Session VII - Tibia

Factors Influencing the Decision to Amputate or Reconstruct following High Energy Lower Extremity Trauma

Marc Swiontkowski, MD, University of Minnesota, Minneapolis, MN; Ellen MacKenzie, PhD, Johns Hopkins School of Public Health and Policy, Baltimore, MD; Michael J. Bosse, MD, Carolinas Medical Center, Charlotte, NC; Tom Travison, Johns Hopkins School of Public Health and Policy, Baltimore, MD, and the LEAP Study Group

Introduction: The Lower Extremity Assessment Project (LEAP) is an 8-center prospective cohort study involving 601 patients who sustained high-energy lower- extremity trauma (HELET).

Decision making surrounding the management of severe lower extremity trauma is complex. Factors thought to influence the decision include injury severity, physiologic reserve of the patient, and characteristics of the patient and his or her support system. The training and experience of the treating surgeons are also considered to play a role.

Purpose: We utilized LEAP data to study the injury, patient and surgeon factors that influence the decision to salvage a limb.

Methods: Eligible patients were between the ages of 16 and 69 with type III B and C tibial fractures, dysvascular limbs due to trauma, type III B ankle fractures or severe open mid- or hindfoot injuries. Data collected at the time of patient enrollment included characteristics of HELET and its treatment, the nature and severity of other injuries, characteristics of the patient and characteristics of the attending surgeon. The injuries were characterized by Gustilo grade, AO/OTA fracture classification, detailed soft tissue assessment type, extent of the injury, and components of the existing limb salvage scales; MESS, MESI, PSI, LSI, and NISSA. Three individuals independently classified all the injuries based on the data and injury photographs.

These data were analyzed in a manner designed to determine the effect of the immediate decision to amputate or the secondary decision of a delayed amputation. Logistic regression and step-wise modeling were used to determine the effect of each covariate.

Results: Of 527 LEAP patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The orthopaedic surgeon was always involved in the treatment decision; plastic surgeons were involved in 14% of the cases and general surgeons in 42% of the cases. The patient and family were involved in treatment decisions in 36% of the cases.

The multi-variate analysis confirmed the bivariate analysis;

· All injury characteristics remained significant predictors with the exception of bone loss.

· Only insurance status was a significant predictor of a delayed amputation (those with private insurance were more likely to undergo an amputation).

· Soft tissue injury (extent of muscle, injury or deep vein injury) and absence of plantar sensation were the most important factors in accounting for model validity.

Factors Influencing the Decision to Amputate or Reconstruct following High Energy Lower Extremity Trauma (cont)

Discussion: The factors of soft tissue injury severity, absence of plantar sensation and patient characteristics of alcoholism and private insurance status have the greatest influence on the current practice of management of HELET.

Orthopaedic surgeons make these decisions with input from the trauma surgeon "team captain" in 42% of cases. The practice of using the absence of plantar sensation as a critical indicator for amputation whether or not the tibial nerve is in continuity as a major factor deserves future attention.

Conclusion: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage. LEAP will provide further insight into the functional and clinical outcomes for the decision to amputate or salvage for HELET.