Limb Salvage vs. Amputation: Factors Influencing the Decision-Making Process and Outcomes for Mangled Extremity Injuries

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.

Open Periprosthetic Knee Fracture: A Case Report and Review of the Literature

Introduction:

With the increase in knee and hip implants, these periprosthetic fractures will become more common especially as the population ages. Open periprosthetic fractures are rare and severe injuries and are more likely to be seen in high-energy injuries. They present challenges to the treating physician due to soft tissue damage, contamination of the existing implants, and the effects of polytrauma in the geriatric patient.

Methods: Case review report and review of literature. Results

A 72-year-old woman was involved in a motor vehicle collision with multiple injuries including an open periprosthetic tibia and femur fracture. This was treated with initial washout and removal of loose tibial component with placement of a cement spacer. The knee was treated with staged revision using a protocol like that used after prosthetic joint infection. After complete soft tissue healing, the patient underwent successful revision with a megaprosthesis. The literature on open periprosthetic fractures is reviewed.

Discussion and Conclusion:

Open periprosthetic fractures present multiple challenges to the orthopedic surgeon. In the presences of poly trauma and soft tissue injury, we present an approach using staged surgery like that used for prosthetic joint infection.

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.