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One of the most difficult decisions taken by orthopaedic surgeons is ascertaining when to salvage or amputate a severely injured limb following an overwhelmingly complex injury. The tendency to consider and take daring initiatives to treat and save the limb should be strengthened by the understanding and recognition that such a decision may or may not be in the favour of the patient and result in repeated hospitalisations, along with a variety of complications, as well as a poor functional outcome. There are many variables or factors that must be taken into consideration. These factors are objective elements associated with the injury and physical state of the injured patient and subjective aspects associated with the social, economic and psychological status of the patient.
When assessing a complex limb injury, we must consider certain variables, such as the injury, the patient and the hospital environment before we reach a decision whether to salvage or amputate the limb.
Firstly, we must assess the extent of the injury and check the skin, muscle, nerve and blood vessels, including the bone. As physicians, we must question which interventions are relevant and which ones will attain the best results for the patient.
The management of complex limb injuries is based on numerous factors, however it is noteworthy that at times this can be conflicting due to the lack of class one evidence.
There are critical factors that have been incorporated by researchers using a scoring system to forecast unavoidable amputation. Mangled Extremity Syndrome Index (MESI) was developed by Gregory et al in 1985. Some major factors are considered by Gregory and colleagues using MESI, including score of injury severity; harm to integument or skin, bone, nerve, vein, and artery; adjournment in immediate treatment; age of patient; acute disease history; and presence of shock.
The Mangled Extremity Severity Score (MESS) was then modified by McNamara et al and they developed the NISSSA score. NISSSA has six variables, including (N) nerve damage; (I) ischaemia; (S) contamination of soft tissue; (S) injury to skeleton; (S) shock presence; and (A) age of patient.
All the above-mentioned scoring system has a critical score prognostic of amputation, typically ascertained via retrospectively applying scores to patients in whom salvage was decided. Most of the investigators have conducted studies to compare precise outcomes with score predictions that provide the sensitivity and specificity and also the predictive value for all the scores. Of course, it has been shown by all the assessments that there are not any precise and accurate scoring systems for all situations. This imprecision may be partially due to considerable differences in inter-observer grouping of severe level of open-limb injuries, specifically in evaluating the injury level of soft-tissue and venous, along with the ischemia degree.
Even though these indices are useful, the status and condition of a patient cannot be simply summed-up by a number. Moreover, these systems fail in taking factors into account associated with the institution and operating team. The major players that definitely contribute their role are the availability of resources, professionals, and the surgeon’s knowledge and experience.
In 2005, the American College of Surgeons recommended that complex limb injuries involving the vascular supply should be treated within a six-hour period in enjoin the maximum chance of limb salvage.
Complex limb injuries can lead to numerous complications, including amputation. Amputation should be considered when the risk of limb loss persists. Another factor is the amputation level.
The primary goal in amputation is preserving the length of limb as much as possible. As an instance, less energy is consumed with lower extremities while walking on longer limbs. For this very reason, amputation below the knee is suitable to an above-knee one and similarly, the treatment of amputation through the knee is suitable to doing so above the knee, specifically as different prosthetic knee systems have made improved amputations through-the-knee and made them easy to fit.
Other considerations and factors in these situations are crucial when determining whether to go with the treatment of amputation or to salvage. The resumption of pre-injury functioning may be predicted by more considerations associated with the patient.
Given the borderline status of the patient, as ascertained by the predictive factors, taking other aspects into account like employment and lifestyle of a patient is helpful in deciding the treatment. Following this comprehensive analysis of factors, the decision can be made by a surgeon.
Patient expectation and satisfaction are important variables which must be considered in the decision-making process. This is evident in the study by Kreuger et al, which suggests that 59 per cent of patients were discontented at the results of the functionality after the limb salvage, so surgeons should properly advise patients who wish for a late amputation.
Patient expectation and satisfaction are important variables which must be considered in the decision-making process
Until recent times, financial conditions have not been examined deeply. It is a fact that this specific variable may become more and more crucial because the cost-awareness of managed care makes a greater impact in ascertaining treatment and burdens the patient with more responsibility.
The hospitalisation cost has been examined by Goldberg et al. In their research study, Goldberg et al recruited 98 patients who were injured in train accidents as the study participants, and 5.2 was their mean MESS for all injured limbs and 37 of the patients required instantaneous amputation of limb — $18,698 per patient was found to be the cost of hospitalisation, and on average, patients (study participants) paid only $2,261 of this total.
The hospital environment is another important factor which influences the decision-making process. Across the healthcare system, it is known that there are different trauma capabilities of surgeons, as well as various capacities available in the hospital trusts.
Variables affecting the outcome
Variables associated with the social, economic and psychological status of the patient with severe limb injury are crucial forecasters of outcome and the future quality of life. It has been reported by Francel that variables related to the patient, instead of his or her injury, are associated with a prosperous return to normal life, which was more probable for those who are aged under 40 years, highly-qualified, educated and skilled and are in white-collar employment. There are other aspects that indicate the lack of success in protracted salvage. These factors are incapability of affording a prolonged absence from their jobs, insufficient system of social assistance and unreliability.
The Belfast Approach suggests that interventions — such as the early shunting in complex limb injuries — offer a huge benefit in terms of outcome, as they decrease the requirement for fasciectomy, amputation (P: p¼ 0.009, P: p¼ 0.012) and hence improve the outcome for complex limb injuries.
A study by Hogendom and Van der Werken et al examined the quality of life of patients who were managed with reconstructive surgery versus amputation following grade three open tibia fractures. They concluded that patients in the limb salvage group had additional surgeries and suffered further complications. There are additional studies which support the idea of belated amputation resulting in worse functional outcome versus primary amputation.
However, if we examine the findings from the LEAP study group, using the sickness impact profile (SIP), they found that patients who had undergone amputation had more severe injuries but did not differ from those who underwent limb salvage.
They also discovered that there were significant factors which influenced a meagre outcome, such as low household income, rehospitalisation, no insurance, poor social network and involvement in the compensation process with the legal system.
The evidence-based Orthopaedic Working group found that there was no considerable difference in the functional outcome up to a period of seven years.
Additionally, a study by Penn–Barwell investigated medium-term outcomes following limb salvage surgery after tibia fractures and compared results with trans-tibial amputees and found that there was no respective difference in quality of life while measuring with the SF-36 tool.
Whether to prefer the treatment through amputation or salvage of the seriously injured limb has been found to be one of the most difficult decisions. As these decisions are rarely easy to make, a majority of considerations must be taken into account, comprising objective variables associated with the level of injury and physical condition of a patient and subjective variables associated with the social, economic and psychological status of a patient.
References available on request
Dr Ahmeda Ali, Queen Mary University, London and Prof Susan I Brundage, Professor of Traum Education, Queen Mary University, London