Session I - Tibia Fractures

Limb Salvage versus Amputation Patients: Are They Different from Each Other and the General Population?

Ellen J. MacKenzie, PhD, Michael J. Bosse, MD,and the LEAP Study Group

Carolinas Medical Center, Charlotte, North Carolina, USA

Purpose: The appropriate management of limb threatening leg injuries remains the subject of extensive debate in the orthopedic trauma literature. A multi-center, prospective study of 520 patients was designed to address this controversy. The objectives of this paper are two fold: (1) to report the sociodemographic, economic and personality characteristics of patients enrolled in the study and compare them with persons of similar age and gender in the general population; and (2) to determine if patients undergoing limb salvage versus amputation differed significantly from each other.

Methods: Eligible for the study were patients aged 16-69 with high energy lower extremity trauma (HELET) who were admitted over a 3-year period to one of 8 level I trauma centers. Patients who agreed to participate in the study were examined and interviewed during their initial hospital stay. The purpose of the interview was to characterize the patients across several dimensions hypothesized to influence functional outcome and well being, including: sociodemographics, economic and social resources, health status and health behaviors pre-injury, characteristics of the pre-injury job (if working), motivation to work, and personality characteristics (as profiled by the NEO-PI, a well validated five factor personality inventory). To ascertain how study patients compared to the general population, the cohort was compared to census information and, where possible, to population survey data and published norms. Patient characteristics were also compared for patients undergoing limb salvage versus amputation and the appropriate statistical tests used to determine the statistical significance of any differences.

Results: A total of 520 patients were enrolled at baseline (91% of those eligible); 26 had bilateral HELET. 45% had grade IIIB or IIIC tibia fractures, 22% severe foot injuries, 8% severe soft tissue injury, 5% traumatic amputation and 20% multiple injuries. Approximately two-thirds of the injuries resulted from motor vehicle/motorcycle crashes. Of the 546 legs with HELET, 28% underwent amputation in the hospital (66% BKA; 34% AKA/TKA). The majority of patients were male (75%), Caucasian (72%) and between the ages of 20 and 45 (70%). 69% had a highschool education (compared to 86% nationally of similar age and gender) (p<.0 1) and 77 % were working per-injury. The distribution by occupation (for those employed) and median personal income was different than found in the general US population of similar age and gender. Seventy-two percent were employed in blue collar jobs with a median annual income of $15,500 (compared to the national average of 53% blue collar workers and median income of $19,730) (<.01). Twenty-eight percent of the patients lived in households with incomes below the federal poverty line compared to 15% nationally (<.0l). The percent with no health insurance (40%) is also higher than the general population (20%) (p <.0l).

Study patients were generally healthy pre-injury (90% rated their health as either excellent or good compared to 92% nationally). Although the percent of patients who were current drinkers pre-injury was similar to national figures (70%), the percent of heavy drinkers (among current drinkers) was two times higher than reported nationally (26% versus 11%) (p<.01). The percent who were smokers is also higher (38% for study patients versus 29% nationally) (p <.05). Underlying personality traits (as measured by the NEO-PI) varied considerably across study patients. Taken as a group, study patients were slightly more neurotic and extroverted than the general population and less open to new experiences, less agreeable and less conscientious. Differences in personality traits, however, were not statistically significant at p = .05.

When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found (p>.05). Similarly, whether amputation versus limb salvage was considered as a treatment option (as reported by the attending surgeon) was not correlated with any of the patient characteristics.

Discussion and Conclusion: Patients with HELET differ significantly in sociodemographic and socioeconomic background when compared to the general population of similar age and gender. Although they also differ somewhat in personality characteristics, these differences were not large or statistically significant. Type of treatment (i.e. amputation versus salvage) was not associated with any of the soiciodemographic, economic and personality characteristics. It will be important to examine how observed variations in patient characteristics and resources influence long-term outcome following amputation and limb salvage.