Revascularization, limb salvage and/or amputation in severe injuries of the lower limb

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.

Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation

The decision of either preserving a member or primary amputation (PA) in severe extremity trauma, especially in the presence of fractures, vascular injuries or serious injuries of soft tissues has always been a challenge for the trauma surgeon. The initial assessment with objective criteria like indexes, such as the Mangled Extremity Severity Score (MESS) or the PSI, can aid in the differentiation of members that can be saved or should be amputated primarily. We report on the design and preliminary results of our ongoing prospective study analyzing laboratory test as predictors of amputation in severe lower limb trauma.

Materials and methods

All patients treated in our emergency department with severe lower limb trauma and open fractures (classified as Gustilo III) were included in this study. We collected blood for laboratory test of all patients at admission. All injured limb were photographed for posterior analysis and MESS classification.

Results

From March 15, 2012, to June 10, 2012, n = 20 patients were included in our study. PA was performed in eight (40%) and preserving procedures (PP) in 12 (60%). Mean age was 30 in PP group and 40.5 in PA. Mean systolic pressure at the emergency room was 130 mm Hg in PP and 107 mm Hg in PA. MESS index was calculated for all patients and the means were 5 for the PP group and 8 for the PA group. Laboratory test of the two groups were compared and statistically analyzed. Acidosis, arterial lactate levels and hemoglobin levels at admission had a statistical difference between the two groups: pH = 7.36 PP vs 7.18 PA (p = 0.001); lactate: PP = 25 vs PA = 63 (p < 0.001); hemoglobin: PP = 13.6 vs PA = 7.85 (p = 0.03).

Conclusion

Laboratory results of tests collected during initial assessment of patients with severe lower limb trauma are different between those submitted to PA or a PP.

How to cite this article

Garcia DFV, de Sá RRC, Bernini CO, Rasslan S . Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):58-61.

Lower limb amputation following injury: a survey of long-term functional outcome

Although there have been significant advances in surgical methods of limb preservation and various injury scores produced to predict the outcome after severe lower limb injury, there is common belief amongst surgeons that patients rehabilitate rapidly and well after amputation. There is however little evidence in the literature supporting this view of functional outcome of amputation following injury. A subjective assessment of post-injury lower limb amputees implied that there was a similar functional outcome in above- and below-knee amputations. Furthermore, there was little functional difference between early and delayed amputations, the delayed group being more satisfied with the end result.