Functional Results of Limb Salvage in Below-Knee Type III C Open Fractures or Traumatic Amputations

Abstract

This study presents the surgical and functional outcomes of below-knee total leg amputation and Gustilo type III C open fracture cases that were considered appropriate for salvage treatment according to a more proactive approach, despite being candidates for amputation according to the current scoring systems. Nineteen patients (21 legs) underwent replantation-revascularization surgery. At least Chen Grade II functional level was the aim. A limb salvage operation was performed in 21 legs in 19 patients (18 male, 1 female). The mean age was 28.5 years (range: 11 to 42 years). Six legs in four patients presented with total amputation, and 15 legs in 15 patients had Gustilo Type III C open fractures. A successful replantation/revascularization was performed in 20 legs, with a Chen Grade I and Grade II functional outcome in 3 and 17 legs, respectively. None of these patients were eligible for salvage operation according to currently used scoring systems. Limb-preserving surgery performed upon the assessment of local and general conditions of the patients with traumatic below-knee amputations or Gustilo Type III C open fractures seems to be a viable therapeutic option that can serve to achieve Chen Grade II functional level in most patients.

Keywords

total leg amputation - Gustilo type III C open fracture - limb salvage

• References

• 1 Chen ZW. Lower limp replantation. In: Brunelli G, , ed, Textbook of Microsurgery. Milano: Masson; 1988: 503-508
• 2 Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am 1994; 76: 1162-1166
• 3 Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma 1993; 34: 99-104
• 4 Hiatt MD, Farmer JM, Teasdall RD. The decision to salvage or amputate a severely injured limb. J South Orthop Assoc 2000; 9: 72-78 , discussion 78
• 5 Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 1996; 172: 569-573 , discussion 573–574
• 6 Walton RL, Rothkopf DM. Judgment and approach for management of severe lower extremity injuries. Clin Plast Surg 1991; 18: 525-543
• 7 Lin CH, Wei FC, Levin LS, Su JI, Yeh WL. The functional outcome of lower-extremity fractures with vascular injury. J Trauma 1997; 43: 480-485
• 8 Hoogendoorn JM, van der Werken C. Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction. Injury 2001; 32: 329-334
• 9 Pollak AN. Common decision-making errors in limb salvage. In: Levin LS, , ed, Complications in Orthopedics - Open fractures. Rosemont, IL: American Academy of Orthopedic Surgeons; 2010: 1-22
• 10 Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993; 75: 1431-1441
• 11 Bosse MJ, McCarthy ML, Jones AL , et al. Lower Extremity Assessment Project (LEAP) Study Group. The insensate foot following severe lower extremity trauma: an indication for amputation?. J Bone Joint Surg Am 2005; 87: 2601-2608
• 12 Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower-extremity trauma: are the outcomes worth the means?. Plast Reconstr Surg 1999; 103: 1212-1220
• 13 Gregory RT, Gould RJ, Peclet M , et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma 1985; 25: 1147-1150
• 14 Howe Jr HR, Poole Jr GV, Hansen KJ , et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 1987; 53: 205-208
• 15 Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clin Orthop Relat Res 1990; 80-86
• 16 Russell WL, Sailors DM, Whittle TB, Fisher Jr DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991; 213: 473-480 , discussion 480–481
• 17 Battiston B, Tos P, Pontini I, Ferrero S. Lower limb replantations: indications and a new scoring system. Microsurgery 2002; 22: 187-192
• 18 Bosse MJ, MacKenzie EJ, Kellam JF , et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001; 83-A: 3-14
• 19 Parmaksizoglu F, Koprulu AS, Unal MB, Cansu E. Early or delayed limb lengthening after acute shortening in the treatment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: The results of a case series. J Bone Joint Surg Br 2010; 92: 1563-1567