1. Primary amputation is associated with similar long-term outcomes to limb salvage and should be considered a reconstructive procedure.
2. The decision to amputate or salvage a limb is based on a careful multidisciplinary analysis of both injury and patient variables and should not be based on an injury severity score tool. The decision to amputate after trauma must involve an orthopaedic surgeon, a plastic surgeon, a rehabilitation specialist, and the patient and their family members or carers whenever possible. Operative photographs illustrating the extent of limb injury should be obtained and stored in the patient’s file.
3. Immediate amputation is indicated in the following cases:
a) when a limb is the source of uncontrollable life-threatening bleeding or as part of damage control in cases of severe limb trauma in unstable polytraumatised patients;
b) an avascular limb with a warm ischaemia time greater than 4–6 hours;
c) extensive crush injuries, particularly involving both the tibia and the ipsilateral foot.
4. Positive neurological findings at presentation including absent plantar sensation and lack of motor function are not absolute indicators for amputation but may warrant direct nerve visualisation.
5. When indicated, a delayed primary amputation should be performed within 72 hours of the injury.
6. Maximising residual limb length is imperative for mobility. A through-the-knee level should be considered in preference to above-knee, and soft tissue reconstructive techniques should be used where there is sufficient bone but inadequate soft tissues to achieve a more distal amputation level.
7. Vigilant follow-up with emphasis on the whole patient including pain management, psychological health, and active rehabilitation is essential to maximise good functional outcomes. Revision surgery can dramatically improve prosthetic use, limb function, and quality of life, and regular orthoplastic review should continue for at least 2 years.
The decision to amputate rather than reconstruct a severely injured limb (‘mangled extremity’) has historically been one of the most difficult choices faced by a trauma surgeon. The surgeon’s responsibility is heightened by the knowledge that delayed or incorrect decision-making may lead to worse outcomes (1). Unfortunately, hard data upon which to base reliable decisions remain elusive. A prospective analysis of the use of scoring systems including the Limb Salvage Index, the Predictive Salvage Index, the Hanover Fracture Scale, and the NISSSA (Nerve injury, Ischaemia, Soft-tissue contamination, Skeletal damage, Shock, Age) and MESS (Mangled Extremity Severity Score) scores did not validate the clinical utility of any of the scoring algorithms (2, 3).
A number of studies, including two meta-analyses, have shown the final outcomes of amputation after trauma are similar to the outcomes after limb salvage, with high rates of long-term disability reported in both patient groups (4, 5, 6). More recent research has focused on injury and patient factors that may impact on the final functional outcome after both amputation and limb salvage (1, 6, 7). We advocate early identification of poor prognostic factors as the basis for the decision to amputate or salvage.
Resuscitation and limb assessment
A severe limb-threatening injury is usually obvious and can be a distraction to the assessment and resuscitation of the patient. Up to 17% of patients with severe limb trauma will have associated life-threatening injuries, which must be identified and treated according to the advanced trauma life support (ATLS) principles of ABCDE (Airway, Breathing, Circulation, Disability, Exposure) (8), but also consider that the limb injury itself may be life-threatening. A thorough limb examination is only performed after the airway is secured and the cardiopulmonary function is stable. Haemorrhage from the limb is traditionally assessed during C (Circulation) of the primary survey and is addressed by either direct pressure or the judicious use of a tourniquet. However, more recently, the need to deal with catastrophic haemorrhage at an earlier stage has been recognised in the sequence CABCDE.
Immediate primary amputation
There are a number of uncommon injury scenarios when immediate amputation is indicated. Incomplete traumatic amputation involving almost complete severance of the limb, often accompanied by extensive injury to the distal segment, requires prompt surgical completion of the amputation. Extensive crush injuries involving both the tibia and the foot and avascular limbs with a warm ischaemic time in excess of 4–6 hours also demand early amputation. Occasionally, unstable polytraumatised patients may need urgent amputation of uncontrolled bleeding mangled extremities as part of a damage control protocol when the patient’s general condition precludes the lengthy reconstruction required for salvage (3). Operative photographs are valuable documentary evidence of the extent of the limb injury and should be taken and stored in the patient’s record (9).
Guillotine amputations are to be avoided as they sacrifice residual limb length and viable tissue. Viable muscle and skin flaps should be retained whenever possible (10). Wounds should not be formally closed and the use of negative-pressure wound therapy dressings is recommended. If immediate amputation is required for life-threatening injuries, complete documentation of the extent of the injury with intra-operative photographs will be helpful in explaining the decision to the patient and their family.
The decision to amputate or reconstruct a severely injured extremity should be based on an analysis of the characteristics of the limb injury and the physiological reserve of the patient (Box 12.1). A multidisciplinary discussion involving an orthopaedic surgeon, a plastic surgeon, rehabilitation specialist, the patient, and their family or carers is essential whenever possible before embarking on surgery. A recent meta-analysis of prognostic factors associated with amputation following repair of lower extremity vascular trauma highlighted a number of factors associated with an increased risk of secondary amputation (11). Risk factors for amputation included major soft tissue injury, compartment syndrome, an ischaemic time beyond 6 hours and age over 55 years.
Reperfusion of an ischaemic limb needs to be achieved within 4–6 hours of injury (see Chapter 10). However, the precise time of injury may not have been established and the ischaemic threshold may be reduced if the patient has been persistently hypotensive (12).
Historically, the absence of plantar sensation in the traumatised limb was considered an indication for amputation due to risk of development of neuropathic ulcers and other chronic complications associated with an insensate foot. However, a study comparing patients presenting with an insensate foot on clinical examination had similar outcomes following limb salvage at over 2 and a half years compared to a matched group with intact plantar sensibility at presentation (13). The presence of abnormal neurological findings at presentation, either motor or sensory, remains a significant finding and the nerve should be inspected at the initial wound excision, particularly in the presence of suspected arterial trauma. Confirmed irreversible nerve trauma, particularly of the posterior tibial nerve due to avulsion, transection, or segmental loss in an adult should be factored into the decision whether to salvage or amputate the limb.
Soft tissue damage and contamination
The level and the extent of soft tissue damage directly influences the surgical options for both amputation and limb salvage, and is a major factor in determining the functional potential of the limb. Soft tissue damage may be caused by the injury, ischaemia, or by compartment syndrome. Localised muscle damage can be offset by muscle transfers, e.g. transfer of tibialis posterior for peroneal or anterior compartment muscle loss. However, more extensive muscle loss, particularly affecting the posterior compartment muscles, usually results in poor final function and amputation should be considered. Severe wound contamination is often associated with major soft tissue loss because of the need for aggressive and repeated wound excision.
Extensive soft tissue damage almost inevitably results in a scarred and atrophic limb with compromised function and an early amputation may be in the best long-term interest of the patient.
Associated foot and ankle trauma.
Severe open tibial fractures are occasionally associated with ipsilateral crush injuries of the foot and ankle. A high proportion of patients continue to have neuropathic pain and poor function despite successful salvage and treatment of crush-type foot injuries (14). Studies of multiply injured patients with foot injuries found significantly worse functional outcome scores compared with those without foot injuries (15, 16). Based on these data, amputation may provide better long-term functional outcomes in patients presenting with a severe open tibial fracture and concomitant severe ipsilateral foot trauma.
Extensive bone defects can be successfully managed by a number of techniques, including autogenous bone grafting, vascularised fibula grafts, or distraction osteogenesis (see Chapter 9). However, the healing index (number of months of treatment per centimetre of new bone) is high. A 5 cm defect can be successfully restored by distraction osteogenesis over approximately 8–9 months. Reconstruction of larger bone defects will take over 12 months and involve multiple operations. In addition, the patient will need to be compliant, motivated, have good social support, and ideally a non-smoker. By contrast, a successful unilateral trans-tibial amputee will be walking largely unaided at around 3–4 months and will be fully ambulant at around 5–6 months.
In addition to being a marker for medical co-morbidities such as coronary heart disease and obstructive airway disease, cigarette smoking is also a prognostic variable influencing both bone and soft tissue healing. Data from the Lower Extremity Assessment Project (LEAP) study demonstrated that current smokers with limb-threatening open tibial fractures were 37% less likely to achieve union than non-smokers, and 3.7 times more likely to develop osteomyelitis than non-smokers (17). Similar results were reported in a recent systemic review, which found smoking significantly increased the overall risk for non-union, particularly in tibial and open fractures (18). Smoking may also adversely affect soft tissue reconstruction. Two recent meta-analyses have revealed significantly increased risks of cutaneous necrosis, delayed wound healing, and surgical site infections in smokers (19, 20).
Timing of delayed primary amputation
In practice, most severe limb injuries are suitable for staged management. Marginally viable tissue may take hours to demarcate and an evolving injury can be definitively declared unsalvageable at 48 hours. A staged approach also allows time to investigate the patient’s general welfare and counsel the patient and their family on the implications of their injury. Involvement of a multidisciplinary limb rehabilitation team is crucial, including patients who have completed their rehabilitation.
Once the decision has been reached, amputation should be performed as soon as possible and within 72 hours of injury (3).
Common injury scenarios where delayed primary amputation should be considered include a major open tibia fracture with a severe foot injury, segmental bone loss involving more than a third of the tibial shaft, loss of two or more muscle compartments, and an ischaemia limb with a proven nerve injury.
Residual limb reconstruction
The aim of residual limb (‘stump’) reconstruction is the preservation of maximal limb length whilst ensuring adequate soft tissue cover (1). Maintaining length in the presence of widespread tissue damage is a major challenge and in practice the most distal level of viable soft tissue dictates the amputation length. Amputation at the level of the fracture site should be avoided if viable distal bone is present, and proximal fractures should be managed with standard fixation techniques (21). The bone ends should be beveled to remove jagged edges, which may cause local discomfort. The construction of a bone bridge between the tibia and shortened fibular (Ertl technique) has been proposed for younger amputees but conflicting data are present in the literature and comparative studies are lacking (1, 22).
Soft tissue reconstruction aims to provide durable and comfortable padding over the bone ends, and to restore muscular control of the leg (1). A sound myodesis is essential to maintain mechanical limb alignment and optimise muscular control of the residual leg. Detached muscle groups should be secured under physiological tension to the distal bone through drill holes using stout sutures. Standard myocutaneous flaps, such as a long posterior flap for trans-tibial amputation are not usually available and ‘flaps of opportunity’ are used to reconstruct the soft tissue envelope. Skin grafting and tissue transfer with pedicled or free flaps may be required to maximise residual limb length. However, skin grafts and scar tissue do not withstand the shear forces associated with prosthetic wear and length preservation should not be at the expense of inadequate soft tissue cover, which may preclude successful limb fitting. Suture lines and compromised integument should also be avoided at key weight-bearing locations on the residual limb.
Neuroma formation is inevitable following nerve transection but is usually asymptomatic unless exposed to mechanical stimulation. Named nerves should be identified, gently handled, cut sharply, and allowed to retract proximally to lie well away from the weight-bearing area. The sural nerve should be identified during trans-tibial surgery because of the high risk for inclusion in the suture line. However, every effort should be made to avoid injury to cutaneous nerves to maintain the sensibility of cutaneous flaps.
The use of a tourniquet is recommended to reduce blood loss and transfusion requirements (23) but the tourniquet should be deflated before closure to allow an assessment of tissue perfusion and aid effective haemostasis. The use of drains may be considered to limit postoperative hematoma formation.
Improving amputation outcomes
Amputation is a life-changing event and the most important issue for amputees is their quality of life after treatment. Disability and poor outcomes can be significantly improved by a number of therapeutic interventions delivered in a multidisciplinary setting (1, 6, 22, 24).
Trans-tibial (below-knee) amputations are associated with superior outcomes compared with more proximal amputations and every effort must be made to preserve the knee, including vascular repair or flap coverage. Occasionally, short trans-tibial residual limbs can be avoided if the foot remnant is not traumatised by raising a pedicled flap of plantar skin and calcaneus and securing it to the end of the divided tibia (25).
If a trans-tibial level is not possible, through-the-knee amputation (TKA) should be considered, particularly if there is a viable posterior myofasciocutaneous flap to provide good soft tissue coverage for the residual limb. The advantages of a TKA over an above-knee amputation (AKA) in ambulatory patients include an end weight-bearing residual limb, enhanced proprioception, preserved adductor muscle insertion, a longer lever arm, and decreased metabolic cost of ambulation compared with AKA (26, 27). The Gritti–Stokes modification of knee disarticulation may offer improved weight-bearing characteristics in the trauma patient (27). In patients unlikely to ambulate, a TKA maximises ease of transfers because the limb is end-bearing and facilitates wheelchair mobility by providing better counterbalance due to the longer residual limb (26).
Although the LEAP study reported poor outcomes in a small cohort of 18 patients, a recent meta-analysis of 27 studies comprising 3105 traumatic amputees including 104 TKA, revealed significantly superior Physical Component Scores in patients with TKA compared with trans-femoral amputees (6). In addition, the proportion of TKA patients who could walk at least 500 m was slightly greater than patients with trans-tibial amputations and significantly more than trans-femoral amputees.
However, the study also found that patients with a TKA wore their prostheses significantly less and reported significantly more pain than those with trans-femoral amputation, which was attributed to potential suboptimal soft tissue coverage and prosthetic fitting difficulties (6). TKA is also associated with knee-level asymmetry, most marked when seated and the lower knee joint axis may complicate gait training. It has been suggested that the greater length of the TKA provides a superior lever arm, which confers greater mobility than a trans-femoral amputation, with less impact on the quality of life (6). TKA currently represents <5% of traumatic civilian amputees and the relative lack of experience with the surgical technique and in caring for patients with a TKA may explain some of the pain and limb-fitting issues and outcomes may be further improved by developments in TKA prosthetic design (6).
Infection is the commonest complication after severe extremity trauma and developed in 34% of the patients undergoing primary amputation in the LEAP study (28). Predisposing factors for infection in the LEAP included diabetes, injury severity, and smoking (17). A higher rate of infection was also reported following delay in performing the primary amputation (29). The highest rate of wound infection in the LEAP study was seen after late amputation with 17 out of 25 patients (68%) experiencing a wound infection and 10 patients developed osteomyelitis (40%). The National Institute for Health and Care Excellence (NICE) recommend that delayed primary amputation should be performed within 72 hours of the injury.
The diagnosis of residual limb infection is predominantly clinical and is characterised by local inflammation and increased drainage. Management is primarily surgical, with prompt drainage of fluid collections and aggressive wound excision of necrotic and devascularised tissue with multiple operative biopsies for microbial analysis. Empiric broad-spectrum antibiotics covering nosocomial organisms should be administered pending culture results (29, 30).
Pain is a common cause of disability after traumatic amputation (1, 31). Phantom limb pain affects 50–80% of amputees and, although the pathogeneses is not completely understood, the development of cortical pain memories is considered important (32). Pre-amputation and residual limb pain plus psychological factors such as emotional stress and anxiety probably all contribute to the development of phantom limb pain (6). Early administration of effective analgesia as soon after injury as possible will not only control acute pain but may also reduce the risk of chronic pain. Pre-emptive analgesia is also indicated to prevent the establishment of central sensitisation and pain memories evoked by surgery and early mobilisation. Although a randomised study of epidural anaesthesia for elective amputation cases showed no benefit (32), the analgesia was not truly pre-emptive as central nervous system changes may have already been established and epidural anaesthesia may have a role in acute pain management.
An intense emotional response following traumatic amputation is common and psychological disorders such as post-traumatic stress disorder (PTSD) anxiety, depression, and substance abuse affect more than half of amputees in the longer term (33). However, only a small proportion of traumatic amputees access mental health care, possibly due to the associated stigma (1). Early counselling and psychological support should begin as soon after resuscitation as possible. PTSD is often overlooked, possibly because avoidance is a symptom of the disorder, and screening for mental health problems should be an important aspect of rehabilitation.
Residual limb pain due to bone and soft tissue problems is nearly twice as common after a traumatic amputation than after amputation for non-traumatic indications (34). Common causes include heterotopic ossification, sharp bone ends, symptomatic neuromata, lack of end-bearing soft tissue padding via a secure myodesis, excess soft tissues, and poor-quality soft tissues in weight-bearing areas causing recurrent skin problems. Revision amputation should be considered when non-operative measures fail. A retrospective review of 71 revision cases reported improvement in 66% of confirmed neuromas, over 80% of patients with bone pathology, and 70% of patients with soft tissue problems (35).
The importance of rehabilitation in delivering good functional outcomes is evidenced by the startling results of the Military Extremity Trauma Amputation/Limb Salvage (METALS) study (24). Unlike the LEAP study, which found similar outcomes in civilians treated by amputation or limb salvage (36), military personnel undergoing amputation had significantly improved functional outcomes compared with those treated with limb salvage. Furthermore, unilateral and bilateral amputees were nearly three times more likely to be engaged in a vigorous sports or recreational activity than limb salvage patients and were less likely to screen positive for post-traumatic stress. The researchers suggested that the results might be explained by the focused rehabilitation military amputees receive early in their recovery and the ready access to optimal prostheses and robust reintegration programmes. In addition, military amputees are generally young and fit and may also have greater access to peer and external support early in their recovery, which may result in better outcomes. The benefit of a comprehensive extremity rehabilitation programme was also demonstrated in a series of limb salvage patients with severe traumatic lower extremity deficits (37).
Surgical advances have provided the means to reconstruct injuries that would have been previously amenable only to amputation. However, the surgeon’s desire for reconstruction and the patient’s wish for limb salvage must be balanced by the poor results of failed limb salvage and the good outcomes of successful amputation. An understanding of the therapeutic variables that affect outcome after both limb salvage and limb amputation will provide a platform for informed decision-making and will maximise the likelihood of a successful outcome.
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