THE MANGLED EXTREMITY LIMB SALVAGE VERSUS AMPUTATION

Matthew L. Jimenez, M.D.

Assistant Professor Lutheran General Hospital Department of Orthopaedic Surgery University of Chicago Medical School Illinois Bone & Joint Institute

I. Introduction a. The management of severe lower extremity trauma is a subject of considerable controversy. b. Since the early 1970s, the number of patients brought to the emergency room alive has increased. c. The evolution of sophisticated microsurgical reconstructive techniques has created the possibility of successful limb salvage, often in even the most severe cases. d. In some situations, protracted limb salvage attempts may destroy a patient physically, psychologically, socially, and financially, with adverse consequences for the entire family. e. For the severely mangled lower extremity, the functional results of limb salvage are often worse than primary amputation. II. Open Fracture Classification (Gustilo and Anderson) a. Type I b. Type II c. Type III -In the Type III injuries, four factors predispose them to major complications: -lack of soft tissue coverage of the bone -contamination of the wound -compromised vascularity -fracture instability

d. Further subclassification of Type III open fractures: (Gustilo) -Type IIIA: adequate coverage of the fracture by soft tissue despite extensive lacerations to or flaps of soft tissue, or high-energy trauma irrespective of the size of the wound -Type IIIB: extensive injury to the soft tissue with stripping of the periosteum and exposure of bone. This is usually associated with massive contamination -Type IIIC: open fracture associated with arterial injury requiring repair

III. The prognostic value of the subclassification scheme of

Type III open fractures has been demonstrated (Caudle and Stern)
a. Type IIIA had the lowest complication rates -27% nonunions -no deep infections -no secondary amputations b. Type IIIB had higher complication rates compared to Type IIIA -43% nonunions -29% deep infections -17% secondary amputations c. Type IIIC had tremendously high complication rates -100% major complications -78% amputations d. It is the Type IIIC injuries which pose the greatest challenge. The decision to attempt limb salvage versus amputation is of critical importance in this unfortunate group of patients.

IV. Limb Scoring Systems a. MESI (Gregory) -A MESI score less than 20 suggested functional limb salvage could be expected, and a score of greater than 20 was associated with an improbable limb salvage and ultimate amputation. FACTORS Injury severity score Skin damage Nerve damage Vascular injury Bone injury Lag time Age of patient Pre-existing disease Shock POINTS 1-3 1-3 1-3 1-4 1-8 1 point for every hour > 6 hrs 1-3 0-1 0-2

b. Predictive salvage score based on a review of 21 patients with combined orthopaedic and vascular trauma (Howe) -Total score greater than 8 points, amputation was preferred to salvage FACTORS Level of arterial injury Degree of bone injury Degree of muscle injury Interval from injury until arrival in the operating room POINTS 1-3 1-3 1-3 0-4

c. Predictive salvage score based on a review of 35 patients (Pozo) -The patient with an injury score of 8 or greater was unlikely to salvage a useful lower limb FACTORS Skin damage or loss requiring a major skin graft of flap Bone injury with marked comminution or bone loss Muscle damage requiring excision of muscle or tendon Vascular damage involving femoral, popliteal, or both tibial arteries Nerve damage involving the sciatic or posterior tibial nerve Wound contamination POINTS 2

2 2 2

2 2

d. Mangle Extremity Score (MESS) (Jahansen) -a MESS score of more than 7 predicted amputation with 100% accuracy FACTORS Skeletal and soft tissue injury Shock Age POINTS 1-4

Degree of limb ischemia 1-3 0-2 0-2

e. Limb Salvage Index (LSI) (Russell) -In 70 limbs studied, 51 patients with an LSI score of less than 6 had successful limb salvage, and all 19 patients with an LSI score of 6 or greater had amputations FACTORS Arterial injury Nerve injury Bone injury Skin injury Muscle injury Vein injury Warm ischemic time POINTS 0-2 0-2 0-2 0-2 0-2 0-1 0-4

f. Criticisms of scoring systems -observer error -often no reference to other life threatening multi-system injuries -not all take into account the site of injury (proximal/distal) -do not differentiate by mechanisms of injury (weapons/MVA/fall) -often do not address long-term function -use of the scores may complicate or even precipitate medicolegal issues V. Absolute indications for primary amputation of the lower limb (Hunter) -Complete amputation at the time of the accident. Replantation of lower extremities not indicated. -Irreparable sciatic or posterior tibial nerve injury in association with a Type IIIC tibia fracture -Warm ischemia time greater than 6-8 hours -Type IIIC injury associated with life threatening injuries with shock, DIC, or ARDS -Cadaveric foot on initial exam VI. Relative indications for primary amputation of the lower limb (Hunter)
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-Type IIIC fractures of the tibia -Crush injuries of the lower limb and ipsilateral foot -Significant tibial bone loss or associated severe damage to knee or ankle joints VI. Summary a. Photograph limb whenever possible b. Obtain a second opinion, directly or indirectly (by telephone), particularly when considering primary amputation c. Use a combination of clinical judgment, common sense, and predictive indices available in recent literature to make the appropriate decision