Session VIII - Polytrauma

*Reconstruction or Amputation of Lower Limb-Threatening Injury: Two-Year Clinical and Functional Outcomes at Level-1 Trauma Centers

Michael J. Bosse, MD; Ellen MacKenzie, PhD; James F. Kellam, MD; Andrew Burgess, MD; Lawrence Webb, MD; Marc Swiontkowski, MD; Roy Sanders, MD; A. Jones, MD; Mark McAndrew, MD; Brendan Patterson, MD; Melissa L. McCarthy, ScD; Thomas Travison; Renan C. Castillo, MS, Carolinas Medical Center, Charlotte, NC (all authors ­ a-NIH-NIAMS)

Background: Limb-salvage protocols have replaced amputation as the primary treatment for severe lower-extremity trauma in many trauma centers. The long-term outcomes of patients with limb reconstruction or amputation have not been fully evaluated.

Methods: A multi-center, prospective, longitudinal study assessed the outcomes of 569 patients with severe lower limb injuries, with use of the Sickness Impact Profile (SIP) as the principle measure of functional outcome. Secondary outcomes included limb status, major complications resulting in re-hospitalization, and impairment as determined by a physical therapist. All outcomes were measured at 3, 6, 12, and 24 months after injury.

Results: A total of 161 patients received amputations during the initial hospital admission. Of the 408 patients discharged with salvaged limbs, 26 required late amputations. Although most of the study participants were independent in transfers, walking, and stair-climbing at the 2-year follow-up visit, a substantial proportion had slow walking speeds and severe disability as reflected in high SIP scores (42% had overall SIP scores >10), and a low percentage (51%) of the patients returned to work. Patients with reconstructed limbs had more re-hospitalizations and more hospital days than did patients whose limbs had been amputated. After controlling for the severity of the injury and the characteristics of the patient, few differences were found between treatment groups in functional outcomes. Factors that predispose patients in both treatment groups to worse outcomes included major complications, lower level of education, non-white race, poverty, lack of private health insurance, heavy smoking, and involvement with disability compensation litigation.

Conclusions: Patients with limbs at high risk for amputation but without risk factors predisposing to poor outcomes can be advised that reconstruction will usually result in a 2-year outcome equivalent to that of an amputee. This advice must be qualified to emphasize that this choice carries with it a higher complication risk, additional surgical procedures, and more hospital re-admissions. Efforts to improve the rate of successful reconstructions may have merit. Emphasis on reduction of complication rates, combined with a proactive modulation of patient risk factors known to influence outcome and targeted rehabilitation for workplace re-entry, could improve overall patient outcome.