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Chapter 2B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

The Choice Between Limb Salvage and Amputation: Trauma

Roy Sanders, M.D. 
David Helfet, M.D. 

HISTORIC PERSPECTIVE: AMPUTATION AS THE STANDARD OF CARE

The choice between limb salvage and amputation of the severely traumatized lower limb is a rather modern concept. For thousands of years, an open fracture was a sentence of death, and although amputation was recommended, most patients died. In 1832, Malgaigne reported that the mortality rate for amputations performed in the hospital was 52% for major amputations overall and 62% for thigh amputations specifically. This is not surprising when the methods employed are scrutinized.

Operations were conducted on the unwashed patient in his bed with the rest of the ward looking on. All surgery before 1846 was performed without anesthesia. Speed was of the essence, and amputations were done with strong men holding the patient down, usually within 3 minutes. Casual onlookers put their hands in the wound. Instruments were simply wiped clean, often on the surgeon's shirt. Because surgeons also performed autopsies, hands were not washed between pro-section and amputation. Wounds were packed with dressings made of old bedsheets and rags. Postoperatively, a pus bucket was used to wash wounds on the ward; by the end of the day this bucket contained the blood and pus of all patients on the ward.

War was even worse. The mortality rate for open fractures in the Franco-Prussian War (1870-1871) was 50% for transtibial and 66% for transfemoral amputations. In the American Civil War, the mortality rate for transtibial amputations was 33% and for transfemoral amputations 54%. In 1874 von Nussbaum recorded a 100% mortality rate for 34 consecutive knee disarticulations!

The development of the germ theory, hand washing, proper sanitation, and improved nursing caused mortality rates from open fractures to virtually disappear. H. Winnett Orr in World War I treated open wounds by using a protocol of wound extension, cleaning, stable reduction of the fracture, and application of plaster with the wound left open. His mortality and amputation rate, as a result, was extremely low. Trueta, using this technique, was able to obtain a 0.6% septic mortality rate in 1,069 open fractures in the Spanish Civil War. It is interesting to note that these two men simply used the principles of Ambroise Pare, who in 1540 advocated irrigation, debridement, stabilization, and open packing of open fractures.

THE MODERN ERA: LIMB SALVAGE

As death from wound sepsis disappeared and safe and effective elective surgery became possible, salvage of the mangled limb became a reasonable consideration. The next important advance was vascular reconstruction. In World War II, DeBakey and Simeone still reported an amputation rate of 75% for popliteal artery injuries associated with fractures, but the Korean War experience paved the way for successful arterial repair, and by the Vietnam conflict, the overall amputation rate for open fractures with vascular injury was negligible.

Advances in all fields of medicine have made salvage of the massively injured lower limb a reality. As orthopedic traumatology developed into a subspecialty, surgeons began to view amputation of a mangled lower limb as an admission of defeat. Salvage of even the most complex injury became technically possible. Published reports of these heroic procedures, however, did not clearly define the nature and severity of the skeletal injury, and little was written about long-term results. Additionally, decision-making alogorithms for amputation vs. salvage were considered unnecessary.

NEWER CONCEPTS: DECISION MAKING

In 1976, Gustilo and Anderson reported on a prognostic classification scheme for open fractures that was based on wound size. They isolated the type III open fracture as having the worst prognosis, with a high rate of infection, nonunion, and secondary amputation. In 1984, Gustilo et al. reported on a subclassification of type III open fractures, which again was prognostic. This included the following: type IIIA, adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps; type IIIB, extensive soft-tissue injury with periosteal stripping and bony exposure, usually associated with massive contamination; and type IIIC, an open fracture with an arterial injury requiring repair. This classification was used by Caudle and Stern and again found to be prognostic. In their review of 62 type III open tibial fractures, type IIIA injuries had a low complication rate, type IIIB open fractures had significant complications, and type IIIC open tibial fractures had disastrous rates with 100% major complications and a 78% secondary amputation rate (Table 2B-1.). These authors began to question the wisdom of salvage in type IIIB and IIIC tibial injuries.

Similarly, Lange et al. analyzed 23 cases of open tibial fractures with limb-threatening vascular compromise. Fourteen cases (61%) underwent amputation, and none had complications or functional disability at the 1-year follow-up visit. In contrast, those patients who underwent limb salvage required several operations and had persistent wound or tibia healing problems at 1 year. The authors suggested that a realistic appraisal of functional outcome be made when deciding in favor of salvage for limbs with type IIIC injuries inasmuch as the overall amputation rate for these injuries in the more recent literature approached 60%(Table 2B-2.)

Bondurant et al. reported on the financial cost of limb salvage in open MB and MC tibia fractures. Of 263 patients, 43 ultimately underwent amputation. Fourteen patients had a primary amputation and averaged 22.3 days in the hospital, 1.6 operative procedures, and $28,964.00 in hospital costs. Those who had attempts at limb salvage averaged 53.4 days in the hospital, 6.9 operative procedures, and $53,462.00 in hospital costs. The authors suggested that with appropriate criteria, early amputation would improve function, shorten hospitalization, and lessen the financial burden placed on both the patient and the institution.

Recently, Hansen and others have noted that when post-traumatic limb salvage patients were candid, they frequently stated that although their limbs were saved, their lives were ruined by the prolonged and costly attempts at reconstruction. Hansen has termed this approach the "triumph of technique over reason." Several authors now suggest that early amputation and prosthetic fitting are perhaps the preferred alternative to salvage of a questionably functional lower limb. It is the goal of this chapter to offer the orthopedist information that will assist in rational decision making in these difficult injuries.

THE TYPE IIIC TIBIAL FRACTURE-CAN SALVAGE BE PREDICTED?

To determine when amputation is not only justified but beneficial, a predictive scale with objective criteria is required. Well-designed, prospective, controlled multicenter studies with large patient populations are needed to obtain these data. Although several studies have attempted to develop objective criteria, to date no predictive scale exists that can be used with confidence in amputation decision making. Furthermore, long-term functional outcome studies on patients with salvage procedures are needed as well. It is uncertain whether donor site morbidity, joint stiffness, shoe modifications, neurologic impairment, and prolonged rehabilitation times justify salvage.

Daines evaluated 26 lower-limb fractures with vascular injuries on the basis of four variables. These included (1) the extent of soft-tissue damage, (2) the duration and severity of ischemia, (3) the presence of shock, and (4) the age of the patient. These authors defined a score that was predictive of amputation and had no Overlap in data. They also felt that soft-tissue grading was the most important variable.

Gregory et al. proposed a mangled extremity severity index (MESI). A point system was developed for the severity of injury to four major organ systems of the limb (integument, nerve, vessel, and bone). This injury severity scale (ISS) considered lag time, age, pre-existing disease, and shock. They found a dividing line at 20, below which limb salvage was predictable and above which amputation was 100%. This initial series was limited to only 12 cases, the fracture type was not identified, and an unspecified number of primary amputations was included.

Lange et al. proposed a protocol based on absolute and relative indications for amputation(Table 2B-3.). The occurrence of one absolute indication or two relative indications was felt to warrant amputation. Unfortunately, only a minority of cases fit these criteria, and the relative indications listed were extremely subjective and required considerable experience.

Recently, Helfet et al. have combined most of the abovementioned studies into a modified version of the MESI to predict amputation rates(Table 2B-4.). This scoring system was used only in documented type IIIC open tibial fractures, first retrospectively in 26 cases and then prospectively in an equal number of cases. The scoring was performed after the salvage-vs.-amputation decision had been made. In both groups there was a significant difference in the mean MESI scores between those limbs that were amputated and those that were salvaged. In both, a score of 7 or greater was 100% predictive of amputation. Although the preliminary data base is small, this scoring system holds promise as the first objective scoring system that can predict poor outcome and thereby justify amputation.

Given the above discussion, when should the surgeon amputate, and when should he consider salvage in a type IIIC tibial injury? At the present time, the basis upon which to make a sound, defensible, and reasonable decision for primary amputation is still insufficient. Lange has recently identified certain variables that are important (Table 2B-5.), but feasibility variables (technically salvageable) combined with advisability variables (best interest of the patient) result in a complex prognostic-treatment interplay. A crush injury in a young laborer is very different from the same injury in a 60-year-old diabetic. Similarly, a tibial injury may need a different approach if severe ipsilateral foot trauma exists. It should therefore be obvious that the majority of cases will fall into a gray zone of indeterminate prognosis. In these cases a decision-making team and a tertiary-care facility are almost mandatory. Lange has stated that

inexperience in evaluating these injuries and the lack of multidisciplinary consultation may render it ethically impossible for a surgeon to recommend a primary amputation and, as well, may make successful limb salvage unrealistic.

In summary, the MESI and Lange's absolute and relative indications should be used to determine possible need. Several surgeons should be consulted. Patient and family conferences (perhaps with an amputee present) are required, and a frank discussion should ensue; then a joint decision can be made with, it is hoped, better patient satisfaction.

TYPE IIIB INJURIES-THE CASE FOR SALVAGE

In type IIIB open fractures, limb salvage has a greater likelihood of success because by definition a vascular injury requiring repair is not present. The preponderant problem in this group of patients is infection from massive contamination and muscle necrosis. Should attempts at salvage be undertaken, standard protocols should be used.

The patient should be examined in the emergency room, and the wound should be identified and then sterilely covered. It is not uncovered until the operating room. Antibiotic treatment is started, and the patient is brought to the operating room as soon as possible. Angiography, if needed, is performed in the operating room and not in the angiography suite. In no other injury is meticulous debridement so important. Damaged and contused skin and all obviously necrotic muscle, tendon, and bone must be initially removed. Thereafter, irrigation with saline is necessary to remove all particulate matter. At this point deep cultures, which will represent true bacterial flora, are taken. After initial debridement of soft tissue and bone, bony stability is obtained, usually with an external fixator, to prevent further soft-tissue compromise. Osseous defects can be filled with antibiotic-impregnated methyl-methacrylate beads (made by mixing 1.2 g of tobramycin and one package of methylmethacrylate) over braided 26-gauge wire. These beads provide a local depot of antibiotic and a space for the later bone graft. Temporary open wound coverage (not closure!) is obtained by the use of dressing sponges or Epigard (Syn-thes USA, Paoli, Penn), a synthetic biological dressing. Once stable, the limb will need repeat debridements at 24 and 48 hours to assess muscle viability. All dead tissue must be removed. Although the patient receives intravenous antibiotics during this period, debridement is without doubt the most important treatment to prevent infection. Once clean, closure of the soft-tissue wound within 5 to 7 days is ideal. This can be accomplished with either split-thickness skin grafting, local flaps, or vascularized free-tissue transfer, most commonly with the latissimus dorsi or serratus anterior muscles. If this treatment is successful, the surgeon has transformed a massively contaminated open fracture into a clean, closed fracture that requires only bony reconstruction. Usually this can be accomplished with a variety of internal fixation devices and/or bone grafting, including vascularized fibula transplantation and the Ilizarov technique.

Because an injury is classified IIIB, however, does not mean that a vascular component is not present; it only means that an arterial repair was not needed. Many limbs therefore again fall into a gray zone. If the posterior tibial artery is severed and the leg is perfused through the anterior tibial artery, partial necrosis of the posterior musculature can occur. Similarly, prolonged arterial kinking that is corrected with realignment of the limb may cause significant myonecrosis. These problems will essentially result in a loss of a large amount of muscle mass during debridement and may in fact result in a loss of foot and ankle function. This, coupled with bony injuries involving the ankle or subtalar joint, may make salvage totally unrealistic.

Recently, Sanders et al. evaluated the results of a salvage protocol in 11 grade IIIB ankle and talus injuries. All patients required anterior plating, multiple-level fusions, free flaps, and bone grafting. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2 per patient (range, 5 to 12). The total in-patient hospital stay averaged 61.6 days (20 to 107 days), and inpatient costs averaged $62,174.43 per patient (range, $33,535.06 to $143,847.45). Overall hospital cost averaged $1,009.32 per day. All injuries healed; the fusion rate and muscle flap success were 100%, no patients developed osteomyelitis, there were no nonunions, and none required subsequent amputations.

When asked about their functional outcome in detail however, all patients stated that the injury had significantly altered their life-style. Five patients returned to an altered job, while the other six became permanently disabled. All stated that their interpersonal relationships with spouses or immediate family members had become strained. Those patients with children or grandchildren stated they could no longer play with them, even on an occasional basis, because this required too much activity. Shopping at the mall or going out at night was equally difficult, with most patients participating in these activities only if absolutely necessary. All stated that they were unhappy with the appearance of their limb, their gait, and their shoes. All patients were offered an amputation as a definitive procedure at the time of final interview; all refused.

Before a decision regarding limb salvage can be made, prognosis for the injury must be known. While the outcome for some injuries is fairly predictable, for most it is not. Prospective grading scales infrequently exist, and outcome studies are few. Again, should salvage be undertaken in a type IIIB open tibia, certain guidelines exist. Posterior tibial nerve disruption in an adult coupled with severe foot and ankle trauma will lead to an extremely poor result. In an adult with underlying vascular disease, this is probably an indication for amputation. In injuries that involve much muscle damage, debridement leaves the patient with little if any functional capabilities, and when associated with significant bony loss in excess of 6 cm, amputation will probably best serve the patient. Finally, a large segmental defect involving the knee joint and extensor mechanism, coupled with a peroneal nerve injury, will, if salvaged, result in a knee fusion and the use of an ankle-foot orthosis. The lack of mobility (especially in older patients) coupled with the large energy expenditure required makes amputation in this situation equally desirable.

CONCLUSIONS

When massive trauma to the lower limb occurs, difficult decisions must be made by the orthopaedic surgeon. Although treatment has changed significantly over the last 200 years, many of the same dilemmas exist. It is the obligation of the physician to treat the entire patient and not the limb in isolation. What is technically feasible may not be in the best interests of the patient. Amputation should not be considered a failure, but rather another therapeutic modality. To return an individual to preinjury function while limiting pain and suffering is the goal of treatment. If this cannot be accomplished by limb salvage, then serious consideration must be given to amputation. It is hoped that future multicenter prospective studies will clearly delineate the necessary guidelines.

References:

1. Bondurant FJ, Cotler HB, Buckle R, et al: The medical and economic impact of severely injured lower extremities. J Trauma 1988; 28:1270-1272.
2. Border J, Allgower M, Hansen ST, et al: Blunt Multiple Trauma: Comprehensive and Pathophysiology and Care, New York, Marcel Dekker Inc, 1990.
3. Caudle RJ, Stern PJ: Severe open fractures of the tibia. J Bone Joint Surg [Am] 1987; 69:801-807.
4. Christian EP, Bosse MJ, Robb G: Reconstruction of large diaphyseal defects, without free fibular transfer, in grade-IIIB tibial fractures. J Bone Joint Surg [Am] 1989; 71:994-1004.
5. Daines M: Severe lower extremity trauma: Can objective criteria predict ultimate amputation? Unpublished data.
6. DeBakey ME, and Simeone FA: Battle injuries of the arteries in World War II: An analysis of 2471 cases. Ann Surg 1946; 123:534-579.
7. Gregory RT, Gould RJ, Peclet M, et al: The mangled extremity syndrome (M.E.S.): A severity grading system for multi-system injury of the extremity. J Trauma 1985; 25:1147-1150.
8. Gustilo RB: Management of Open Fractures and Their Complications. Philadelphia, WB Saunders Co, 1982.
9. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: A retrospective and prospective analysis. J Bone Joint Surg [Am] 1976; 58:453-458.
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11. Hansen ST: Overview of the severely traumatized lower limb. Clin Orthop 1989; 143:17-19.
12. Hansen ST: The type IIIC tibial fracture. J Bone Joint Surg [Am] 1987; 69:799-780.
13. Helfet DL, Howey T, Sanders R, et al: Limb salvage versus amputation: Preliminary results of the mangled extremity severity score. Clin Orthop 1990; 256:80-86.
14. Hicks JH: Amputation in fractures of the tibia. J Bone Joint Surg [Br] 1964; 46:388-392.
15. Lange RH: Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop 1989; 243:92-99.
16. Lange RH, Bach AW, Hansen ST, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985; 25:203-208.
17. Rich NB, Baugh JH, Hughes CW: Popliteal artery injuries in Vietnam. Am J Surg 1969; 118:531-534.
18. Sanders R, Helfet DL, Pappas J, et al: The salvage of grade IIIB open ankle and talus fractures. Orthop Trans
19. Wangensteen O, Wangensteen S: The Rise of Surgery from Empiric Craft to Scientific Discipline. Minneapolis, University of Minnesota Press, 1978.

Chapter 2B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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