Chapter 12: Principles of Mangled Extremity Management

Sarina K. Sinclair, Erik N. Kubiak

Chapter Outline

Introduction

The term “mangled extremity” refers to an injury to an extremity so severe that the viability of the limb is often questionable and loss of the limb a likely outcome. The mangled extremity has been previously defined as a complex fracture with additional involvement of at least two of the following: artery, tendon, nerve, or soft tissue (skin, fat, and muscle).35,43 This injury is always a result of high-energy trauma caused by some combination of crush, shear, and/or blast. Associated fractures usually verify the high-energy forces of the mechanism of injury by exhibiting extensive comminution patterns frequently a result of a combination of three-point bending, axial load, and torsional forces imparted to the extremity. The skin is often degloved with large areas of loss secondary to avulsion or ischemia and the fascial compartments are typically incompletely opened by explosion or tear. Muscles are typically damaged at both local and regional levels by direct as well as indirect injury. Furthermore, soft tissue planes are usually extensively disrupted and, when present, contaminants generally infiltrate all of these tissue planes (Fig. 12-1). Not only are the injury patterns themselves complex, but the medical, psychological, and socioeconomic impacts that these injuries have on the patient make their management a difficult task, even in the most experienced of hands. 
Figure 12-1
Soft tissue injury demonstrating gross contamination in multiple tissue planes.
 
Caution should be used in making viability determinations prior to debridement and irrigation in the controlled setting of the operating room.
Caution should be used in making viability determinations prior to debridement and irrigation in the controlled setting of the operating room.
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Figure 12-1
Soft tissue injury demonstrating gross contamination in multiple tissue planes.
Caution should be used in making viability determinations prior to debridement and irrigation in the controlled setting of the operating room.
Caution should be used in making viability determinations prior to debridement and irrigation in the controlled setting of the operating room.
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Although most of the advances that have taken place in the management of the mangled extremity have occurred during times of war, the majority of limb-threatening injuries seen in practice today are the result of high-speed motor vehicle collisions. Injuries to the lower and upper extremities occur more frequently than head injuries in motorcycle crashes.59 Modification of passenger restraints, vehicle safety engineering, and the legislation of seatbelt and air bag protection appear to be decreasing the mortality rate associated with motor vehicle crashes. As a result, the incidence of severe lower extremity trauma may be increasing. In the United States, injuries to the lower extremity account for over 250,000 hospital admissions annually for patients 18 to 54 years of age. It is estimated that over half of these admissions result from high-energy mechanisms.45 An analysis of the largest available registry of trauma patients in the United States, the National Trauma Data Bank, found that 1% of all trauma patients sustained an amputation between 2000 and 2004.7 Although less frequent than the lower extremity, 90% of upper extremity amputations are a result of trauma.6 It is evident from these reported figures that a large population of extremity trauma patients do not undergo amputation and must endure long-term treatment with the goal of functional restoration to preinjury levels. Orthopedic surgeons providing emergency department trauma coverage need to understand the historical concepts surrounding the care for these complex injuries as well as recent modifications of these concepts based on numerous advances in technology combined with a better understanding of the long-term clinical outcomes of these injury patterns. 

Historical Background

From the time of Hippocrates, the management of the limb-threatening lower extremity injury has plagued patients and surgeons alike. Until the implementation of amputation, most severe open fractures resulted in sepsis and these injuries were often fatal.4 Historically, amputation itself was associated with high mortality rates, often from hemorrhage or sepsis. Amputations performed during the Franco-Prussian War and American Civil War carried mortality rates ranging from 26% to as high as 90%.28,112 As amputation techniques improved, so did our understanding of the concepts of bacterial contamination and infection. By the mid 1880s, through the pioneering works of Pasteur, Koch, and Lister on bacterial contamination and infection, there was a rapid increase in the use of antiseptic agents, soon followed by the introduction of aseptic methods, and then mortality rates rapidly declined.150 Subsequently, topical sulfa agents were introduced just before World War I and systemic antibiotics became available during World War II and the Korean War.112,114 Because of advances in surgical technique, as well as through a better understanding of microbial prophylaxis and treatment, extremity injuries that were once considered to be life threatening have now been rendered, at the very least, survivable.39 
Despite the relative success of amputation surgery in reducing mortality in the treatment of patients with a life- or limb-threatening injury of the extremity, many patients and physicians have historically perceived amputation as a failure of therapy and have fought aggressively to salvage the mangled limb. Although a pioneer in the field of amputation, Ambroise Paré knowingly risked his own life over limb when he insisted on conservative management of his own open tibia fracture rather than amputation. Not only did he survive the injury, but also his documentation of the conservative treatment of a potentially limb- and life-threatening injury serves as one of the first known documented cases of “limb salvage.”119 Nevertheless, for the years to come, most complex extremity injuries were routinely treated with amputation. After World War II, medical and surgical training became more specialized and numerous developments in the civilian medical arena led to a revolution in the management of limb-threatening battlefield injuries, which dictates our treatment today. Arterial repair and bypass were attempted on a wide scale during the Korean and Vietnam Wars, subsequently reducing the amputation rates in extremities with vascular injuries from 50% to 13%.69,70,71,112,126 On the battlefields of Iraq and Afghanistan, body armor, the widespread use of tourniquets, and in-theater resuscitation techniques have saved a higher percentage of combat casualty victims than in any previous US military conflicts;120 however, because of the nature of body armor coverage, the extremities are often left exposed. The high energy explosive mechanism of injury resulting from improvised explosive devices (IEDs) has led to a high prevalence of “mangled” extremities with severe damage to the hard and soft tissues. Subsequently, the incidence of amputations within the United States military population has doubled during the most recent conflicts compared to previous wars.127 Soldiers with strong wishes to return to active duty following their injury have driven the strong interest in limb salvage.121 Advances in all aspects of wound and fracture management have improved our ability to reconstruct the severely injured extremity. Limbs that would have required an amputation over 25 years ago are now routinely entered into complex reconstruction protocols. The development of second- and third-generation antibiotics, microsurgical tissue transfers,18,81,133,146 and the use of temporary intraluminal vascular shunts,74 wound irrigation strategies, and tissue-friendly fracture fixation methods have combined to make initial limb salvage, at the very least, feasible in most cases. Furthermore, by using massive autogenous grafts and/or osteoinductive materials,26,44,54,77,83 as well as through the technique of bone transport,32,105,118,128 delayed large-segment bone defect reconstruction has become routine. Although limb salvage has become technically feasible, the initial assessment and management of the patient and the injury are paramount in determining whether salvage is advisable. 

Principles of Management

Initial Evaluation

Most limb-threatening injuries are very impressive on presentation and can often be distracting to the treating surgeon and the medical team. Because these injuries are usually the result of a high-energy mechanism, routine trauma protocols should be followed that first address the patient as a whole and not just the injured extremity, because 10% to 17% of these patients will have an associated life-threatening injury.22,88 Evaluation should begin by following the principles of Advanced Trauma Life Support (ATLS). Once the patient has been stabilized and the primary and secondary trauma surveys have been completed, a thorough orthopedic evaluation is mandatory (Table 12-1). 
Table 12-1
The Current Algorithmic Approach to Mangled Extremity Decision Making as Defined by the Orthopaedic Trauma Association Open Fracture Committee 20122
Management of the Mangled Extremity
Criteria for Immediate Amputation
  •  
    Life-threatening injury to the extremity
  •  
    Hemodynamic instability
  •  
    Prolonged limb ischemia (>6 hr lower extremity, >8 hr upper extremity)
  •  
    Severe soft tissue loss without option for free flap reconstruction
  •  
    Nonreconstructable bone injury
  •  
    Muscle loss affecting more than two lower leg compartments
  •  
    Bone loss involving more than one-third of the length of the tibia
Management Steps After Patient Stabilization
  •  
    Debridement and stabilization by senior surgeon
    •  
      Zones of injury: central, marginal stasis, minimally injured
    •  
      Serial debridements will be required
    •  
      Be conservative with muscle on first debridement
  •  
    Document injury in photographs
  •  
    Evaluation of five major areas of concern:
Discussion with Patient
  •  
    Present all objective information and recommendation
  •  
    Discuss outcome data of amputation vs. salvage
  •  
    Psychosocial factors to consider: type of employment, support system, access to medical and rehabilitation facilities
  •  
    Self efficacy
Limb Salvage
  •  
    Multiple procedures
  •  
    30–50% usefully employed at 2 years if successful
  •  
    30% rate of late amputation
Amputation
  •  
    Beneficial in short term
  •  
    Permanent
  •  
    Lifelong issues with prosthetic device
  •  
    Most distal level possible
  •  
    Preserve as much viable tissue as possible
Important that patient makes final treatment decision
Major Areas of Concern
  1.  
    Skin
    •  
      Pattern of soft tissue injury
    •  
      Extent of damage
    •  
      Availability of tissue for reconstruction
    •  
      Reconstruction needs to be performed within 14 days
  2.  
    Muscle
    •  
      Muscle necrosis (Four Cs)
    •  
      Amount of muscle function
    •  
      Muscle-tendon unit
  3.  
    Arterial
    •  
      Vessel injury with or without distal ischemia
    •  
      Duration of ischemia:
      •  
        Lower extremity limits
        •  
          Cold > 10 hr
        •  
          Warm > 6 hr
      •  
        Upper extremity limits
        •  
          Warm > 8 hr
    •  
      Observe for hard and soft signs of vascular injury
    •  
      Arterial pressure indices
    •  
      <0.9 or absent distal pulse should consult with vascular surgery
  4.  
    Contamination
    •  
      Surface versus embedded in tissues
    •  
      From high-risk environment (i.e., fecal)
  5.  
    Bone Loss
    •  
      Size of defect
    •  
      Is critical-sized defect too great for grafting or transplant?
X
The mechanism of injury, age of the patient, and the presence of any other social or medical comorbidities should also be determined. Prophylactic antibiotics should be administered as soon as possible and tetanus prophylaxis should be administered as indicated. The injured extremity should first be evaluated for adequate vascular perfusion and, if a vascular injury is suspected, vascular surgery consultation should be obtained. A determination of the time of injury is of great importance to assess the duration of limb ischemia. The soft tissue wound should be inspected and the pattern of soft tissue injury and contamination should be noted. If possible, a cursory removal of any gross contamination via irrigation should be performed before dressing the wounds and immobilizing the extremity, especially if a fracture reduction or joint reduction is thought to be necessary before transporting to the operating room for initial wound debridement. A detailed motor and sensory examination should be performed and documented, both before and after any manipulation of the extremity. The presence of an associated compartment syndrome, which occurs at a rate of 1% to 10% in open fractures,84 should be considered and ruled out. Radiographic evaluation should include two orthogonal views of any involved joints or long bones, as well as the joint above and below any confirmed fractures. Photographs of the extremity should be obtained whenever possible with permission of the patient or legal representative if possible. These can provide invaluable documentation of the extent of the initial injury and, during the course of treatment, serve as a visual record of progress to or away from a functional salvaged extremity,37 as long as the patient’s right to privacy is not violated. 
Not only should the orthopedic examination include the extremity in question, but a comprehensive musculoskeletal examination should be performed to rule out any concomitant musculoskeletal injuries. In the case of a polytrauma patient with a mangled extremity, the initial diagnostic workup and treatment of any life-threatening injuries can often be time consuming and precede the management of the injured limb; therefore, a sterile dressing should be applied to all wounds and the limb immobilized as soon as possible to prevent any ongoing soft tissue damage until proper debridement and stabilization procedures can be performed in the controlled setting of the operating room. 

Vascular Assessment

Limb-threatening injuries are often associated with vascular insult. Arterial injuries usually present with either hard or soft signs suggestive of injury. Examples of hard signs that should be documented and investigated include pulsatile bleeding, the presence of a rapidly expanding hematoma, a palpable thrill, or audible bruit, as well as the presence of any of the classic signs of obvious arterial occlusion (pulselessness, pallor, paresthesia, pain, paralysis, poikilothermia). Soft signs of arterial injury include a history of arterial bleeding, a nonexpanding hematoma, a pulse deficit without ischemia, a neurologic deficit originating in a nerve adjacent to a named artery, and the proximity of a penetrating wound, fracture, or dislocation near to a named artery.109 In addition to observing for these hard and soft signs of vascular injury, a formal vascular examination should be conducted. The skin color and time required for capillary refilling of the skin of the distal extremity should be compared with and documented against that of the uninjured contralateral side. The distal extremity should be evaluated for the presence of palpable peripheral pulses and/or Doppler signal. The limb with gross deformity secondary to fracture or dislocation with questionably palpable pulses or reduced Doppler audible flow should undergo immediate gentle reduction of the deformity and immobilization of the reduced limb in an effort to relieve possible kinking or compression of the vascular structures. Subsequently, pulse assessment of the distal extremity should again be performed and documented after any reduction maneuvers. Arterial pressure indices (APIs) should also be obtained in the presence of a history of pulselessness in the extremity or if the vascular status of the distal extremity remains unclear even after reduction attempts have been made to restore reasonable alignment to the extremity. APIs are obtained by first identifying the dorsalis pedis and posterior tibial arteries of the injured extremity using a Doppler probe. Next, a blood pressure cuff is placed proximal to the level of injury and then inflated to a suprasystolic level causing cessation of the normal Doppler signal. The cuff is then slowly deflated and the pressure at which the Doppler signal returns identifies the ankle systolic pressure to the injured limb. This procedure should then be repeated on the contralateral extremity as well as in the arm (brachial pressures). The pressure in the injured extremity is then compared with the pressure in the arm or the unaffected extremity and reported as a ratio of the normal systolic pressure (e.g., if the brachial systolic pressure is equal to 120 mm Hg and the systolic pressure in the injured limb is equal to 90 mm Hg, then API is reported as 0.75). If the API is lower than 0.9 or distal pulses remain absent despite reduction, angiography and/or vascular surgery consultation is indicated. 
Once the location of an arterial injury has been identified, treatment should first address restoration of arterial inflow and skeletal stabilization. In the patient with a pulseless but perfused limb, the priority and sequence of vascular and orthopedic repair depend primarily on the experience and availability of both the orthopedic and vascular teams. At times, if the fracture is relatively stable and will require little manipulation, immediate arterial repair should precede bony stabilization. However, if the fracture is excessively comminuted, displaced, or shortened, rapid bony stabilization should be performed before any attempts at vascular repair. Not only will this aid in the exposure of the vascular injury, but doing so brings the limb out to its proper resting length, ensuring the vascular repair is of sufficient length to allow for further manipulation and reduction of the extremity with less risk of vascular complications after the repair has been completed.73 
In the patient who has undergone a period of prolonged ischemia, the restoration of arterial inflow should be the highest priority and consideration should be given to temporary intraluminal vascular shunting of the extremity.74,36,111 The insertion of an intraluminal shunt can rapidly restore arterial inflow and allow for a more detailed examination to better determine the extent of the injury and whether the limb is indeed salvageable. Because the shunt will hold up to fairly vigorous manipulation, it will also allow for a more thorough debridement and appropriate stabilization of the bone and soft tissues. Once the debridement has been completed and the bony injury temporarily or definitively stabilized, formal vascular repair can then either proceed immediately or in a delayed fashion if the patient remains in extremis. 
A compartment syndrome is not uncommon after restoration of arterial inflow to an ischemic and traumatized limb. The diminished arterial inflow during the ischemic period combined with the “reperfusion injury” that occurs after arterial repair can result in interstitial fluid leakage and elevated compartment pressures. Fasciotomies should be performed after any revascularization procedure in the mangled extremity.88,90,103 Whereas most vascular and general surgeons are adequately trained to perform decompressive fasciotomies, ideally, these should be performed by or under the supervision of the orthopedic surgeon to ensure adequate compartment decompression as well as appropriate fasciotomy placement that will not compromise later bony and soft tissue reconstructive procedures. 

Operative Debridement and Stabilization

Once the extremity has been evaluated in the emergency department and photographs have been taken for the medical record, any open wounds should be gently rinsed with a copious amount of normal saline and dressed with sterile gauze.29 The dressings should be left in place until the patient reaches the operating room for definitive debridement. 
In the operating room, a sterile tourniquet should be placed to prevent the possibility of exsanguination, unless tourniquet placement restricts prepping of the limb. It should not be inflated unless absolutely necessary to avoid further ischemic injury to the extremity. Once the tourniquet is in place, the splint and dressings can be removed and the extremity again examined for perfusion. Although typically referred to as “irrigation and debridement,” the first and most important step is a thorough debridement of the wound. (Fig. 12-2) This should be done in a methodical manner to ensure adequate removal of any contaminating material and devitalized tissues. The skin and subcutaneous tissue should be addressed first. Whereas the initial open skin wounds are obvious, the energy imparted at the time of injury typically produces a shock wave that causes stripping of the soft tissues and typically results in so-called zones of injury. A gradient of energy extends peripherally from the site of impact, variably damaging tissues along its path. A central zone of necrotic tissue exists at and around the point of impact and greatest injury. These tissues are typically nonviable regardless of the intervention. Surrounding this area lies a zone of marginal stasis. This ischemic penumbra consists of tissue that is variably injured and may or may not survive despite appropriate intervention. Finally, at the periphery of the injury exists a zone of noninjured or minimally injured tissue that, while not subject to the primary injury, could be at risk from the delayed physiologic responses to the primary area of injury.56,90 To address these zones of injury, the open wounds should be extended or separate extensile incisions should be performed to adequately assess and debride the wound. These incisions should be axially aligned and thoughtfully placed so as not to create “at-risk” flaps or preclude any later reconstructive efforts. 
Figure 12-2
An 8-year-old child slipped and fell under a lawn mower sustaining extensive soft tissue injury with severe contamination (A).
 
After extensive debridement as much soft tissue as possible was preserved (B) and then secondary closure with skin grafting was performed in a delayed fashion.
After extensive debridement as much soft tissue as possible was preserved (B) and then secondary closure with skin grafting was performed in a delayed fashion.
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Figure 12-2
An 8-year-old child slipped and fell under a lawn mower sustaining extensive soft tissue injury with severe contamination (A).
After extensive debridement as much soft tissue as possible was preserved (B) and then secondary closure with skin grafting was performed in a delayed fashion.
After extensive debridement as much soft tissue as possible was preserved (B) and then secondary closure with skin grafting was performed in a delayed fashion.
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Once the skin wounds have been extended, all necrotic muscle, fat, fascia, skin, and other nonviable tissue within the central zone of injury should be removed. Muscle should be tested for viability based on its contractility, consistency, color, and capillary bleeding (the four Cs), and if it is found to be obviously nonviable, it should be debrided, regardless of the expected functional loss. Marginally questionably viable muscle should be preserved during the initial debridement. Although the amount of tissue damage seen on the initial debridement can be quite extensive, the quantity of tissue necrosis from the delayed response to the injury within the zone of marginal stasis can far exceed the loss and destruction caused by the initial traumatic injury. Because the exact degree of expected tissue loss and necrosis cannot be determined easily at the time of initial debridement, serial debridements will be required until the identification and removal of all nonviable tissue has been achieved and wound homeostasis obtained. 

Skeletal Stabilization

Skeletal stabilization is an extremely important tenant in the initial management of the limb at risk. Stabilization of the bony skeleton prevents ongoing soft tissue damage, promotes wound healing, and is thought to protect against infection. In an animal study, Worlock et al.159 examined the rate of infection and osteomyelitis associated with stable and unstable skeletal fixation. They reported that the infection rate in the unstable group was nearly double than that in the skeletal stabilization group. 
The choice of skeletal stabilization is dependent on the location of the bony injury, the degree of soft tissue injury, and the overall condition of the patient at the time of initial operative management. Stabilization options range from splint immobilization or skeletal traction to internal or external fixation. Whereas no one technique has proved to be superior to all others in all clinical situations, in general, the more severe the injury, the greater is the need for direct skeletal fixation to provide improved access to the traumatic wound. Immediate intramedullary stabilization or plate fixation of type I, II, and IIIA open fractures remains an accepted treatment strategy. However, most limb-threatening injuries present as type IIIB or type IIIC open fractures. These injuries are perhaps most judiciously managed with temporizing external fixation. External fixation in this setting offers many advantages. It can be applied relatively quickly and without the use of fluoroscopy while still providing excellent stability and alignment of the limb until definitive fixation can be performed. External fixation also allows for redisplacement of the fracture fragments for a more thorough evaluation and debridement of the soft tissues during any repeat procedures. Once wound homeostasis has been obtained, conversion to definitive internal fixation can be performed on a delayed basis with good results.5,136,137 External fixation can also be chosen as the form of definitive fixation for diaphyseal fractures, but multiple studies have found this approach to have slightly higher complication rates and poorer outcomes when directly compared with intramedullary fixation. (Fig. 12-3). Henley et al.63 prospectively compared unreamed intramedullary nailing with external fixation in patients with type II, IIIA, and IIIB open fractures of the tibial shaft. Both groups underwent identical soft tissue management before and after skeletal fixation. Their study showed that those patients in the intramedullary nail fixation group had significantly fewer incidences of malalignment and underwent fewer subsequent procedures than did those in the external fixation group. Tornetta et al.151 also reported on the early results of a randomized, prospective study comparing external fixation with the use of nonreamed locked nails in type IIIB open tibial fractures. Again, both groups had the same initial management, soft tissue procedures, and early bone grafting. They found that the intramedullary nail treatment group had slightly better knee and ankle motion and less final angulation at the fracture site. They also concluded that the nailed fractures were consistently easier to manage, especially in terms of soft tissue procedures and bone grafting. Furthermore, they thought that intramedullary nailing was preferred by their patients and that it did not require the same high level of patient compliance as external fixation. Using data obtained through the Lower Extremity Assessment Project (LEAP), Webb et al.156 reviewed 156 patients with the combination of a fractured tibia in association with a mangled lower extremity. One hundred and five patients with 17 type IIIA, 84 type IIIB, and 4 type IIIC tibial fractures had follow-up to 2 years. The authors found that definitive treatment with a nail yielded better outcomes than definitive treatment with external fixation. In their series, the external fixation patients had a significantly increased likelihood of both infection and nonunion. 
Figure 12-3
An intramedullary nail can be used for both provisional and definitive stabilization of the tibia during the multiple phases of limb salvage.
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Hyperbaric Oxygen

Hyperbaric oxygen (HBO) allows patients to breathe 100% oxygen in a chamber under increased barometric pressure. This results in a supraphysiologic arterial oxygen saturation level, creating an expanded radius of diffusion for oxygen into the tissues that results in increased oxygen delivery at the periphery of certain wounds. As a result, HBO is thought to enhance oxygen delivery to injured tissues affected by vascular disruption, thrombosis, cytogenic and vasogenic edema, and cellular hypoxia as a result of trauma to the extremity. 
This improved oxygen delivery is believed to be most beneficial in the peripheral zone of injury where tissue that is variably injured may or may not survive despite other appropriate interventions. Injured but viable cells in this area have increased oxygen needs at the very time when oxygen delivery is decreased by disruption of the microvascular supply.72,117 As such, HBO can be applied in an effort to mitigate this process of secondary injury in extremity trauma and minimize the resultant tissue loss at different points in both the pathologic and recovery processes.56 
Most clinical reports on HBO therapy in the treatment of extremity trauma are observational with fairly anecdotal reports on its efficacy. However, in 1996, Bouachour et al.15 performed a randomized placebo-controlled human trial of HBO as an adjunct to the management of crush injuries to the extremity. Thirty-six patients with crush injuries were assigned in a randomized fashion, within 24 hours after surgery, to treatment with HBO (session of 100% O2 at 2.5 atm for 90 minutes, twice daily, over 6 days) or placebo (session of 21% O2 at 1.1 atm for 90 minutes, twice daily, over 6 days). Both treatment groups (HBO group, n = 18; placebo group, n = 18) were similar in terms of age; risk factors; number, type, or location of vascular injuries, neurologic injuries, or fractures; and type, location, or timing of surgical procedures. The authors found complete wound healing without tissue necrosis in 17 of the 18 HBO patients and in 10 of the 18 control patients. Whereas two patients in the control group eventually required amputation, no patients in the HBO group went on to amputation. Furthermore, a decreased number of surgical procedures such as skin flaps and grafts, vascular surgery, or eventual amputation were required for patients in the HBO group compared with the placebo group. A subgroup analysis of patients matched for age and severity of injury showed that HBO was especially effective in patients older than 40 with severe soft tissue injury. They concluded that HBO improved wound healing and reduced the number of additional surgical procedures required for treatment of the injury, and that it could be considered a useful adjunct in the management of severe crush injuries of the limbs, especially in patients over 40 years old. 
To date, controlled animal experiments, select human case series, and a small number of randomized studies seem to suggest a potential benefit of HBO therapy as an adjunct to the management of the severely traumatized limb. However, if efficacious, HBO use in the mangled extremity patient will be selective as many patients are critically ill and are often unable to travel to receive and to tolerate HBO therapy. At this time, more data and stringent clinical investigations are needed to determine the exact indications for, optimal timing of, and appropriate duration and dosage of HBO therapy before it can be recommended in the routine management of complex injuries of the limb. An international multicenter, randomized control trial is currently being conducted to study repair of open tibia fracture involving severe soft tissue injury with or without a concurrent course of HBO treatments (Clinical Trials Identifier NCT00264511). Patients randomized to the experimental (HBO) group will receive a course of HBO therapy in addition to normal trauma care for a total of 12 sessions over 8 days to measure the incidence of acute complications after injury as the primary endpoint. The findings of this trial could offer better insight into the use of this technology in mangled extremity treatment. 

Soft Tissue Coverage

Wound closure and soft tissue reconstruction are covered in more depth in Chapter 15. However, a few principles are worth discussing here. The first addresses the type of soft tissue coverage selected in the reconstruction pathway. Whereas multiple options for coverage exist, such as skin grafts, local flaps, or free flaps, complications will occur with each. Pollak et al.123 found that 27% of high-energy tibia injuries requiring soft tissue reconstruction had at least one wound complication within the first 6 months after injury. They also found that the rate of complication differed based on the type of flap coverage. For limbs with the most severe osseous injury (OTA type C fractures), treatment with a rotational flap was 4.3 times more likely to lead to an operative wound complication than was treatment with a free flap. The rate of complications for the limbs with less severe osseous injury did not differ significantly based on soft tissue coverage selection. Based on this information, one should be very cautious when selecting a local flap in the setting of high-energy trauma as the flap, although originally healthy in appearance, may have indeed been included in the initial zone of injury. 
A second and perhaps more controversial principle is the timing of the soft tissue reconstructive procedure. The primary argument for early soft tissue reconstruction is to reduce the risk of nosocomial contamination because of repeated exposures of the vulnerable wound to the hospital environment. Some more recent data have brought into question the efficacy of early soft tissue reconstruction. When analyzing a subset of patients with open tibial fractures in association with a mangled extremity, Webb et al.156 failed to observe any advantages related to the performance of early muscle flap wound coverage within the first 72 hours after the injury. In contrast, multiple authors have shown that early reconstruction (within 72 hours) reduces postoperative infection, flap failure, and nonunion rates as well as the risk for the development of osteomyelitis.46,51,53,64 Others have recommended muscle flap coverage on a more delayed basis (7 to 14 days).160 Recently, with the advent of negative pressure wound therapy (NPWT) and the decreasing availability of surgeons trained in rotational flaps and free tissue transfer, there seems to be a trend toward increased delays until definitive soft tissue reconstructive procedures are performed. While NPWT can be a very effective tool in the initial soft tissue management of high-energy open fractures, its routine use in open tibia fractures has not been found to reduce the overall infection rates compared with historical controls nor has it been shown to reduce the need for free tissue transfer or rotational muscle flap coverage in these injuries.34 Bhattacharyya et al.8 evaluated whether the use of NPWT could allow for a delay of flap coverage for open tibia fractures without a subsequent increase in the infection rate. They concluded that despite the routine use of NPWT before definitive soft tissue reconstruction in patients with Gustilo type IIIB fractures, patients who underwent definitive soft tissue coverage within 7 days had significantly decreased infection rates compared with those who underwent soft tissue coverage at 7 days or more after injury (12.5% versus 57%). 
Despite best efforts, delays in soft tissue reconstruction are often inevitable; however, based on a preponderance of evidence, it still appears that soft tissue coverage should be performed as early as possible once both the patient and the wound bed appear stable enough for such a procedure. 

Patient Assessment and Decision Making

In 1943, US Army Major General NT. Kirk, a leader at the field of amputation during World War I and World War II, wrote, “Injury, disability, or deformity incompatible with life and function indicates amputation. The surgeon must use his judgment as to whether the amputation is indicated and at what level it can safely be done.”82 Since that time, numerous physicians caring for the patient with a mangled extremity have delineated a multitude of clinical factors to help better guide in the decision-making process in the setting of a potentially salvageable versus an unsalvageable limb injury (Table 12-2).89 
 
Table 12-2
Limb Salvage Decision-Making Variables
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Table 12-2
Limb Salvage Decision-Making Variables
Patient Variables
Age
Underlying chronic diseases (e.g., diabetes)
Occupational considerations
Patient and family desires
Extremity Variables
Mechanism of injury (soft tissue injury kinetics)
Fracture pattern
Arterial/venous injury (location)
Neurologic (anatomic status)
Injury status of ipsilateral foot
Intercalary ischemic zone after revascularization
Associated Variables
Magnitude of associated injury (Injury Severity Score)
Severity and duration of shock
Warm ischemia time
X
In 2002, factors that influenced the mangled extremity treatment decision process were studied by Swiontkowski147 and the LEAP Study Group. Orthopedic and general trauma surgeons caring for the mangled limbs were surveyed to determine the factors they typically used to make a reconstruction or amputation treatment decision. More than 33% of 52 orthopedic surgeons indicated that plantar sensation was the most important determinant for limb salvage. The severity of the soft tissue injury (17%) and limb ischemia (15%) followed in importance. No orthopedic surgeon ranked the patient’s Injury Severity Score (ISS) as a critical factor. In contrast, 33 general trauma surgeons from the same centers ranked the ISS as the most critical determinant (31%), followed by limb ischemia (27%) and plantar sensation (21%). An analysis of the patient, injury, and surgeon characteristics determined that the soft tissue injury (i.e., the extent of muscle injury, deep vein injury, skin defects, and contamination) and the absence of plantar sensation were the factors considered to be most important at the time to predict amputation. Patient characteristics and the experience level of the surgeon did not appear to influence the decision-making process. Of important note, the orthopedic surgeon was responsible for the initial treatment decision in all cases. General trauma surgeons participated in the decision-making process 58% of the time and plastic surgeons contributed to the process 26% of the time. Although all of these variables play a key role in decision making by the orthopedic surgeon and the trauma team, a few of these warrant further discussion, as new evidence suggests that we should reconsider their importance. In the final analysis limb salvage is dependent on the reconstructability of the soft tissue envelope which is both provider and patient resource dependent as the bone is almost always reconstructable. Provider resources include, but are not exclusive to, the availability of appropriately trained personnel for soft tissue management. Patient resources include, but are not exclusive to, the intrinsic physiologic and psychological reserves of the patient. 

Survivability

Often, the decision to amputate a severely injured limb can be a long, drawn-out, and difficult decision for both the patient and the treating surgeon. However, on rare occasions, the decision for amputation can be quite simple (Fig. 12-4). Amputation is generally the only treatment option in cases of a severely injured extremity with an irreparable vascular injury or in the setting of prolonged warm ischemia (longer than 6 hours for a lower extremity and 8 hours for an upper extremity).88 In some instances, when the patient’s life would be threatened by attempts to save the limb, the dictum of “life over limb” supersedes the feasibility issue of limb salvage, and amputation should be the only option despite the presence of a potentially salvageable limb. Immediate amputation should also be considered in patients critically injured with significant hemodynamic instability, coagulopathy, or an injury constellation that would preclude the multiple surgeries required for limb salvage.88,89 In these cases, an immediate open amputation (as opposed to a “guillotine” amputation which is no longer performed) is performed to minimize the soft tissue wound area. In the leg, the initial amputation is performed 2 to 3 cm distal to the distalmost extent of the gastrocnemius muscle, if possible, leaving the bone long and not transecting muscle bellies. This amputation is then revised to a formal closure once the patient’s condition is improved. 
Figure 12-4
A 38-year-old woman was involved in a rollover motor vehicle accident (MVA) and presented in extremis with her blood pressure only transiently responsive to IV fluid administration.
 
A CT scan demonstrates an unstable comminuted segmental tibia fracture (A). Because of extensive soft tissue damage to the leg and the hemodynamic instability a through-knee amputation (B) was performed at the time of crash laparotomy to control intra-abdominal bleeding. An above knee amputation (C) was performed later as the definitive procedure.
A CT scan demonstrates an unstable comminuted segmental tibia fracture (A). Because of extensive soft tissue damage to the leg and the hemodynamic instability a through-knee amputation (B) was performed at the time of crash laparotomy to control intra-abdominal bleeding. An above knee amputation (C) was performed later as the definitive procedure.
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Figure 12-4
A 38-year-old woman was involved in a rollover motor vehicle accident (MVA) and presented in extremis with her blood pressure only transiently responsive to IV fluid administration.
A CT scan demonstrates an unstable comminuted segmental tibia fracture (A). Because of extensive soft tissue damage to the leg and the hemodynamic instability a through-knee amputation (B) was performed at the time of crash laparotomy to control intra-abdominal bleeding. An above knee amputation (C) was performed later as the definitive procedure.
A CT scan demonstrates an unstable comminuted segmental tibia fracture (A). Because of extensive soft tissue damage to the leg and the hemodynamic instability a through-knee amputation (B) was performed at the time of crash laparotomy to control intra-abdominal bleeding. An above knee amputation (C) was performed later as the definitive procedure.
View Original | Slide (.ppt)
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Plantar Sensation

The origin of the concept that initial plantar sensation is critical to the salvage of an extremity is difficult to trace. Although the LEAP Study Group’s147 decision-making analysis supported the inclusion and perceived importance of plantar sensibility, the fact that this was an established treatment axiom at the time of that study may have driven a self-fulfilling prophesy phenomenon. Because surgeons believed that absent plantar sensation was a reason to amputate a limb, they acted accordingly. Indeed, the literature before 1980 warns of neuropathic ulcers and chronic complications associated with absent plantar sensation. Johansen et al.,75 Howe et al.,68 and Russell et al.130 however, describe a confirmed avulsion or complete transection of the tibial nerve as the definition of absent plantar sensation in their limb salvage algorithms. Lange et al.88 considered complete tibial nerve disruption in adults to be an absolute indication for amputation. 
In most clinical scenarios, however, the assessment of the limb is performed in the emergency department. Once in the operating room, additional dissection of the deep posterior compartment to assess the tibial nerve is usually considered unwise, as surgical exploration of the nerve within the zone of injury is contraindicated because doing so can cause additional soft tissue injury. Therefore, in many centers, the absence of initial plantar sensation has been considered the same as a physiologic disruption of the nerve. Ischemia, compression, contusion, and stretch can temporarily affect the function of the tibial nerve. Once these factors resolve, nerve function typically returns. Furthermore, in the face of no sensory return, orthopedic surgeons have successfully demonstrated the ability to care for the insensate foot in other conditions (diabetes or incomplete spine lesions) through education and shoe modifications. Furthermore, the orthopedic oncology literature has documented cases of limb salvage in the face of tumor with acceptable results after sciatic, peroneal, or tibial nerve resection.9,16 
In an effort to better understand the true importance of plantar sensation in the mangled extremity, Bosse et al.14 used the variations in physician practice patterns to explore the outcomes of patients admitted to the LEAP study with absent plantar sensation. They examined the outcomes of a subset of 55 subjects without plantar foot sensation at the time of initial presentation. The patients were divided into two groups depending on their hospital treatment (i.e., insensate amputation group [n = 26] and insensate salvage group, the study group of primary interest [n = 29]). In addition, a control group was constructed from the parent cohort so that a comparison could also be made to a group of patients in whom plantar sensation was present and whose limbs were reconstructed. The sensate control group consisted of 29 subjects who were matched to the 29 insensate salvage subjects on four limb injury severity characteristics (i.e., severity of muscle, venous, and bony injury as well as the presence of an associated foot injury). Patient and injury characteristics and functional and health-related quality of life outcomes at 12 and 24 months after injury were compared between subjects in the insensate salvage and the other study groups. 
The insensate salvage patients did not report or exhibit significantly worse outcomes at 12 or 24 months after injury compared with subjects in the insensate amputation or the sensate control cohort. Among those with a salvaged limb (insensate salvage and sensate control groups), equal proportions (55%) had normal foot sensation at 2 years after injury regardless of whether plantar sensation was reported as intact (sensate control group) or absent (insensate salvage group) on admission. Pain, weight-bearing status, and the percentage of patients who had returned to work were similar for subjects in the insensate salvage group compared with subjects in the insensate amputation and the sensate control groups. Furthermore, there were no significant differences noted in the overall, physical, or psychosocial Sickness Impact Profile (SIP) scores between subjects without plantar sensation whose limbs were salvaged (insensate salvage group) and subjects who had undergone amputation (insensate amputation group) or subjects with intact sensation whose limbs were salvaged (sensate control group). More than one-half of the patients initially presenting with an insensate foot and treated with limb reconstruction had regained normal sensation at 2 years. At 2 years, only two patients in the insensate salvage group and one patient in the sensate control group had absent plantar sensation. In this cohort, initial plantar sensation was not found to be prognostic of long-term plantar sensory status or functional outcomes. Based on these data, the authors concluded that plantar sensation should not be included as a factor in the decision making for limb salvage in lower extremity trauma. 

Decision-Making Protocols and Limb Salvage Scores

Because the decision to amputate or salvage a severely injured lower extremity is difficult, several researchers have attempted to enumerate certain indications for amputation or quantify the severity of the trauma to establish numerical guidelines for the decision to amputate or salvage a limb. These lower extremity injury scoring systems (ISSs) all vary in terms of the factors considered relevant to limb salvage and the relative weights assigned to each element. These scoring systems were validated by the developers and demonstrated a high sensitivity and specificity in predicting limb salvage at the time of their design. It is impossible to achieve 100% accuracy using a scoring system in a clinical setting and any metric evaluation must be weighed carefully in conjunction with knowledge of the surgical skills of the clinician, the technical facilities available, and subjective factors that can impact the overall success of the treatment. 
In 1985, Lange et al.88 proposed a decision-making protocol for primary amputation in type IIIC open tibial fractures. They suggested that the occurrence of one of two absolute indications (complete tibial nerve disruption in an adult or a crush injury with a warm ischemia time of longer than 6 hours) or at least two of three relative indications (serious associated polytrauma, severe ipsilateral foot trauma, or a projected long course to full recovery) warranted amputation. This protocol, however, presented several limitations in that only a minority of cases could be resolved based on the absolute indications and that the relative indications were quite subjective. Furthermore, this protocol did not address individual patient variables such as age, medical comorbidities, or occupational and other psychosocial factors that can have a significant effect on the overall outcome, and no subsequent clinical studies were performed to validate this protocol. 
Beginning in 1985, research teams reported attempts to quantify extremity injury severity with scoring systems. Over a 10-year period, six scoring systems were published that valued different injury components as critical to the treatment decision (Table 12-3).57,62,68,75,106,130,145 These components were assigned arbitrary weights and the summation scores were used to establish “cutoffs” for limb salvage or amputation. 
 
Table 12-3
Index Domains
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Table 12-3
Index Domains
MESI PSI MESS LSI NISSSA HFS 98
Injury Severity Score Ischemia Ischemia Ischemia Ischemia Ischemia
Bone Bone Bone/tissue Bone Bone Bone
Age Muscle Age Muscle Muscle Muscle
Integument injury Timing Shock Skin Skin Skin
Nerve Nerve Nerve Nerve
Lag time to operation Vein Age Contamination
Pre-existing disease Shock Bacteria
Shock Onset of treatment
 

MESI, Mangled Extremity Syndrome Index; MESS, Mangled Extremity Severity Score; NISSSA, Nerve injury, Ischemia, Soft tissue injury, Skeletal injury, Shock, and Age of patient Score; HFS 98, Hanover Fracture Scale 98; PSI, Predictive Salvage Index; LSI, Limb Salvage Index.

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Gregory et al.57 published the first grading system for the mangled extremity, the Mangled Extremity Syndrome Index (MESI). In this study, the authors included 17 patients over a 3-year period who met their criteria of a mangled extremity syndrome (defined by three of four organ/tissue systems—integument, nerve, vessel, bone—injured in the same extremity). These patients’ charts were retrospectively reviewed and their injuries classified according to a point system based on the degree of integumentary, nervous, vascular, and osseous injury. Additional scoring schemes were also included to address patient age, the time lag to treatment, pre-existing medical comorbidities, and the presence or absence of shock. In their series, they found that 100% of patients with an MESI score of greater than 20 underwent either primary or secondary amputation. From their data, they suggested that if applied prospectively, the MESI could have been used to identify those patients in their series who ultimately underwent amputation and guide their treatment at the time of initial evaluation. They suggested that their scoring system could help better identify the salvageable versus the unsalvageable extremity. Unfortunately, the MESI had numerous faults, and 5 of the 17 cases studied were injuries to the upper extremity. The system can also be both cumbersome and somewhat subjective in nature, making it prone to interobserver variability and difficult to apply during the initial evaluation of the patient. These factors prevented its widespread acceptance and application in orthopedic practice. 
The Predictive Salvage Index (PSI)68 was introduced in 1987 as another scoring system to help predict amputation versus salvage in patients with combined musculoskeletal and vascular injuries of the lower extremity. The PSI ascribes points based on information from four key categories (level of arterial injury, degree of bone injury, degree of muscle injury, and interval from injury to treatment). In the initial retrospective analysis, all 12 patients in the salvage group had PSI scores of less than 8, while 7 of 9 in the amputation group had scores of 8 or higher. The authors concluded that the PSI determined the likelihood of amputation with a sensitivity of 78% and a specificity of 100%. Although less complex than the MESI, it still had similar faults in that many of the scores attributed were subjective in nature and thus prone to interobserver variability. And as with the MESI, the information necessary to complete the scoring can be difficult to ascertain readily during the patient’s initial evaluation. 
In 1990, Johansen et al.75 and Helfet et al.62 proposed and reported on the utility of the Mangled Extremity Severity Score (MESS) (Table 12-4). Like the PSI, the MESS system is also based on four clinical criteria (skeletal/soft tissue injury, shock, ischemia, and patient age), and it was developed through the retrospective review of 26 severe lower extremity open fractures with vascular compromise. It was then validated in a prospective trial involving 26 patients at two separate trauma centers. In both the prospective and retrospective studies, all salvaged limbs had scores of 6 or lower and an MESS score of 7 or greater had a 100% positive predictive value for amputation. 
 
Table 12-4
Mangled Extremity Severity Scoring System (MESS)
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Table 12-4
Mangled Extremity Severity Scoring System (MESS)
Criterion Score
Skeletal/Soft Tissue Injury
Low energy 1
Medium energy 2
High energy 3
Very high energy 4
Limb Ischemia
Pulse reduced or absent but normal perfusion 1a
Pulseless, diminished capillary refill 2a
Cool, paralyzed, insensate, numb 3a
Shock
SBP always >90 mm Hg 1
SBP transiently <90 mm Hg 2
SBP persistently <90 mm Hg 0
Age (yr)
<30 0
30–50 1
>50 2
 

SBP, systolic blood pressure.

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Shortly after the MESS scoring system had been published, Russell et al.130 proposed the Limb Salvage Index (LSI). In this study, the authors performed a 5-year retrospective review of 70 limbs in 67 patients. Their proposed index was slightly more complex in that it quantified the likelihood of salvage according to the presence and severity of arterial injury, nerve injury, bone injury, skin injury, muscle injury, and venous injury as well as the presence and duration of warm ischemia. They reported that all 59 limbs with an LSI score of less than 6 were able to undergo successful limb salvage, whereas all 19 patients with an LSI score of 6 or greater had amputations. Criticisms of the LSI are that it is very detailed and requires a thorough operative evaluation to complete the initial scoring. Furthermore, because accurate scoring of the skin category requires a prior knowledge of the treatment and final outcome, the LSI is essentially ineffective during the initial phases of treatment. 
In 1994, McNamara et al.106 modified the MESS by including nerve injury in the scoring system and by separating soft tissue and skeletal injury. Their modification was named the NISSSA (Nerve Injury, Ischemia, Soft tissue Injury, Skeletal Injury, Shock, and Age of patient) scoring system. Subsequently, the authors applied the MESS and the NISSSA to retrospective data of 24 patients previously treated for limb-threatening injuries. The authors found both the MESS and the NISSSA to be highly accurate in predicting amputation. The NISSSA was also found to be more sensitive (81.8% versus 63.6%) and more specific (92.3 versus 69.2%) than the MESS in their patient population. Despite the improved statistical outcomes when comparing the NISSSA to the MESS, it inherently retains all the faults of the MESS scoring system while increasing its complexity. The NISSSA has also not been validated in prospective clinical trials. 
Lastly, a version of the Hanover Fracture Scale (HFS) was first published in 1980 that consisted of 13 weighted variables that included a analysis of the bacterial colonies present in the wound and was weighted toward vascular injuries.40,134 It was later simplified to only include eight domains by Krettek et al.85 and renamed the HFS 98. The HFS 98 was found to have higher sensitivity and equivalent specificity when compared to the NISSSA and MESS scales when prospectively applied to 87 open long-bone fractures.85 
Although the introduction of these scoring systems has helped highlight certain key factors considered relevant to limb salvage, each system, in and of itself, is not without its own limitations. First, although these scoring systems were validated by the developers and demonstrated a high sensitivity and specificity in predicting limb salvage in their respective studies, the development of the lower extremity ISSs has been flawed by retrospective designs and small sample sizes. In each study, with the exception of the small prospective series in which the MESS system was validated, each proposed classification system was applied retrospectively to patients with known outcomes, rather than prospectively to patients with unknown outcomes. Another important flaw in the development of the scoring systems lies in the fact that component selection and weighting in all of the indices were affected by the clinical bias of the index developers. The NISSSA and LSI include the result of the initial plantar neurologic examination. Age, the presence of shock, severity of contamination, and time to treatment are included in some of the other scoring strategies. Whereas each of these factors plays a key role in decision making, strict reliance on certain criteria with disregard to others via strict adherence to a scoring system might lead to premature amputation in an otherwise salvageable situation. As an example, the commonly cited MESS assigns an additional point if the patient is above the age of 29, a point for normal perfusion but with a diminished pulse, and points for transient or persistent hypotension without qualifying cause or response to treatment. The suggested MESS threshold score for amputation is 7. Thus using the MESS, for example, in a 30-year-old patient (1 point) with a high-energy open tibia fracture (3 points), with normal perfusion but a diminished pulse secondary to spasm or compression (1 point), who has persistent hypotension before laparotomy related to a spleen injury (2 points) would undergo amputation at the conclusion of the laparotomy despite the fact that the limb perfusion will likely return to normal and splenectomy and appropriate resuscitation will resolve the patient’s hypotension. 
Since the time of their initial publication, various other authors have attempted to validate several of the proposed scoring systems. In a later study Lin et al.91 suggested attempted salvage should be done for MESS scores of ≤9 because of improvements that have been made in clinical techniques and patient care. Support for the higher score cut-off was recently provided by Soni et al.143 in a 15-year retrospective study of patients with Gustilo type III fractures that also found the MESS score was a positive predictor of functional outcomes. 
Roessler et al.129 and Bonanni et al.10 both attempted to apply the MESI retrospectively to each of their patient populations. Both authors determined that the MESI inaccurately predicted amputation versus salvage. Furthermore, they found that MESI scores were often only approximate at best because many of the variables required surgical intervention for accurate determination of the scores, which negated its usefulness as a prediction tool in the acute phase of assessment and treatment. 
Bonanni et al.10 also evaluated the MESS, LSI, and PSI limb salvage score strategies. They retrospectively applied each limb salvage scoring system to 58 lower limb salvage attempts over a 10-year period. Failure of the reconstruction effort was defined as an amputation or functional failure at 2 years. A limb was considered to be a functional failure based on the ability to walk 150 feet without assistance, climb 12 stairs, or independently transfer. Based on their data, they were not able to support the use of any of the three scores to determine limb treatment. 
In an attempt to further clarify the clinical utility of any of the limb salvage scores, the LEAP study prospectively captured all of the elements of the MESS, LSI, PSI, NISSSA, and the HFS145 at the time of each patient’s initial assessment and critical decision making.13 The elements were collected in a fashion so as to not provide the evaluator with a “score” or impact on the decision-making process. The analysis did not validate the clinical utility of any of the lower extremity ISSs. The high specificity of the scores did, however, confirm that low scores could be used to predict limb salvage potential. The converse was not true, though, and the low sensitivity of the indices failed to support the validity of the scores as predictors of amputation (Table 12-5). The authors concluded that lower extremity ISSs at or above the amputation threshold should be used cautiously by surgeons deciding the fate of a mangled lower extremity. 
 
Table 12-5
Clinical Usefulness of Limb Salvage Scores
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Table 12-5
Clinical Usefulness of Limb Salvage Scores
Score All Gustilo Type III Fractures (n = 357)a Gustilo Type IIIB Fractures (n = 214)a Gustilo Type IIIC Fractures (n = 59)a
MESS
Sensitivity 0.45 (0.35–0.55) 0.17 (0.1–0.3) 0.78 (0.64–0.89)
Specificity 0.93 (0.9–0.95) 0.94 (0.89–0.97) 0.69 (0.39–0.91)
PSI
Sensitivity 0.47 (0.37–0.57) 0.35 (0.22–0.51) 0.61 (0.45–0.75)
Specificity 0.84 (0.79–0.88) 0.85 (0.79–0.9) 0.69 (0.39–0.91)
LSI
Sensitivity 0.51 (0.41–0.61) 0.15 (0.10–0.28) 0.91 (0.79–0.98)
Specificity 0.97 (0.94–0.99) 0.98 (0.95–1) 0.69 (0.39–0.91)
NISSSA
Sensitivity 0.33 (0.24–0.43) 0.13 (0.05–0.25) 0.59 (0.43–0.73)
Specificity 0.98 (0.96–1) 1 (0.98–1) 0.77 (0.46–0.95)
HFS-97
Sensitivity 0.37 (0.28–0.47) 0.1 (0.04–0.23) 0.67 (0.52–0.81)
Specificity 0.98 (0.95–1) 1 (0.97–1) 0.77 (0.46–0.95)
 

MESS, Mangled Extremity Severity Scoring System; PSI, Predictive Salvage Index; LSI, Limb Salvage Index; NISSSA, Nerve Injury, Ischemia, Soft tissue Injury, Skeletal Injury, Shock, and Age of Patient; HFS-97, Hanover Fracture Scale.

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Ideally, a trauma limb salvage index would be 100% sensitive (all amputated limbs will have scores at or above the threshold) and 100% specific (all salvaged limbs will have scores below the threshold). In the decision to amputate, high specificity is important to ensure that only a small number (ideally, none) of salvageable limbs are incorrectly assigned a score above the amputation decision threshold. A high sensitivity is also important to guard against inappropriate delays in amputation when the limb is ultimately not salvageable. Unfortunately, few clinical scoring systems perform ideally and the limb salvage scoring systems have proved to be no exception. 
Ultimately it falls to the treating physicians in consultation with the patient and their family to come to a decision regarding when to salvage and when to amputate. We have historically relied on multiple physicians in multiple specialties (vascular, general surgery trauma, orthopedics, and/or plastics) to concur in those circumstances where the injury is life threatening. In those circumstances where the injury is not immediately life threatening, we have found the provisional fixation (external fixator or intramedullary nail) and serial debridements combined with ongoing patient counseling is the best means by which to determine whether or not a prolonged limb salvage attempt can succeed. 

Concomitant Foot and Ankle Injuries

When discussing the mangled extremity or massive lower extremity trauma, the prototypical injury is the severe open tibial fracture. However, in reality these injuries often occur in conjunction with severe crushing type injuries to the ankle, hindfoot, and forefoot and this factor should also be carefully considered when opting for salvage versus amputation. Myerson et al.110 and others155,157 have shown that despite successful salvage and treatment of crush injuries to the foot, a substantial proportion of these patients will continue to have pain, often neuropathic in nature, and poor functional outcomes. 
Turchin et al.153 also assessed the effect of foot injuries on functional outcomes in the multiply injured patient. They matched 28 multiply injured patients with foot injuries against 28 multiply injured patients without foot injuries and compared their outcomes using the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and the modified Boston Children’s Hospital Grading System. They found that the outcome of the multiply injured patients with foot injuries was significantly worse than that of the patients without foot injuries when using any of the three outcome measures. Postinjury evaluation also showed that not only were the physical scores affected in the patients with associated foot injuries, but also the pain and social and emotional health perceptions were dramatically reduced compared with a control population of trauma patients without foot injuries. When using the SF-36, the patients in their study were similar to patients with well-recognized chronic debilitating conditions such as congestive heart failure, ischemic heart disease, or chronic obstructive pulmonary disease. In a similar study, Tran and Thordarson,152 using validated outcome instruments such as the SF-36, the American Academy of Orthopaedic Surgeons (AAOS) lower limb core questionnaire, and the AAOS foot and ankle questionnaire,76,116 found that the multiply injured patients with associated foot injuries in their study had dramatically lower Physical Function (38.9 versus 80.7), Role Physical (a perception of their physical function, 41.1 versus 87.5), Bodily Pain (50.6 versus 81.8), and Social Function (67.9 versus 96.6) compared with the control group of multiply injured patients without associated foot injuries. By use of the AAOS questionnaire, their study also addressed specific lower extremity musculoskeletal endpoints. All five of these scales also showed significantly lower scores for factors such as pain, treatment expectations, satisfaction with symptoms, and shoe comfort in those patients with associated foot injuries. 
Armed with this information and the knowledge of the severity of injury to the ipsilateral foot, one should proceed cautiously when recommending salvage in the face of severe crush injuries to the foot. In this situation, a given tibial injury or “mangled” lower limb with concomitant severe injuries to the foot might preclude achieving reasonable limb function despite the feasibility of salvage, and amputation may indeed be a better long-term option. 

The Mangled Foot

Severe mangled foot injuries are rare in civilian patients and these injuries have not been widely studied.41,80,135 Both civilian and military clinicians have determined that the extent of the soft tissue injury is the major deciding factor for salvage versus amputation of the mangled foot. Keeling et al.80 suggested that an assessment by at least two surgeons with limb salvage experience is the most consistent way to decide whether a limb has the potential to be saved. Ellington et al.41 reported on 174 open severe hindfoot or ankle injuries that were part of the prospective LEAP study, of which 116 were salvaged and 58 had a below-knee amputation (BKA). Using the SIP as the major outcome measure at 2 years, patients with foot injuries that required flaps or ankle fusions did significantly worse than the BKA patients.41 Shawen et al.135 also noted that foot injuries requiring free flaps and patients whose pain management require large doses of narcotics or nerve blocks had the worst clinical outcomes. 
There is insufficient literature to determine what is salvageable in the foot and at what level the amputation should be performed. In our hands, most patients with mangled feet with severe soft tissue injuries rarely undergo free flap coverage. The most common reason for this is the low success rates of microvascular anastomosis in the distal lower extremity. Because of the high rates of infection in the setting of a severe unreconstructable soft tissue envelope of the foot many patients end up with BKAs. 

Smoking

Not only is cigarette smoking a marker for potential medical comorbidities such as coronary heart disease and chronic obstructive pulmonary disease in a patient with a potentially limb threatening injury, but also it also can be used early as a prognostic variable to help inform the patient of potential long-term treatment complications and perhaps better guide treatment recommendations. Both basic science and clinical studies have consistently documented links between cigarette smoking and complications of the fracture healing process. Several studies have provided preliminary evidence of a link between smoking and delayed bone healing and nonunion,1,12,17,25,27,58,61,87,102,113,132 infection,48,102,148 and osteomyelitis.48,138 Laboratory studies have also shown that nicotine reduces vascularization and inhibits bone cell metabolism at bone healing sites, and this is associated with delayed healing in animal models.31,67,78,154 Smoking has also been associated with decreased immune function.79,92,139 
A concern with many of the current clinical studies has been the presence of many potential confounding variables that may have also affected the outcomes, thus refuting the overall impact of smoking on such negative outcomes as delayed union, nonunion, and infection. Patient age, education, and socioeconomic status have all been shown to have deleterious effects on overall health status, access to treatment, treatment compliance, and other health behaviors, which may have affected the higher complication rates seen in some of the smoking cohorts. In an effort to address these issues, Castillo et al.19 used data from the LEAP project to determine if cigarette smoking increased the risk of complications in patients with a limb-threatening open tibial fracture, while adjusting for the previously mentioned confounders. They were able to demonstrate that current smoking and even a previous smoking history independently placed the patient at an increased risk for nonunion and infectious complications. Current smokers and previous smokers were 37% and 32%, respectively, less likely to achieve union than nonsmokers. Current smokers were also more than twice as likely to develop an infection and 3.7 times more likely to develop osteomyelitis than were nonsmokers. Furthermore, previous smokers were also 2.8 times more likely to develop osteomyelitis than were patients without a prior history of tobacco use. 
Not only has cigarette smoking been shown to correlate with increased bone healing complications in the patient with a limb-threatening injury, but also smoking can significantly threaten the likelihood of success of the soft tissue portion of the reconstructive effort. Smoking is associated with a significant reduction in peripheral blood flow. Sarin et al.131 have shown that blood flow to the hand is reduced by as much as 42% after smoking just one cigarette. Cigarette use has also been shown to negatively affect peripheral blood flow in free transverse rectus abdominus flaps.11 Microsurgeons have reported poor outcomes after digital replantation in smokers. Chang et al.24 noted that approximately 80% to 90% of cigarette smokers will lose their replanted digits if tobacco use has occurred within 2 months before their surgery. Cigarette use has been shown to lead to increased local flap and full-thickness graft necrosis compared with nonsmoking status.52 Smoking has also been shown to adversely affect the success and complication rates associated with microvascular free tissue transfer. Reus et al.125 studied the incidence of free tissue transfer survival and complications in nonsmokers, active smokers, and patients who had discontinued smoking before surgical intervention. In their series, they found that complications occurred more often in active smokers, with these complications often occurring at the interface between the flap and its bed or an overlying skin graft. They also found that smokers required more secondary surgical procedures at the recipient site to accomplish ultimate wound closure. Lovich and Arnold93 examined the effect of smoking on various muscle transposition procedures. They performed a retrospective review of 300 pedicled muscle flap procedures and determined that active smokers had a significantly higher complication rate than nonsmokers and smokers who had previously quit. Not only is smoking associated with an increased complication rate at the recipient site, but also smokers have been shown to have an increased rate of complications at the donor site.23 
Clearly, both a history of previous cigarette use and current cigarette smoking places the patient with a limb-threatening injury at increased risk for both osseous and soft tissue complications These factors must be discussed at length and weighed very carefully with the patient before embarking on a prolonged course to salvage a mangled limb. 

Patient Characterization

Successful treatment of the mangled extremity and the return of the patient to as close to a preinjury level of performance and social interaction as possible are dependent on the interaction of the patient, the patient’s environment, the injury, and the treatment course. Understanding the potential impact of elements outside of the surgeon’s control—the patient and the patient’s environment—is critical to the development of an effective care plan. Through data obtained by the LEAP Study Group, Mackenzie et al.98 were able to characterize and help provide the medical community with a better understanding of the type of patients who face the challenge of amputation versus salvage in the face of a limb-threatening injury. In that study, most of the patients were male (77%), white (72%), and between the ages of 20 and 45 years (71%). These patients were often less educated, as only 70% were high school graduates versus a national rate of 86%. Significantly, more of the patients (25%) lived in households with incomes below the federal poverty line compared with the national rate (16%). This patient cohort also had significantly higher rates of uninsured individuals (38%) and had double the national average of heavy drinkers. Not only do these patients typically present with socioeconomic challenges, but many will have psychological and psychosocial issues, which can make the treatment plan and recovery even more of a challenge. Patients in this study were also found to be slightly more neurotic and extroverted and less open to new experiences compared with the general population. No significant differences were detected between the characteristics of patients entered into the reconstruction or amputation groups. Interestingly, in a thorough review of LEAP study-related publications, Higgins et al.66 conclude that the single most important characteristic of patient success following treatment for a mangled limb is the patient’s “self-efficacy” and ability to handle change.66 
Although the LEAP study is still considered the most comprehensive study on the topic of mangled extremity trauma, it was conducted more than 15 years ago and was limited to level I trauma centers. de Mestral et al.35 performed a retrospective analysis of lower limb trauma patients from the National Trauma Database, which is inclusive of a wide range of Level I and II trauma centers in the United States, between 2007 and 2009.35 A total of 1,354 patient records were examined for information on the frequency and timing of amputation, which occurred at nearly equal rates: early (<24 hours), 9% and late (>24 hours), 11%. Characterization of the early amputees in this cohort found that limb injury factors (i.e., higher energy mechanism, shock in the emergency department, severe head injury) were the strongest determinants of early amputation, whereas age was not.35 
These findings are important to surgeons planning to care for patients with mangled lower extremities. Compared with the general population, patients with limb-threatening injuries have fewer resources, which can potentially limit their access to rehabilitation services and affect their ability to accommodate to residual disability. These patients are typically employed in more physically demanding jobs, which may impede efforts to return to work, and they have poorer health habits, which may complicate recovery. The personality traits identified in this population could also predispose these patients to a more difficult recovery. 

Outcomes: Amputation Versus Limb Salvage

The clinical challenge faced in every case is deciding, as early as possible, the correct treatment pathway for the patient. The surgeon must weigh the fact that, in most cases, limb reconstruction is possible given the appropriate application of current techniques and counterbalance the expected result of salvage against that which is possible with amputation. Prosthetic bioengineering innovations have significantly improved the function and comfort of lower extremity amputees. Most series reporting on the results of limb salvage or amputation are single center, small, and retrospective. Their conclusions provide a glimpse into the complexity of the clinical decision-making process, but these studies alone should not be used to guide clinical decisions. 
Several of these series have supported amputation as the optimal treatment option in the setting of the mangled extremity. Georgiadis et al.50 retrospectively compared the functional outcomes of 26 patients with successfully reconstructed grade IIIB open tibia fractures with the outcomes of 18 patients managed with early BKA. Five patients in the reconstruction group required a late amputation to treat infection complications. The reconstruction patients had more operations, more complications, and longer hospital stays than did patients treated by early amputation. The functional outcomes of the 16 successful reconstructions were compared with the outcomes of the early amputation patients. They found that the reconstruction patients took more time to achieve full weight bearing and were less willing or able to return to work. Validated outcomes instruments were used to assess the quality of life for a subset of the patients. Significantly more limb salvage patients considered themselves to be severely disabled and impaired for both occupational and recreational activities. The authors concluded that early BKA resulted in a quicker recovery with less long-term disability. Ly et al.94 attempted to use the previously described limb scoring systems (MESS, LSI, PSI, NISSSA, HFS-98) as predictors of functional outcome status. Using a cohort of 407 limb salvage subjects from the LEAP study who had successful outcomes at 6 months, physical SIP scores were compared to the limb salvage scores at 6 and 24 months. It was determined that the injury scores were not able to predict the functional recovery of patients who undergo successful limb reconstruction.94 
Francel et al.,49 in a retrospective review of 72 acute grade IIIB open tibia fractures requiring soft tissue reconstruction from 1983 to 1988, also showed that although limb salvage can be successful, over 50% of the patients in the salvage group had severe limitations in the salvaged limb by objective motion measurements, and 48% of the patients in the salvage group at least intermittently required the use of an assistive device for ambulation after complete healing. They also found that in the salvage group, the long-term employment rate was 28% and no patient returned to work after 2 years of unemployment. In contrast, 68% of trauma-related lower extremity amputees from their institution over the same time period returned to work within 2 years. 
Based on these studies, proponents of early amputation claim that patients undergoing amputation often have shorter initial hospital stays, decreased initial hospital costs, and a higher likelihood of resuming gainful employment, thus decreasing the financial burden of this life-altering injury. 
Hertel et al.65 also retrospectively compared below-knee amputees with patients receiving complex reconstructions after a grade IIIB or IIIC open tibial fracture. They also concluded that for the first 4 years after injury, amputation resulted in lower mean annual hospital costs than reconstruction, and amputation patients required 3.5 interventions and 12 months of rehabilitation compared with an average of 8 interventions and 30 months of rehabilitation for the reconstruction patients. However, amputation patients were reported as having a higher dollar cost to society, a figure that was inflated by adding the amounts of permanent disability assigned to an amputee compared to a reconstruction patient. Despite this fact, the authors eventually concluded that functional outcome based on pain, range of motion, quadriceps wasting, and walking ability was better in the reconstruction group than in the amputation group, and therefore, limb reconstruction was advisable (although the data to support this conclusion was soft and no patient-based outcome measures were used). 
Dagum et al.33 also touted reconstruction as the preferred option in the management of the mangled extremity. They retrospectively evaluated 55 grade IIIB and IIIC tibia fractures cared for over a 12-year period. The SF-36 was used as the primary outcomes measure. Although both groups had SF-36 (physical component) outcomes scores as low as or lower than those of many serious medical illnesses, successful salvage patients had significantly better physical subscale scores than did amputees. Both groups had psychological subscores similar to a healthy population. Furthermore, 92% of their patients preferred their salvaged leg to an amputation at any stage of their injury, and none would have preferred a primary amputation. Based on their findings, the authors suggested that a BKA was an inferior option to a successfully reconstructed leg. 
Whereas some authors have found that amputation may be less costly in the short term, reconstruction may be more cost effective compared with amputation when lifelong prosthetic costs are taken into account. Smith et al.141 reviewed hospital and prosthetist records for 15 of 20 patients who survived initial trauma and eventually underwent isolated BKA from 1980 through 1987. Using the medical record and the billing records of the prosthetist, they calculated the number of prostheses fabricated and the overall prosthetic charges since the initial amputation. They found that during the first 3 years, the mean number of prostheses acquired per patient was 3.4 (range 1 to 5), with an average total prosthetic charge of $10,829 (range $2,558 to $15,700). Over the first 5 years, the mean number of prostheses acquired per patient increased to 4.4 (range 2 to 8), with average total prosthetic charges of $13,945 (range $6,203 to $20,070). Williams158 also compared hospital costs and professional fees of 10 patients with Ilizarov limb reconstruction to the hospital costs, professional fees, and prosthetic costs of 3 patients with acute and 3 patients with delayed lower extremity amputation. The average treatment time was higher in the Ilizarov reconstruction group. The hospital costs and professional fees for the amputation group averaged $30,148 without prosthetic costs, whereas the total cost of the Ilizarov limb reconstruction averaged $59,213. However, with projected lifetime prosthetic costs included, the average long-term cost for the amputee was estimated to be $403,199. Thus, he concluded that Ilizarov limb reconstruction is a more cost-effective treatment option than amputation when long-term prosthetic costs are considered. 
The issue of the health care cost of amputation versus limb reconstruction has best been analyzed through information collected via the LEAP study. MacKenzie et al.100 compared the 2-year direct health care costs and projected lifetime health care costs associated with both treatment pathways. The calculated patient costs included the initial hospitalization, all rehospitalizations for acute care related to the limb injury, any inpatient rehabilitation, outpatient physician visits, outpatient physical and occupational therapy, and the purchase and maintenance of any prosthetic devices. When the costs associated with rehospitalizations and postacute care were added to the cost of the initial hospitalization, the 2-year costs for reconstruction and amputation were similar. However, when prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). Furthermore, the projected lifetime health care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively). Based on these estimates, they concluded that efforts to improve the rate of successful reconstructions have merit and that not only is reconstruction a reasonable goal, but also it may result in lower lifetime costs to the patient. 
Whereas most of the conclusions reached in the previous studies offer important insight into the various arguments for amputation or salvage of the mangled extremity, they are also somewhat contradictory, which is likely a result of the retrospective design and small sample sizes in many of the series. The research teams could not adequately assess or control for the injury, treatment, patient, and patient environment variables that could influence the outcome. 
The LEAP study prospectively compared the functional outcomes of a large cohort of patients from eight level I trauma centers who underwent reconstruction or amputation following an open tibial shaft fracture. The hypothesis was that after controlling for the severity of the limb injury, the presence and severity of other injuries, and patient characteristics, amputation would prove to have a better functional outcome than reconstruction. Detailed patient, patient environment, injury, and treatment (hospital and outpatient) data were collected for each patient.97 The SIP was used as the primary outcome measurement. The SIP is a multidimensional measure of self-reported health status (scores range from 0 to 100, scores for the general population average 2 to 3, and scores of greater than 10 represent severe disability). Secondary outcomes included the limb status and the presence or absence of a major complication that required rehospitalization. Five hundred and sixty nine patients were followed over 2 years. No significant difference was detected at 2 years in the SIP scores between the amputation and the reconstruction patients. After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had outcomes that were similar to those who underwent limb reconstruction.12,60,66,95,124 
The analysis of all patient, injury, treatment, and environmental variables in the LEAP study also identified a number of predictors of poorer SIP scores. Negative factors included the rehospitalization of a patient for a major complication, a low education level, nonwhite race, poverty, lack of private health insurance, a poor social support network, a low self-efficacy (the patient’s confidence in being able to resume life activities), smoking, and involvement with disability-compensation litigation (Table 12-6). To underscore the combined influence of these multiple factors on outcome, adjusted SIP scores were estimated for two subgroups of patients. A patient with a high school education or less, poor social support, and rehospitalization for a major complication had a mean adjusted SIP score of 15.8. A comparable score for a patient with some college education, strong social support, and an uncomplicated recovery was 8.3. Although patients with substantial economic and social resources and no complications could not function at the level of a healthy adult of similar age and gender (SIP typically less than 4), they were still significantly better off than those without such resources. 
Table 12-6
Predictors of Poor Outcome Found in the LEAP Study After Adjusting for Extent of Injury
  •  
    Major complication
  •  
    High school education or less
  •  
    Nonwhite
  •  
    Low income and no private insurance
  •  
    Current smoker
  •  
    Low self-efficacy and social support
  •  
    Involvement with legal system
X
The study also found that patients who underwent reconstruction were more likely to be rehospitalized than were those who underwent amputation (47.6% versus 33.9%). Nonunion and wound infection were the most common complications reported.60 Osteomyelitis develop in 7.7% of the LEAP cases. The limb salvage group displayed a higher risk of complication. At 2 years, nonunion was present in 10.9% of the reconstruction patients and 9.4% had developed osteomyelitis. Additional operations were required for 14.5% of the amputation patients to revise the stump, and the reconstruction patients required twice as many operations.60 The levels of disability, as measured by the SIP, were high in both groups. More than 40% of the patients had an SIP score of greater than 10, reflecting severe disability. Except for scores on the psychosocial subscale, there was significant improvement in the scores over time in both treatment groups. Return to work success was disappointing. At 24 months, only 53% of the patients who underwent amputation and 49.4% of those who underwent reconstruction had returned to work. 
Subsequent to the publication of the original LEAP data, MacKenzie et al.99 re-examined the outcomes of patients originally enrolled in the study to determine whether their outcomes improved beyond 2 years and whether differences according to the type of treatment emerged. A total of 397 of the 569 patients who had originally undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of 84 months after the injury. Functional outcomes were assessed using the physical and psychosocial subscores of the SIP and were compared with the scores obtained at 24 months. On average, physical and psychosocial functioning deteriorated between 24 and 84 months after the injury. At 84 months, half of the patients had a physical SIP subscore of 10 or more points, which is indicative of substantial disability, and only 34.5% had a score typical of the general population of similar age and sex. There were few significant differences in the outcomes of the two groups according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points and those treated with a through-knee amputation were 11.5 times more likely to have a physical subscore of 5 points. There were no significant differences in the psychosocial outcomes according to the treatment group. At 7-year follow-up, patient characteristics that were significantly associated with poorer outcomes included older age, female sex, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at 24 and 84 months after the injury. These results confirmed the previous conclusion of the LEAP study that limb reconstruction results in functional outcomes equivalent to those of amputation. The results also showed that regardless of the treatment option, long-term functional outcomes are likely to be poor. 

Clinical Practice Considerations

Generalization of the findings of the LEAP study beyond level I trauma centers must be cautioned against. In the level I trauma center, surgeons should advise their patients with mangled lower limbs that the functional results of reconstruction are equivalent to amputation. The reconstruction process requires more operations and more hospitalizations and is associated with a higher complication rate. At 2 years, both patient groups were significantly disabled, and only 48% had returned to work. Both patient groups show evidence of lingering psychosocial disability. Given the “no outcome difference” at 2 years, patients and surgeons can be comfortable recommending or selecting limb-preservation surgery. Efforts to minimize complications and hastened fracture union might improve the outcome of the reconstruction patients (Fig. 12-5). 
Figure 12-5
A 54-year-old man caught his leg in a rotor tiller blade.
 
The blade was removed from the machine and the patient was transferred for definitive care to a regional facility where the limb was extracted from the tiller blade (A). Radiographs demonstrate a relatively simple ankle fracture and do not adequately reflect the extensive soft tissue injury (B). Initial spanning external fixation and provisional pin fixation of the medial malleolus were performed (C). After counseling with the family and the patient a plan was made to proceed with limb salvage. Definitive fixation of the fractures was performed 10 days from the initial injury and at the same time a latissimus free flap was placed to provide anterior soft tissue coverage (D). Over the next 2 years he had three deep infections requiring debridement and intravenous antibiotics and at that point he elected to proceed with a below-knee amputation (E).
The blade was removed from the machine and the patient was transferred for definitive care to a regional facility where the limb was extracted from the tiller blade (A). Radiographs demonstrate a relatively simple ankle fracture and do not adequately reflect the extensive soft tissue injury (B). Initial spanning external fixation and provisional pin fixation of the medial malleolus were performed (C). After counseling with the family and the patient a plan was made to proceed with limb salvage. Definitive fixation of the fractures was performed 10 days from the initial injury and at the same time a latissimus free flap was placed to provide anterior soft tissue coverage (D). Over the next 2 years he had three deep infections requiring debridement and intravenous antibiotics and at that point he elected to proceed with a below-knee amputation (E).
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Figure 12-5
A 54-year-old man caught his leg in a rotor tiller blade.
The blade was removed from the machine and the patient was transferred for definitive care to a regional facility where the limb was extracted from the tiller blade (A). Radiographs demonstrate a relatively simple ankle fracture and do not adequately reflect the extensive soft tissue injury (B). Initial spanning external fixation and provisional pin fixation of the medial malleolus were performed (C). After counseling with the family and the patient a plan was made to proceed with limb salvage. Definitive fixation of the fractures was performed 10 days from the initial injury and at the same time a latissimus free flap was placed to provide anterior soft tissue coverage (D). Over the next 2 years he had three deep infections requiring debridement and intravenous antibiotics and at that point he elected to proceed with a below-knee amputation (E).
The blade was removed from the machine and the patient was transferred for definitive care to a regional facility where the limb was extracted from the tiller blade (A). Radiographs demonstrate a relatively simple ankle fracture and do not adequately reflect the extensive soft tissue injury (B). Initial spanning external fixation and provisional pin fixation of the medial malleolus were performed (C). After counseling with the family and the patient a plan was made to proceed with limb salvage. Definitive fixation of the fractures was performed 10 days from the initial injury and at the same time a latissimus free flap was placed to provide anterior soft tissue coverage (D). Over the next 2 years he had three deep infections requiring debridement and intravenous antibiotics and at that point he elected to proceed with a below-knee amputation (E).
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The results of the LEAP study also suggest that major improvements in outcome might require greater emphasis on nonclinical interventions such as early evaluation by vocational rehabilitation counselors. The study also confirms previous research that found both self-efficacy and social support to be important determinants of outcome.42,101 Interventions aimed at improving support networks and self-efficacy may benefit patients facing a challenging recovery. Surgeons also need to acknowledge the long-term psychosocial disability associated with the mangled extremity, regardless of the treatment. Posttraumatic stress disorder screening and appropriate referral of patients for therapy should become a proactive part of the postoperative treatment plan.104,107,108,144 
For patients undergoing limb amputation, the LEAP study also identified a number of clinical issues that can be used by the surgeon in planning amputation level and stump coverage. There were no significant differences between above-knee amputations and BKAs in return to work rates, pain, or SIP scores. Patients with through-knee amputations had SIP scores that were 40% worse than those patients who received either a BKA or an above-knee amputation. Patients with through-knee amputations also demonstrated significantly lower walking speeds. Physicians were less satisfied with the clinical, cosmetic, and functional recovery of through-knee amputations compared with above-knee and below-knee amputation. Thus, as a generality, in the adult trauma population, a through-knee amputation should be avoided whenever possible. 
Atypical wound closures, skin grafts, and flaps did not adversely affect the outcome in this study, suggesting that efforts to preserve the knee are worthwhile.96 Furthermore, patient outcomes were not affected by the technical sophistication of the prosthesis, although patients with higher-technology prostheses were more satisfied. These findings will challenge the physician who currently fits a patient with a sophisticated (and expensive) prosthesis and the results underscore the need for controlled studies that examine the relationships between the type of prosthetic device, the fit of the device, and its functional outcomes.30,96 

Psychological Considerations

Most studies related to management options for the mangled extremity have centered on functional outcomes and the complications that are associated with each procedure. While these are the most obvious areas of concern for clinicians, the psychological well being of the patient must also be explored when considering the best approach. Data on depression, anxiety, and pain were also collected from patients enrolled in the LEAP study using a psychological self-report symptom scale. Patients were categorized as having normal (58.4%), moderate (15.8%), or severe (25.7%) depression or anxiety at the 3-month follow-up.21 Patients in the latter category were found to be at highest risk (40%) for suffering from chronic pain at 7 years post discharge after adjusting for pain intensity at 3 months (p < 0.001). The authors suggested that early referral to psychological intervention for patients found to be at moderate and severe levels of anxiety or depression within 3 months of injury could be beneficial in reducing the risk of prolonged suffering from pain. Two years after injury, the LEAP study participants were also surveyed regarding their satisfaction with the treatment of their lower extremity.115 The level of satisfaction was found to be independent of the details of the injury, treatment option, patient demographics, or psychological profile of the patient. O’Toole et al.115 listed physical function, pain intensity, the absence of depression, and the ability to return to work at 2 years as the most important factors affecting patient satisfaction. 
A systematic meta-analysis of 11 peer-reviewed studies centered around amputation versus limb salvage in the mangled lower limb was performed by Akula et al.3 with the goal of comparing the two treatments based on the patient perspective of quality of life. The analysis only included studies that administered the widely validated SF-36 and SIP to establish which injury treatment method yields better psychological outcomes. The 11 studies were compiled to include 1,138 cases involving unilateral lower limb trauma, of which there were 769 amputations and 369 limb salvage cases. Findings from this unique analysis supported the previous conclusion that there was no significant difference in physical recovery between the two treatment modalities; however, limb reconstruction patients fared better than the amputees when comparing psychological outcomes. The results of these studies highlight the importance of using a systematic approach to patient treatment that is concerned with both the physical and mental aspects of patient recovery. 

Military Trauma Care

It is a harsh reality that military conflicts lead to advancements in the field of trauma care. A specific subgroup of mangled extremity patients has emerged from the most recent conflicts experiencing combat blast injuries. Most soldiers who are fortunate to survive an attack by an IED sustain a mangled extremity, which comprise 54% to 71% of all traumatic combat injuries.47 The systematic process by which these patients are stabilized in the field and evacuated to level V facilities has led to reconstruction being a viable option in many cases. Limb salvage is approached in the same way as in the civilian populations, although in many cases less tissue is available for reconstruction increasing the need for bone grafts, graft substitutes and nontraditional material options during repair. When reconstruction is not an option, guillotine amputations are avoided with the goal of preserving as much viable tissue as possible.47 The military hospital system of care for the combat casualty patient population is unmatched in the civilian community.55 Care for these extremity trauma patients includes prolonged stays on the medical campus and intensive nursing, therapy (mental and physical) interventions, and the provision of the best orthotic and prosthetic devices available. A unique aspect of the military treatment of extremity trauma is that the majority of care is done in group treatment facilities. A comprehensive team of physicians, prosthetists, and physical and occupational therapists work together using a standardized five-phase protocol that has been developed to manage amputees: (1) Acute management and wound healing; (2) introduction to prosthetic training; (3) intensive prosthetic training; (4) advanced functional training; and (5) discharge planning.142 Different therapies are introduced within each phase to meet the individual needs and progress each soldier to occupational therapy. Pain management and psychological support are also important aspects of the military protocol. 
The Military Extremity Trauma Amputation/Limb Salvage (METALS) study was a comprehensive retrospective cohort study of US service members or reservists who sustained a major limb injury while serving in Afghanistan or Iraq between 2003 and 2007 to compare the two treatment options.38 Doukas et al.38 reported the findings for 324 lower limb patients that were included in the METALS study. The levels of disability in the military patients were at levels comparable to those found in the LEAP civilian study; however, unlike the LEAP study, a significantly higher level of function was reported for military amputee patients when compared to those that underwent limb salvage procedures (p < 0.01). The military amputees were 2.6 times more likely to be at high levels of activity compared to the reconstructed group. These results may be indicative of the intensive rehabilitation program that military amputees are subjected to as quickly as possible following the procedure and their access to state-of-the-art prosthetic devices and care. Military limb salvage patients are not exposed to the same organized rehabilitation protocols and have longer recovery times, which may have contributed to their lower function outcomes at 2-year follow-up. 

Rehabilitation of the Mangled Extremity

The civilian sector does not currently have a system in place to require a specific amount of inpatient rehabilitation for patients following severe extremity trauma. There are still questions about the effectiveness of rehabilitation, and there is great variability in the methods and outcome measures used in studies that have examined this issue. A secondary analysis of the LEAP subjects found that physical therapy was beneficial for the patients and that those subjects identified as having an unmet need by a physical therapist had statistically significantly less improvement overtime in five measures of physical impairment.20 Pezzin et al.122 examined the effect of inpatient rehabilitation on lower limb traumatic amputees from the University of Maryland Shock Trauma Center between 1984 and 1994. Using a retrospective chart review and administering the SF-36 (n = 78, 68% response rate), it was determined that inpatient rehabilitation significantly improved outcomes in terms of return to work rates and functional and vocational prospects. Factors that influenced the discharge to rehabilitation at the level I trauma center included age, gender, and ethnicity; however, these findings did not translate to the larger statewide results for Maryland, where these factors where found to not affect discharge to inpatient rehabilitation. Insurance status was not found to be a factor in determining how much inpatient rehabilitation was provided. These independent studies in conjunction with the recent advances made within the military trauma patient population suggest a need for improved standards for prescribing rehabilitation therapies in civilian medical centers. 

Upper Extremity

Whereas traumatic injuries to the upper extremity do not occur as frequently, they are the leading cause of amputations in the civilian population.124,142 Prasarn et al.124 discussed some important differences between the upper and lower extremities in terms of trauma care. The critical ischemic time is longer for the arms at 8 to 10 hours versus 6 hours for the lower extremity. Nerve reconstruction has been more successful in the upper extremity and shortening of the limb has less of an effect on successful postoperative function than it does in the lower extremity.39,142 Limb salvage for the upper extremity has a different set of considerations than the lower extremity since an upper limb with severe limitations of motor and/or sensory function may still be more useful to the patient than a prosthetic device. The same advancements have not been made in upper extremity prosthetic systems as have been achieved in the lower extremity systems, and attachment and wearability of the devices are still a major issue for this patient population.39 Kumar et al.86 reported a low infection rate (8%) and a high flap success rate (96%) in a set of 26 mangled upper extremity military patients with wounds necessitating soft tissue coverage by means of flap reconstruction (pedicled or free tissue transfer). Their “Bethesda limb salvage protocol” stressed the importance of vascularized coverage of a clean wound over the specific type of flap used, and they achieved 100% coverage without amputation. Patients underwent an average of six debridements and/or wound washouts before reconstruction was attempted and all had early (≤ 5 days) occupational hand therapy treatment in addition to physical therapy (supervised active and passive postoperative splint protocols), physical medicine, and prosthetics evaluations within 30 days. 
Although it was originally devised to assess injuries to the lower limb, Slauterbeck et al.140 applied the MESS to high-energy injuries of the upper extremity. In their series, they retrospectively reviewed the data of 37 patients with 43 mangled upper extremities and found that all nine upper extremity injuries with an MESS of greater than or equal to 7 were amputated and 34 of 34 with an MESS of less than 7 were successfully salvaged. Based on their findings, they concluded that the MESS system was an accurate predictor of amputation versus salvage when applied to the upper extremity. Conversely, Togawa et al.149 also retrospectively applied the MESS to patients with severe injuries of the upper extremity with associated arterial involvement. In their series, they successfully salvaged two of three upper extremity injuries with an MESS score of 7 or higher with good functional outcomes. They concluded that because of the decreased muscle mass in the upper extremity compared with the lower extremity and the increased collateral circulation and tolerance to ischemia seen in the upper extremity, the MESS score was inappropriate for application to the upper limb. 
At our institution we will attempt to salvage all mangled upper extremity injuries. Vascular repair takes precedence over nerve and bone repair which can be performed in a staged manner. The microvascular (hand/plastics) service is enlisted early on in the management of these injuries as tendon transfers, nerve grafts, and soft tissue transfers are frequently necessary to recreate a functional hand (Fig. 12-6). In many circumstances, a partially functional hand that can be used for positioning objects and grasping is more functional than prosthesis. 
Figure 12-6
A 51-year-old man sustained an open-fracture dislocation of the left elbow in a motor vehicle crash (A).
 
Sixteen months after the initial injury the lateral radiograph (B) demonstrates a fused elbow and the clinical image of the hand and forearm (C) demonstrates excellent soft tissue coverage.
Sixteen months after the initial injury the lateral radiograph (B) demonstrates a fused elbow and the clinical image of the hand and forearm (C) demonstrates excellent soft tissue coverage.
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Figure 12-6
A 51-year-old man sustained an open-fracture dislocation of the left elbow in a motor vehicle crash (A).
Sixteen months after the initial injury the lateral radiograph (B) demonstrates a fused elbow and the clinical image of the hand and forearm (C) demonstrates excellent soft tissue coverage.
Sixteen months after the initial injury the lateral radiograph (B) demonstrates a fused elbow and the clinical image of the hand and forearm (C) demonstrates excellent soft tissue coverage.
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Summary

The decision to amputate or salvage a severely injured lower extremity is a difficult one, which relies not only on the expertise of the orthopedic surgeon but also on the input of subspecialty colleagues (general trauma surgeons, vascular surgeons, and plastic surgeons) as well as the patient. The decision to reconstruct or amputate an extremity cannot depend on limb salvage scores, as all have proved to have little clinical utility. Using current technology and level I trauma center orthopedic clinical experience, combined with multispecialty support, current data appear to suggest that the results of limb reconstruction are equal to those of amputation following severe lower extremity trauma, and this observation should encourage the continued efforts to reconstruct severely injured limbs. Ideally, the patient with a mangled extremity should be directed to an experienced limb injury center, where strategies to minimize complications, address related posttraumatic stress disorder, improve the patient’s self-efficacy, and target early vocational retraining may improve the long-term outcomes in patients with these life-altering injuries. 

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