjae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/10/2024] [Indexed: 01/30/2024] Open
Abstract
This case report describes the intricate aspects of managing pediatric lower limb trauma. A 7-year-old patient had a severe compound fracture and significant soft tissue damage in the left lower limb, classified as Gustilo Grade IIIC. This necessitated the use of scoring systems such as the Mangled Extremity Severity Score and limb salvage index to assess the likelihood of limb preservation. Despite these high amputation risk indicators, a multidisciplinary approach has led to limb salvage surgery with internal fixation. Detailed postoperative monitoring revealed progressive recovery culminating in restored sensation, bone healing, and functional recovery. The discussion emphasizes the difficulties in deciding between limb salvage and amputation, stressing the importance of tailored care and cautious scoring system interpretation in pediatric cases. This conclusion advocates the prioritization of limb salvage in children owing to their unique healing capabilities while highlighting the need for further research to refine treatment protocols for pediatric lower limb trauma.
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Affiliation(s)
- Jamal Ataya
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Rawan Daaboul
- Faculty of Medicine, AlBaath University, Homs, Syria
| | - Hassan Alhomsi
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Hassan Issa
- Department of Orthopedic Surgery, Damascus Hospital, Damascus, Syria
| | - Ahmad Elewee
- Department of Orthopedic Surgery, Damascus Hospital, Damascus, Syria
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Prasad M, Kaul R, Thakur K, Gupta TD, Shakya AR. Efficacious Enactment of Ilizarov for Mangled Forearm: A Case Report on Our Resolution for the Revitalization of a "Nearly Lost Limb". J Orthop Case Rep 2023; 13:122-126. [PMID: 37753134 PMCID: PMC10519319 DOI: 10.13107/jocr.2023.v13.i09.3900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/18/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction Mangled is the evocative term for a grievance caused by crushing, resulting in a limb confiscation. Motor vehicle crashes and industrial/farm accidents are the leading causes of such occurrences. The verdict to reconstruct or to amputate still commonly lies with the surgical skills and experience of the treating surgeon. Case Report We present a case of 33-year-old male military personnel involved in a road traffic accident who presented to our center with a mangled forearm with segmental fracture radius and fracture shaft of ulna with vascular injury. He was immediately taken up for early debridement, intramedullary fixation, vascular repair, and temporizing skin graft. After definitive soft-tissue flap coverage and a period of convalescence, the patient underwent Ilizarov external fixator application with successful rehabilitation. The patient achieved pain-free limb with functional range of motions of both elbow and wrist with functional capabilities of basic needs and activities of daily living. Conclusion The combination of osseous, vascular, soft-tissue, and nerve injury after severe trauma to an extremity is a great challenge in the mangled extremity. However, in young patients without significant systemic involvement and borderline injury scores, limb salvage should be attempted.
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Affiliation(s)
- Manish Prasad
- Department of Orthopaedic, Indian Field Hospital Level II plus, Juba, UNMISS, South Sudan
| | - Rajiv Kaul
- Department of Orthopaedics, Military Hospital, Dehradun, Uttarakhand, India
| | - Kamparsh Thakur
- Department of Orthopaedics, 166 Military Hospital, Jammu, Jammu and Kashmir, India
| | - Tirthankar Das Gupta
- Department of Orthopaedics, Base Hospital Delhi Cantt and Army College of Medical Sciences, Delhi, India
| | - Amir Ratna Shakya
- Department of Orthopaedics, Shree Birendra Hospital, Chhauni, P76R+GG6, Kathmandu, Nepal
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Noh M, Kyoung KH, Kim S, Keum MA, Choi S, Choi K, Kim J. Uncommon Mechanism of Mangled Extremity; Three Cases of Rope Entanglement Injury of the Lower Leg. JOURNAL OF ACUTE CARE SURGERY 2023. [DOI: 10.17479/jacs.2023.13.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023] Open
Abstract
Rope entanglement injury is a rare entity. Previous reported studies mainly consisted of finger-related injuries. We describe three cases of rope entanglement injury of the lower leg. In the first patient, a belowthe- knee amputation was performed as the primary treatment for unilateral amputated lower limb. In the second patient, a below-the-knee amputation and perineal wound management were simultaneously performed. The third patient had vascular injury combined with internal soft tissue injury without related bone fracture. He suffered serious sequelae from a delay in transfer from a local hospital. Rope entanglement injuries of the lower leg do not present in a consistent manner, and the treatment of accompanying injuries should be considered from an early stage. Care should be taken to ensure that there are no internal injuries missed because the exterior appears to be stable.
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Muacevic A, Adler JR. Limb Salvage vs. Amputation: Factors Influencing the Decision-Making Process and Outcomes for Mangled Extremity Injuries. Cureus 2022; 14:e30817. [PMID: 36451632 PMCID: PMC9702595 DOI: 10.7759/cureus.30817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 01/25/2023] Open
Abstract
In the setting of acute severe limb injury, the clinical decision to either attempt limb salvage or to perform a primary amputation presents a significant challenge to the trauma team. The initial step in the management of a mangled limb is invariably resuscitation and stabilisation of the patient and an evaluation of the limb. However, the decision-making process on whether to amputate vs attempt limb salvage is dependent on a range of complex factors. This includes assessing the degree of injury to the components of the limb architecture, essential skeletal stability, soft tissues, vasculature, and neurological structures. Whether or not the patient would survive an attempt to limb salvage is of course not the only variable to be taken into account. The likely and expected outcomes of attempted salvage in each individual case must be considered and furthermore, what the acceptable side-effect profile including the risk of failure would be for each individual patient should be assessed against the importance, real or perceived, that limb function is maintained. Finally, the patient's choice should also be taken into account alongside their occupation and pre-morbid functional status. How the surgeon makes this life-changing, or life-threatening decision, is of great clinical significance, and there are myriad scoring systems published that purport to assist in this matter. However, the changing structures of the trauma system, expansion and advancement of skillsets and technology means an updated review is required to help weigh up the challenging decision of limb amputation vs salvage, which usually takes place in a time-pressured and highly emotional emergency setting. An evidence-based, standardised structure to assist in these calculations could support surgeons and improve outcomes for these patients.
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Dabestani PJ, Ramsey MD, Chappell AG, Fracol ME, Stover MD, Ko JH. Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00001. [PMID: 36240298 DOI: 10.2106/jbjs.cc.22.00286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/10/2022] [Indexed: 02/24/2023]
Abstract
CASE A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.
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Affiliation(s)
- Parinaz J Dabestani
- Division of Plastic and Reconstructive Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Matthew D Ramsey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ava G Chappell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Megan E Fracol
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael D Stover
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Okereke I, Abdelfatah E. Limb Salvage Versus Amputation for the Mangled Extremity: Factors Affecting Decision-Making and Outcomes. Cureus 2022; 14:e28153. [PMID: 36148195 PMCID: PMC9482680 DOI: 10.7759/cureus.28153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Complex limb injuries are severe injuries of the extremities that affect most or all components of the limb. Industrial/farm accidents and motor vehicle crashes are the mechanisms of injury for a large proportion of these presentations in the civilian population. While recent advances in surgery have led to more patients with complex limb injuries (that would have qualified for a primary amputation a few decades ago) undergoing limb-reconstruction surgeries, the existing evidence is inconclusive on the merits of limb salvage over amputation. Limb salvage surgery still carries considerable morbidity and mortality risks and requires careful consideration of several factors by the managing surgeons.
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Bui G, Buckwalter J, Wilken J, Davison J, Palmer J, Shurr D, Davidson N, Gracia-Fleury I, Willey M. Comparison of Early versus Late Below Knee Amputation After Trauma With Standardized Prosthetic Care. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:89-96. [PMID: 35821918 PMCID: PMC9210393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND High energy, lower extremity trauma is associated with longstanding pain and functional limitations. The clinical decision to proceed with early amputation or limb salvage is often controversial. This study was designed to compare differences in complications, costs, and clinical outcomes of below knee amputation (BKA) performed early after injury or after attempted limb salvage in a hospital with standardized prosthetic care following amputation. METHODS This is a retrospective comparative study of subjects who underwent BKA for a traumatic injury at a single level 1 trauma center and received standardized prosthetic care from a single manufacturer from 1999-2016 with minimum 2-year post-amputation follow up. Outcomes collected included demographics, surgical management, unplanned re-operations, and hospital and prosthetic cost data 2 years from time of injury. RESULTS Overall, 79 subjects met criteria. Early amputation (EA) was defined by median duration between injury and amputation (6 weeks) with 41 subjects in the EA group and 38 subjects in the late amputation (LA) group. Subjects in the EA group were more likely to have open fractures, high energy mechanism, and less likely to have medical comorbidities. Post-amputation infection was common in both groups (17/41 (42%) vs 17/38 (45%), p=0.77). Subjects undergoing EA were more likely to require unplanned post-amputation revision, 22/41 (54%) versus 10/38 (27%), p=0.017. Hospital costs and prosthetics/orthotics costs from the time of injury to two years following amputation were comparable, with mean hospital EA costs $136,044 versus LA costs $125,065, p=0.38. Mean prosthetics/orthotics costs of EA subjects were $33,252 versus LA costs $37,684, p=0.59. CONCLUSION Unplanned post-amputation revision surgeries were more common when BKA was performed early after trauma. Otherwise, outcomes and cost were comparable when amputation was performed early versus late. Level of Evidence: IV.
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Affiliation(s)
- Gabrielle Bui
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Joseph Buckwalter
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jason Wilken
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - John Davison
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jeffrey Palmer
- American Prosthetics and Orthotics, Muscatine, Iowa. USA
| | - Don Shurr
- American Prosthetics and Orthotics, Muscatine, Iowa. USA
| | - Nathan Davidson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ignacio Gracia-Fleury
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Michael Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Fujimura R, Adachi K, Shitozawa H, Kiyono M, Fujii Y, Shiozaki Y, Sato R. Ten-year outcome of unilateral leg replantation after bilateral lower leg amputation following traumatic injury: A case report. Trauma Case Rep 2022; 38:100631. [PMID: 35265746 PMCID: PMC8898973 DOI: 10.1016/j.tcr.2022.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 12/03/2022] Open
Abstract
The absolute indications for lower limb replantation are not unequivocally established; rather, this procedure is still challenging and controversial. We report a case of a young male who underwent bilateral leg amputation, followed by unilateral replantation. The patient demonstrated good 10-year outcomes. A 23-year-old man had both of his lower legs crushed by heavy machinery that fell from the back of a truck, leading to amputation of bilateral lower limbs. Although bilateral amputation was recommended due to severe contusion on both sides, the patient and his family strongly requested replantation of the right leg, and surgery was started approximately 3 h after the injury. In addition to the emergency replantation, six surgeries were performed thereafter. Five months after the first surgery, the patient was fitted with a left lower leg prosthesis and started gait training. He was discharged 8 months later. Ten years after the replantation, the patient is satisfied with his leg. He has a normal gait with a prosthesis and has integrated into society with no functional deficit. There are still no clear standards for replantation after leg amputation, and individual decisions must be made based on the severity of the injury and the patient's general condition. In this case, we respected the patient's strong will to preserve the right leg and decided on the treatment plan. As a result, the patient was highly satisfied, and the spared right leg facilitated the patient's physical and mental recovery. Lower limb replantation after amputation is challenging and controversial. We report unilateral replantation after bilateral amputation in a young male. Seven surgeries, including debridement and skin and nerve grafting, were required. The patient demonstrated good 10-year outcomes with no functional deficit. The spared right leg facilitated the patient's physical and mental recovery.
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Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
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Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
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Sharrock M. The mangled extremity: assessment, decision making and outcomes. Acta Orthop Belg 2021; 87:755-760. [PMID: 35172444 DOI: 10.52628/87.4.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management of the mangled extremity continues to pose a significant challenge for ortho- paedic trauma surgeons. This article provides a comprehensive, up-to-date literature review on the assessment of complex limb injuries, and the variables that affect decision-making and outcomes in both limb salvage and amputation. Initial assessment involves using a systematic approach, saving life before limb, with early involvement of the relevant surgical specialities and multidisciplinary team. The decision to attempt limb salvage or perform amputation can be extremely difficult. Scoring systems can be used as a guide but should not be wholly relied upon; instead more emphasis should be placed on the surgeon's experience, extent of soft tissue damage, and patient factors and wishes. Outcomes following amputation versus limb salvage are comparable, with some studies suggesting amputation may be favourable. It is important to advise patients and families on what treatment is in their best interest so they can make an informed decision, and this must utilise a multidisciplinary approach.
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Bumbaširević M, Matić S, Palibrk T, Glišović Jovanović I, Mitković M, Lesić A. Mangled extremity- Modern concepts in treatment. Injury 2021; 52:3555-3560. [PMID: 33766434 DOI: 10.1016/j.injury.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.
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Affiliation(s)
- M Bumbaširević
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia; Serbian Academy of Sciences and Arts, Belgrade
| | - S Matić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | - T Palibrk
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | | | - M Mitković
- Clinic for orthopedic surgery and traumatology, Clinical Centre Nis
| | - A Lesić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Tillmann BW, Guttman MP, Nathens AB, de Mestral C, Kayssi A, Haas B. The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database. J Trauma Acute Care Surg 2021; 91:447-456. [PMID: 34039934 DOI: 10.1097/ta.0000000000003302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While limb salvage does not result in improved functional outcomes among patients with a mangled lower extremity, the impact of attempted limb salvage on mortality and complications is poorly understood. The objective of this study was to evaluate the relationship between attempted limb salvage and in-hospital outcomes among patients with a mangled lower extremity. METHODS We performed a retrospective cohort study of adults, 16 years or older, with a mangled lower extremity. Data were derived from the American College of Surgeons' Trauma Quality Improvement Program (2012-2017). We compared mortality, complications (severe sepsis, acute kidney injury [AKI], decubitus ulcers) and length of stay between patients managed with the intention of limb salvage (amputation beyond 24 hours or no amputation) and those who underwent early amputation (within 24 hours of presentation). Instrumental variable analysis was used to evaluate the relationship between management strategy and outcomes. RESULTS We identified 5,527 patients with a mangled lower extremity, of which 901 (16.3%) underwent early amputation. Among those managed with attempted limb salvage, 42.5% underwent amputation prior to discharge. After adjusting for patient and hospital characteristics, there was no association between initial management strategy and mortality (odds ratio, 1.20; 95% confidence interval [CI], 0.83-1.74 early amputation vs. attempted limb salvage). Early amputation was associated with lower odds of AKI (OR, 0.59; 95% CI, 0.39-0.88) and a trend toward shorter length of stay (relative risk, 0.77; 95% CI, 0.52-1.14). CONCLUSION Over half of patients who sustain a mangled lower extremity undergo amputation during their initial hospital course. While a limb salvage strategy is associated with an elevated risk of AKI, there is no association between attempted limb preservation and mortality. These findings suggest that in patients in which there is no clear indication for early amputation, attempts at limb salvage do not come at the cost of increased mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Bourke W Tillmann
- From the Institute of Health Policy, Management, and Evaluation (B.W.T., M.P.G., A.B.N., B.H.), University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine (B.W.T., B.H.), University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine (B.W.T., B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery (M.P.G., A.B.N., C.dM., A.K., B.H.), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute (A.B.N., A.K., B.H.), Toronto, Ontario, Canada; Division of Vascular Surgery (C.dM.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; and Division of Vascular Surgery (A.K.), Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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Hoogervorst LA, Hart MJ, Simpson PM, Kimmel LA, Oppy A, Edwards ER, Gabbe BJ. Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7. Bone Joint J 2021; 103-B:769-774. [PMID: 33789468 DOI: 10.1302/0301-620x.103b4.bjj-2020-1647.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). METHODS Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. RESULTS In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. CONCLUSION A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769-774.
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Affiliation(s)
- Lotje A Hoogervorst
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Melissa J Hart
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Orthopaedic Surgery Department, Royal Melbourne Hospital, Melbourne, Australia
| | - Pamela M Simpson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lara A Kimmel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Physiotherapy Department, The Alfred, Melbourne, Australia
| | - Andrew Oppy
- Orthopaedic Surgery Department, Royal Melbourne Hospital, Melbourne, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Elton R Edwards
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Orthopaedic Surgery Department, The Alfred, Melbourne, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Health Data Research UK, Swansea University Medical School, Swansea, UK
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Clinical outcome of staged surgery after primary amputation for mangled extremity. Arch Orthop Trauma Surg 2021; 141:411-417. [PMID: 32506175 DOI: 10.1007/s00402-020-03497-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation. MATERIALS AND METHODS This study included 47 patients (38 men, 9 women; average age, 52.4 years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed. RESULTS No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1 year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation. CONCLUSION Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.
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SIGNIFICANCE OF THE STEPWISE SURGICAL APPROACH TO SEVERE HAND INJURY. WORLD OF MEDICINE AND BIOLOGY 2021. [DOI: 10.26724/2079-8334-2021-1-75-167-171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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19
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Saini UC, Hooda A, Aggarwal S, Dhillon MS. Patient profiles of below knee-amputation following road traffic accidents - An observational study from a level 1 trauma centre in India. J Clin Orthop Trauma 2021; 12:83-87. [PMID: 33716432 PMCID: PMC7920334 DOI: 10.1016/j.jcot.2020.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Primary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India. OBJECTIVE To evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center. METHODS An observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files. OBSERVATIONS 125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days. CONCLUSION We have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.
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Affiliation(s)
- Uttam Chand Saini
- Department of Orthopaedics, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Aman Hooda
- Department of Orthopaedics, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Sameer Aggarwal
- Department of Orthopaedics, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Mandeep Singh Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
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Inzidenz, präklinisches Management und Klassifikation schwerer Extremitätenverletzung. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-00635-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Carroll JJ, Henderson C, Watson J, Larsen K, Kobayashi K. Interposition Arthroplasty of the Elbow After Proximal Ulna Reconstruction With the Masquelet Technique: A Case Report. JBJS Case Connect 2020; 10:e0084. [PMID: 32649104 DOI: 10.2106/jbjs.cc.19.00084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Periarticular bone loss in the upper extremity poses challenges for a functional reconstruction. CASE A 32-year-old man sustained an open elbow fracture-dislocation from a high-velocity gunshot resulting in significant bone and soft-tissue loss about the proximal ulna. He underwent bony reconstruction with the Masquelet technique and delayed interposition arthroplasty in an attempt to preserve function. CONCLUSIONS The Masquelet technique, coupled with interposition arthroplasty, may be used to address significant articular bony defects about the proximal ulna, allowing patients to maintain function and limit pain.
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Affiliation(s)
- John J Carroll
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas
| | - Chance Henderson
- Department of Orthopaedic Surgery, United States Air Force Academy, Colorado Springs, Colorado
| | - Jeff Watson
- Colorado Springs Orthopaedic Group, Colorado Springs, Colorado
| | - Karl Larsen
- Colorado Center of Orthopaedic Excellence, Colorado Springs, Colorado
| | - Ky Kobayashi
- Colorado Center of Orthopaedic Excellence, Colorado Springs, Colorado
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22
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Management of Nerve Trauma in the Mangled Extremity. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00195-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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van Bekkum S, van der Avoort DJJC, Zuidam JM, Coert JH. Free muscle flap coverage as last resort for therapy-resistant neuropathic pain in the upper extremity: A long-term retrospective follow-up study. J Plast Reconstr Aesthet Surg 2020; 73:2171-2177. [PMID: 32601015 DOI: 10.1016/j.bjps.2020.05.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/27/2020] [Accepted: 05/15/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Persistent neuropathic pain severely impacts physical functioning and quality of life (QoL). However, optimal surgical management of persistent neuropathic pain remains unclear. Extensive neurolysis with subsequent free muscle flap coverage, a new surgical procedure for neuropathic pain in the upper extremity, can be performed as a final option to establish pain reduction. METHODS All consecutive patients who received extensive microsurgical neurolysis with subsequent free muscle flap for persistent neuropathic pain in the upper extremity between 2007 and 2014 were identified. Patient-reported upper extremity function and QoL were assessed using three questionnaires (36-item short-form health survey (SF-36), the disabilities of the arm, shoulder, and head questionnaire, and the Michigan hand outcomes questionnaire). RESULTS Fifteen patients were identified; 80% had neuropathic pain in the upper extremity due to nerve injury and a median of 3.0 previous surgeries (range 1-6). Sixty-seven percent developed some kind of complication, flap loss occurred in 22%, and all received a new free flap (one failed again). At last follow-up, pre- and postoperative visual analog scale (VAS) scores significantly differed (p = 0.002), and the median VAS at last follow-up was 1.5. Ten patients (67%) responded to the questionnaires after a median follow-up of 5.7 year (range 2.6-7.3 years). Patients on average reported poorer SF-36 "Physical Component Score" (PCS) and "Bodily Pain" compared to Dutch norms. Forty percent of patients reported still having always (very) severe pain. However, 64% had a postoperative decrease of at least 3.0 on VAS. CONCLUSION Extensive neurolysis with free muscle flap coverage for persistent neuropathic pain in the upper extremity showed a positive effect on pain reduction on short-term follow-up, and also at five-year follow-up. The impact of pain on functional outcomes remained. Nevertheless, 60% of the patients still experience sufficient pain reduction.
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Affiliation(s)
- Sara van Bekkum
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dirk-Jan J C van der Avoort
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Michiel Zuidam
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, UMCU, University Medical Center Utrecht, Utrecht, the Netherlands.
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Factors Associated with Primary and Secondary Amputation following Limb-Threatening Upper Extremity Trauma. Plast Reconstr Surg 2020; 145:987-999. [DOI: 10.1097/prs.0000000000006644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mangled Lower Extremity Is Associated With Pulmonary Embolism But Not Deep Venous Thrombosis: Results From the Trauma Quality Improvement Program Database. J Surg Res 2020; 248:7-13. [DOI: 10.1016/j.jss.2019.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 10/15/2019] [Accepted: 11/02/2019] [Indexed: 11/21/2022]
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26
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Hohenberger GM, Konstantiniuk P, Cambiaso-Daniel J, Matzi V, Schwarz AM, Lumenta DB, Cohnert TU. The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe. World J Surg 2019; 44:773-779. [DOI: 10.1007/s00268-019-05263-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Black CK, Ormiston LD, Fan KL, Kotha VS, Attinger C, Evans KK. Amputations versus Salvage: Reconciling the Differences. J Reconstr Microsurg 2019; 37:32-41. [PMID: 31499559 DOI: 10.1055/s-0039-1696733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. METHODS In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. RESULTS The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. CONCLUSION Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.
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Affiliation(s)
- Cara K Black
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Laurel D Ormiston
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Kenneth L Fan
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Vikas S Kotha
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Karen Kim Evans
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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Mahajan RK, Srinivasan K, Singh M, Jain A, Kapadia T, Tambotra A. Management of Post-Traumatic Composite Bone and Soft Tissue Defect of Leg. Indian J Plast Surg 2019; 52:45-54. [PMID: 31456612 PMCID: PMC6664845 DOI: 10.1055/s-0039-1688097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Management of composite defects of leg following trauma requires a planned ortho-plastic approach right from the outset. Timely, planned intervention results in reduced amputation rates and improved limb salvage and function. Right from the time of presentation of the patient to the emergency with such injury, the process of decision making in terms of salvage or amputation, local flap cover/free flap cover, bone reconstruction first or soft tissue or both combined, come into play. Guidelines on management are unclear for such defects, a literature search yielding various methods being used by different authors. This article is a review of current literature on management of composite leg defects. A summary of the literature search in terms of various management options given by various authors including the rationale, advantages and disadvantages of each strategy has been provided in this article. The management protocol and method followed by the author in his institute for management of such composite defects have been described in detail. The article seeks to provide readers with an understanding of the management strategies so that appropriate method could be chosen to provide best result.
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Affiliation(s)
- Ravi K Mahajan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
| | - Krishnan Srinivasan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
| | - Mahipal Singh
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
| | - Adish Jain
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
| | - Taha Kapadia
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
| | - Ankush Tambotra
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital and Clinics, Amritsar, Punjab, India
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Kim JY, Jung YJ, Keum MA, Kwon SK, Hong SK. Comparison of Quality of Life among Patients with Mangled Trauma. JOURNAL OF ACUTE CARE SURGERY 2019. [DOI: 10.17479/jacs.2019.9.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Joon-Young Kim
- Department of Surgery, Asan Medical Center, Asan Medical Center, Seoul, Korea
| | - Yooun Joong Jung
- Clinical Nurse Specialist, Critical Care Nursing Team, Asan Medical Center, Seoul, Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Su Kyung Kwon
- Division of Vascular and Transplant Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Trauma & Surgical Critical Care, Department of Surgery, Asan Medical Center, Seoul, Korea
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Kish AJ, Pensy RA. The Mangled Extremity: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Webster JB. Lower Limb Amputation Care Across the Active Duty Military and Veteran Populations. Phys Med Rehabil Clin N Am 2019; 30:89-109. [DOI: 10.1016/j.pmr.2018.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Guerado E, Bertrand ML, Cano JR, Cerván AM, Galán A. Damage control orthopaedics: State of the art. World J Orthop 2019; 10:1-13. [PMID: 30705836 PMCID: PMC6354106 DOI: 10.5312/wjo.v10.i1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Damage control orthopaedics (DCO) originally consisted of the provisional immobilisation of long bone - mainly femur - fractures in order to achieve the advantages of early treatment and to minimise the risk of complications, such as major pain, fat embolism, clotting, pathological inflammatory response, severe haemorrhage triggering the lethal triad, and the traumatic effects of major surgery on a patient who is already traumatised (the “second hit” effect). In recent years, new locations have been added to the DCO concept, such as injuries to the pelvis, spine and upper limbs. Nonetheless, this concept has not yet been validated in well-designed prospective studies, and much controversy remains. Indeed, some researchers believe the indiscriminate application of DCO might be harmful and produce substantial and unnecessary expense. In this respect, too, normalised parameters associated with the acid-base system have been proposed, under a concept termed early appropriate care, in the view that this would enable patients to receive major surgical procedures in an approach offering the advantages of early total care together with the apparent safety of DCO. This paper discusses the diagnosis and treatment of severely traumatised patients managed in accordance with DCO and highlights the possible drawbacks of this treatment principle.
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Affiliation(s)
- Enrique Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Maria Luisa Bertrand
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Juan Ramon Cano
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Ana María Cerván
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
| | - Adolfo Galán
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella 29603, Malaga, Spain
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Alassaf N, Alhoukail A, Alsahli A, Althubaiti G. Salvage of mangled upper extremity using the Masquelet technique in a child: A case report. SAGE Open Med Case Rep 2017; 5:2050313X17741011. [PMID: 29201370 PMCID: PMC5697582 DOI: 10.1177/2050313x17741011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 10/16/2017] [Indexed: 11/17/2022] Open
Abstract
Aim To report our experience with the Masquelet concept in a pediatric upper extremity following an open injury to the elbow. Methods A case report and literature review. Results An 11-year-old boy was transferred to our institution after a motor vehicle collision. There was a primary loss of the ulnohumeral articulation and the surrounding soft tissues as well as the ulnar nerve. Reconstruction used the Masquelet-induced membrane technique and a soft tissue flap. At the 30-month follow-up, the extremity was pain free and functional. Conclusion This case highlights the value of the Masquelet technique in pediatric extremity injuries, where there is a loss of a major articular segment, as well as significant soft tissue compromise.
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Affiliation(s)
- Nabil Alassaf
- Department of Surgical Specialties, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Amro Alhoukail
- Department of Surgical Specialties, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah Alsahli
- General Department of Medical Services, Ministry of Interior, Riyadh, Kingdom of Saudi Arabia
| | - Ghazi Althubaiti
- Department of Surgical Specialties, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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Shasti M, Jauregui JJ, Malik A, Slobogean G, Eglseder WA, Pensy RA. Magnitude of Soft-Tissue Defect as a Predictor of Free Flap Failures: Does Size Matter? J Orthop Trauma 2017; 31:e412-e417. [PMID: 29189524 DOI: 10.1097/bot.0000000000000958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the relationship between the magnitude of soft-tissue defect and the risk of free-flap and limb-salvage complications/failures. DESIGN Retrospective cohort. SETTING Level I Trauma Center. PATIENTS One hundred twelve patients with free tissue transfers between January 2009 and June 2015. INTERVENTION A standardized approach using a consistent team of 2 orthopaedic microvascular surgeons was used for each free-flap reconstruction. MAIN OUTCOME MEASURE Soft tissue defect size, total or partial flap failure, and unplanned reoperations. RESULTS Of 112 free-flap reconstructions, 57 complications occurred in 43-cases (38%) including 5 total flap failures (4.5%), 7 partial flap failures (6%), and 8 early (7%) and 38 delayed complications (33%). There was a significant correlation between the large defect size (≥200 cm) and partial/total flap failure (n = 80, P = 0.023). There was also a significant correlation between large soft tissue defect size and any complication that is, total or partial failure and early or delayed unplanned return to the operating room (n = 80, P = 0.002). Of the flaps used, multivariate analysis revealed that latissimus flaps had higher odds for failure. CONCLUSIONS Soft-tissue defect size ≥200 cm can be associated with a higher rate of total or partial flap failure and any complication in acute trauma setting, which may be due to a larger zone of injury, a higher level of difficulty in achieving complete debridement, and a more complex microvascular dissection. Current and future efforts will need to continue to focus on risk stratification for limb salvage efforts because an accurate assessment of risk is important to the patient, health care provider, and the health care system in general. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mark Shasti
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.,Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD
| | - Julio J Jauregui
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.,Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD
| | - Awais Malik
- University of Maryland School of Medicine, Baltimore, MD
| | - Gerard Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.,Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD
| | - Walter Andrew Eglseder
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.,Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD
| | - Raymond A Pensy
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.,Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD
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Abstract
BACKGROUND The Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to use the extent of skeletal and soft tissue injury, limb ischemia, shock, and age to predict the need for amputation after extremity injury. Subsequently, there have been mixed reviews as to the use of this score. We hypothesized that the MESS, when applied to a data set collected prospectively in modern times, would not correlate with the need for amputation. METHODS We applied the MESS to patient data collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment registry. This registry contains prospectively collected demographic, diagnostic, treatment, and outcome data. RESULTS Between 2013 and 2015, 230 patients with lower extremity arterial injuries were entered into the PROspective Vascular Injury Treatment registry. Most were male with a mean age of 34 years (range, 4-92 years) and a blunt mechanism of injury at a rate of 47.4%. A MESS of 8 or greater was associated with a longer stay in the hospital (median, 22.5 (15, 29) vs 12 (6, 21); p = 0.006) and intensive care unit (median, 6 (2, 13) vs 3 (1, 6); p = 0.03). Of the patients' limbs, 81.3% were ultimately salvaged (median MESS, 4 (3, 5)), and 18.7% required primary or secondary amputation (median MESS, 6 (4, 8); p < 0.001). However, after controlling for confounding variables including mechanism of injury, degree of arterial injury, injury severity score, arterial location, and concomitant injuries, the MESS between salvaged and amputated limbs was no longer significantly different. Importantly, a MESS of 8 predicted in-hospital amputation in only 43.2% of patients. CONCLUSION Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury. LEVEL OF EVIDENCE Prospective, prognostic study, level III.
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Hanley MG, Chi B, Bernstock JD, Caples CM, Kang DG, Potter BK, Gordon WT. Late Amputation Following Refracture After Removal of Multiplanar Circular External Fixator for Treatment of Severe Combat-Related Tibial Fracture: A Case Report. JBJS Case Connect 2016; 6:e32. [PMID: 29252666 DOI: 10.2106/jbjs.cc.15.00156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
CASE The multiplanar circular external fixator is commonly used in the treatment of severe combat-related tibial fractures. We present the case of a patient who sustained a refracture after removal of such a fixator. This complication contributed to failure of the limb salvage and ultimately resulted in the patient undergoing transtibial amputation. CONCLUSION The choice to pursue limb salvage or amputation must be a shared decision between the patient and provider. This discussion must now include the possibility of refracture if limb salvage is pursued using multiplanar circular external fixation. Further study is also required to define fracture stability after the removal of a multiplanar circular external fixator.
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Affiliation(s)
- Matthew G Hanley
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
| | - Benjamin Chi
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
| | - Joshua D Bernstock
- Stroke Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland.,Division of Stem Cell Neurobiology, Department of Clinical Neurosciences, Wellcome Trust-Medical Research Council Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
| | - Connor M Caples
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
| | - Daniel G Kang
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
| | - Benjamin K Potter
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
| | - Wade T Gordon
- Uniformed Services University and Walter Reed National Military Medical Center Department of Surgery, Bethesda, Maryland
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Jain S, Rajan S, Srivastava A. Severely comminuted radius fracture presenting as a signature patterned injury. Indian J Orthop 2016; 50:213-7. [PMID: 27053813 PMCID: PMC4800966 DOI: 10.4103/0019-5413.177585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dilemma still prevails, regarding the exact management of mangled extremity injuries between limb salvage versus amputation, each having there own set of complications. We here present a case of severely comminuted fractures of radius (bag of bones) along with the multiple criss-cross shaped lacerated wounds on the forearm and wrist presenting as a "signature pattern injury" caused by entrapment of the limb in the concrete mixer. MESS score of patient was 8, a score valid for amputation, but contrary, we successfully salvaged the patient's limb with use of radio-carpal distracter. Management of mangled injuries should be individualized, with due consideration to the mechanism and force of injury, associated injuries, and the patient profile.
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Affiliation(s)
- Saurabh Jain
- Department of Orthopaedics, Mahavir Hospital, Indore (M.P.), India,Address for correspondence: Dr. Saurabh Jain, A-2, Mahavir Hospital, Footi Khothi Square, Indore, Madhya Pradesh - 452 009, India. E-mail:
| | - Sunil Rajan
- Department of Orthopaedics, Synergy Hospital, Indore (M.P.), India
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Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord 2015; 16:372. [PMID: 26796522 PMCID: PMC4722671 DOI: 10.1186/s12891-015-0832-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/27/2015] [Indexed: 11/27/2022] Open
Abstract
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.
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Successful salvage of the upper limb after crush injury requiring nine operations: a case report. Int Surg 2015; 100:540-6. [PMID: 25785341 DOI: 10.9738/intsurg-d-14-00018.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Emergency treatment of amputation is one of the most frequently used therapeutic methods for patients with severe upper limb crush injury with a mangled extremity severity score (MESS) of more than 7. With the development of advanced surgical repair techniques and reconstructive technology, cases that once required amputation can now be salvaged with appropriate management, and some limb functions may also be reserved. A patient with a severe upper limb crush injury with a MESS score of 10 was treated in our hospital. The limb was salvaged after 9 surgeries over 10 months. The follow-up visits over the next 18 months post-injury showed that the shoulder joint functions were rated as "excellent" (90) according to the Neer score, the Harris hip evaluation (HHS) for elbow joint functions was "good" (80), and the patient was very satisfied with the overall therapeutic outcome. We conclude from the successful outcome of this extreme injury that salvage attempts should be the first management choice for upper limbs with complex injuries to save as much function as possible. Amputation should only be adopted when the injury is life-threatening or no more function can be saved. The level of evidence was V.
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Abstract
Patients with complex upper extremity injuries represent a unique subset of the trauma population. In addition to extensive soft tissue defects affecting the skin, bone, muscles and tendons, or the neurovasculature in various combinations, there is usually concomitant involvement of other body areas and organ systems with the potential for systemic compromise due to the underlying mechanism of injury and resultant sequelae. In turn, this has a direct impact on the definitive reconstructive plan. Accurate assessment and expedient treatment is thus necessary to achieve optimal surgical outcomes with the primary goal of limb salvage and functional restoration. Nonetheless, the characteristics of these injuries places such patients at an increased risk of complications ranging from limb ischemia, recalcitrant infections, failure of bony union, intractable pain, and most devastatingly, limb amputation. In this article, the authors present an algorithmic approach toward complex injuries of the upper extremity with due consideration for the various reconstructive modalities and timing of definitive wound closure for the best possible clinical outcomes.
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Affiliation(s)
- Zhi Yang Ng
- Department of Orthopaedic Surgery, Alexandra Hospital, Singapore
| | - Morad Askari
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Harvey Chim
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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