Traumatic Decision: To Amputate Or Salvage A Limb?

An accident victim arrives at a hospital emergency room with a mangled leg — exposed tendons, shredded muscles, nerve damage and missing flesh. No, this is not an episode of ER or Grey’s Anatomy, but rather a challenging scenario that orthopaedic surgeons in trauma centers face on a daily basis.

Non-medical observers might consider it a foregone conclusion that the leg must be amputated, but the orthopaedic surgeon has a big decision to make — with more available options than ever.Limb Salvage vs. amputation: When is it time to call it quits was presented by J. Tracy Watson, MD, in a seminar of the Limb Lengthening and Reconstruction Society in conjunction with the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons.Treating mangled extremities amid significant bone loss from acute trauma is a complex surgical problem. Numerous procedures have been created to reconstitute bone stock, obtain fracture union (alignment of bone sections), and provide a stable functional limb. “The issue becomes one of a triumph of technology over reason… the individual patient’s soft tissue status determines whether limb salvage is possible,” stated Dr. Watson. “When high energy blunt or penetrating trauma occurs, the shock wave produces a massive zone of injury that may progress over several days. The surgeon has to determine if a biologically sound healing environment is present or achievable. A patient may be returned to surgery every 48 hours for additional irrigation and debridement until the zone of injury is clear or until there is a distinction between viable and non-viable tissue. If this wound area continues to be plagued with necrosis after multiple debridements then limb salvage should be questioned. Dr. Watson noted that “Aggressive debridements followed by soft tissue coverage techniques must be successful in order to save a limb.” Every patient is unique and the treatment plan must reflect that. Orthopaedic surgeons involve patients in the decision if clinical conditions suggest amputation as the only option. Patients now can look forward to a quality of life unimaginable even two decades ago with prosthetic devices and rehabilitation.A recent Lower Extremity Assessment project (LEAP) multi-center study of severe lower extremity trauma in the US civilian population reinforces that soft tissue injury severity has the greatest impact on decision-making on limb salvage vs. amputation.Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. There were 119 amputations; 55 were immediate and 64 delayed. Early (three month) assessments of pain and physical functioning were significant predictors of return to work status for patients.Dr. Watson reported that patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation. “Priority should be given to efforts to improve post-acute-care services to assist patients achieve optimal recovery, whether they proceed with a salvaged limb or prosthesis,” he emphasized.(Source: American Academy of Orthopaedic Surgeons : Wayne State University : School of Medicine : March 2007.)