Heroic reconstruction or amputation in limb trauma.
Before I start off the article would like people have a different perception about prosthesis.
Can Prosthetics Outperform Real Limbs?
Salvage or amputation?
One of the most difficult decisions an orthopaedic surgeon may face is that of whether to salvage or amputate a severely injured limb. Such a decision is rarely clear-cut. Several factors require consideration: the degree of damage to the extremity and the severity of the overall injury, as well as the nature of the patient’s physical, psychologic, social, and economic status, including such aspects as age, previous state of health, attitude, wishes, reliability, support system, life-style, occupation, and financial resources.
In the 1960s, the presence of a severe crush injury or a vascular injury was sufficient to warrant an amputation. However, the evolution of sophisticated microsurgical reconstruction techniques along with the development of modern skeletal fixation and reconstruction devices in the 1980s made limb salvage technically possible even in the most extreme cases. Surgeons began undertaking prolonged attempts at reconstruction, and patients who sustained severe Grade III B and C open tibia fractures were subjected to two to three years of hospitalization; multiple surgeries, sometimes up to 20 surgeries including debridement, fixation attempts, soft tissue cover procedures, and bone grafts, were performed.
” Most initial studies the primary goal was limb salvage, but we must understand limb salvage doesn’t equate to functional limb”
Despite such heroic but not very wise efforts, failures were common because of infection, nonunions, soft tissue cover failures, and delayed secondary amputation. In the process, many patients lost their jobs, families, savings, and most importantly, their self-image and self-respect. As a result of secondary amputation, not just the limb is lost, but the patients and their families are frequently devastated and destroyed physically, psychologically, socially, and financially. It became obvious that technical advances can be double-edged swords, and prolonged attempts at salvage may actually be a “triumph of technique over reason”. The salvaged limb, in some cases, may become a liability instead of an asset.
Salvage, certainly, is no guarantee of functionality or employability. Francel et al found that 50% of patients with a salvaged lower extremity required an assistive device to walk. Such a device may be cumbersome: walking with crutches and a non-functioning lower extremity requires about 15% more energy than a below-knee prosthesis. Only 28% of the patients with salvaged limbs in Francel’s study were able to achieve long-term employment, compared with 67% of early amputees in a study by Penn and Barwell.
” The primary goal of any limb trauma reconstruction should be functionality and social rehabilitation not just limb salvage”
In attempting to keep the whole body intact, surgeon and patient may fail to see the whole picture. Saving a limb may sacrifice a life; that is, salvage may compromise a patient’s quality of life in the long run. For some patients, resuming their pre-injury level of functioning may be better achieved through early amputation, with subsequent prosthetic fitting, than through prolonged salvage and the associated discomforts and risks of repeated operations and hospitalizations.The difficulty is identifying which patients might have a better quality of life if their severely injured limb were amputated in the days immediately after the trauma.
How To Decide
The decision to amputate a limb is chiefly mandated by the severity of injury to the lower limb, associated injuries, and the health status of the patient. However, the assessment of severity of injury to the limb is usually done based on subjective criteria rather than objective criteria. The fallacy of this method led several authors to attempt to quantify the severity of trauma and to propose scores so as to establish numerical guidelines. The currently available scores include the Mangled Extremity Severity Score (MESS), the Predictive Salvage Index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of the Patient (NISSSA) score; the Hannover Fracture Scale-97 (HFS-97), and the Ganga Hospital Open Injury Severity Score (GHOISS).
The purpose of these scores is to allow accurate prediction of either the need for amputation or the possibility of salvage. Ideally, a trauma limb-salvage score should have a perfect accuracy with a sensitivity of 100% (all amputated limbs with trauma limb-salvage scores at or above the threshold) and specificity of 100% (all salvaged limbs with scores below the threshold). However, this level of accuracy is impossible in any clinical setting, especially in an open injury, where the variables influencing the outcome are often difficult to numerically quantify and not confined to the status of the limb or the even the individual. There are important external factors such as the technical facilities available and the surgical skills of the treating team.
With various scoring systems in place to help decide salvagability of limb a comparison of scoring system is necessary. The biggest study ever taken to compare the scoring systems was LEAP
It was found that Limb salvage index had the highest specificity and sensitivity for Type 3C fractures.
|Artery||contusion, intimal tear, partial laceration or avulsion (pseudo-aneurysm) with no distal thrombosis and palpable pedal pulses||0|
|complete occlusion of 1 of 3 shank vessels or profunda||0|
|occlusion of 2 or more shank vessels||1|
|complete laceration, avulsion, or thrombosis of femoral or popliteal vessels without palpable pedal pulses||1|
|complete occlusion of femoral or popliteal vessels with no distal runoff available||2|
|complete occlusion of 3 shank vessels with no distal runoff available||2|
|Nerve||contusion or stretch injury||0|
|minimal clean laceration of femoral, peroneal or tibial nerve||0|
|partial transection or avulsion of sciatic nerve||1|
|complete or partial transection of femoral, peroneal or tibial nerve||1|
|complete transection or avulsion of sciatic nerve||2|
|complete transection or avulsion of both peroneal and tibial nerves||2|
|Bone||closed fracture at 1 or 2 sites||0|
|open fracture with comminution or with minimal displacement||0|
|closed dislocation without fracture||0|
|open joint without foreign body||0|
|closed fracture at 3 or more sites on same extremity||1|
|open fracture with comminution or moderate to large displacement||1|
|open joint with foreign body||1|
|bone loss <3 cm||1|
|bone loss ≥ 3 cm||2|
|type III-B or III-C fracture (open fracture with periosteal stripping, gross contamination, extensive soft tissue injury or loss)||2|
|Skin||clean laceration, single or multiple||0|
|small avulsion injury with primary closure||0|
|first degree burn||0|
|delayed closure due to contamination||1|
|large avulsion requiring split thickness skin graft or flap closure||1|
|second and third degree burn||1|
|Muscle||laceration or avulsion involving a single compartment||0|
|laceration or avulsion involving a single tendon||0|
|laceration or avulsion involving 2 or more compartments||1|
|complete laceration or avulsion of 2 or more tendons||1|
|Deep vein||contusion, partial laceration, or partial avulsion||0|
|complete laceration or avulsion if alternative route of venous return is intact||0|
|superficial vein injury||0|
|complete laceration, avulsion or thrombosis with no alternative route of venous return||1|
|Warm ischemia time||<6 hours||0|
- minimum score: 0
- maximum score: 14
- The higher the score the more severe the injury.
|Limb Salvage Index||Outcome|
|0−5||Limb salvage successful|
All of these scores give importance to prescence of vascular injury. But there are various types of Type III B fractures which pose reconstructive challenges. The best predictive scoring ststem for Type IIIB fractures was proposed by Rajasekaran et al. in 2006 Ganga Hospital Open Injury Severity Score(GHOISS).
The score was developed in 1994 and was subsequently modified to the published form after three clinical trials. It assessed the severity of the injury to the limb separately to each of the three components of the limb: the covering tissues (skin and facia), the skeleton (bones and joints), and the functional tissues (muscles, tendons and nerve units) . Seven systemic factors, which may influence, the treatment, and outcome were given two points each, and the final score is arrived by adding all the individual scores together. The total score was used to assess the possibilities of salvage, and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group 1 scored less than 5, group II 6–10, group III 11–15, and group IV 16 or more.
|Covering structures: Skin and fascia||Score|
|Wounds with out skin loss|
|Not over the fracture||1|
|Exposing the fracture||2|
|Wounds with skin loss|
|Not over the fracture||3|
|Over the fracture||4|
|Circumferential wound with skin loss||5|
|Skeletal structures: Bone and joints|
|Transverse/oblique fracture/butterfly fragment < 50% circumference||1|
|Large butterfly fragment > 50% circumference||2|
|Comminution/segmental fractures without bone loss||3|
|Bone loss < 4 cm||4|
|Bone loss > 4 cm||5|
|Functional tissues: Musculotendinous (MT) & Nerve units|
|Partial injury to MT unit||1|
|Complete but repairable injury to MT units||2|
|Irreparable injury to MT units/partial loss of a compartment/complete injury to posterior tibial nerve||3|
|Loss of one compartment of MT units||4|
|Loss of two or more compartments/subtotal amputation||5|
|Co-morbid conditions: Add 2 points for each condition present|
A score of 14 to indicate amputation had the highest sensitivity and specificity. GHOISS was found to compare favorably with the MESS in sensitivity (98% vs 99%), specificity (100% vs 17%), positive predictive value (100% vs 97.5%), and negative predictive value (70% vs 50%). The scoring system was found to be simple in application and reliable in prognosis for salvage and outcome measures.
A unique factor of the score was that it provided thresholds for salvage and amputation and also a grey zone in between. It was emphasized that injuries with a score of 14 and below should be attempted for salvage, those with the score of 17 and above should be considered for primary amputation, and those in between must be assessed by an experienced team on a case-to-case basis. They stated that it was important to have an intermediate grey zone rather than a strict threshold score because the management of these severe injuries is influenced by many other factors such as skill and experience of the treating team, the social and cultural background of the patient, the cost, and the personality of the patient.
Variables related to the patient’s psychologic, social, and economic status are important predictors of future quality of life. Interestingly, factors associated with the patient, rather than the patient’s injury, correlated with a successful return to work, which was more likely for patients younger than 40, more highly educated, and employed in white-collar jobs. Other factors that predict failure of prolonged salvage include inability to afford a protracted absence from work, poor social support system, and unreliability.
Financial status has not been closely analyzed until recently. Indeed, this factor may become increasingly important as the cost consciousness of managed care assumes greater influence in determining treatment and saddles the patient with greater responsibility for the cost of care.
“In attempting salvage, the question therefore is not “whether you can” but “whether you should or not.” There is good evidence that patients with primary amputation and who have been rehabilitated well not only perform better but are also saved of the agony of multiple surgical procedures and severe financial strain. However, a limb that could be saved must never be amputated.”
Before ending I would like to Quote the Words of Dr Raja Sabapathy from Ganga hospital, Coimbatore. Before you embark on reconstructing a lower limb trauma, one should answer three questions that every patient has in his mind
- Will I walk normally?
- When will I walk normally?
- How much will it cost?
Only when the Doctor is able to answer all three questions and patient accepts them, one should attempt complex reconstruction as there is nothing more devastating to patient than a incomplete or failed reconstruction.