Download PDF
J Reconstr Microsurg 2021; 37(01): 032-041
DOI: 10.1055/s-0039-1696733
Original Article

Amputations versus Salvage: Reconciling the Differences

Cara K. Black
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
,
Laurel D. Ormiston
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
,
Kenneth L. Fan 
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
,
Vikas S. Kotha 
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
,
Christopher Attinger
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
,
Karen Kim Evans
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation.

Methods In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population.

Results The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease.

Conclusion Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

Keywords

lower extremity - salvage - amputation - free tissue transfer - free flap


Publication History

Received: 21 June 2019

Accepted: 18 July 2019

Article published online:
09 September 2019

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Barla M, Gavanier B, Mangin M, Parot J, Bauer C, Mainard D. Is amputation a viable treatment option in lower extremity trauma?. Orthop Traumatol Surg Res 2017; 103 (06) 971-975
    CrossrefPubMedGoogle Scholar
  • 2 Doucet JJ, Galarneau MR, Potenza BM. et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011; 70 (05) 1241-1247
    CrossrefPubMedGoogle Scholar
  • 3 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 (10) 1431-1441
    CrossrefPubMedGoogle Scholar
  • 4 Smith DG, Horn P, Malchow D, Boone DA, Reiber GE, Hansen Jr ST. Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J Trauma 1995; 38 (01) 44-47
    CrossrefPubMedGoogle Scholar
  • 5 Bosse MJ, MacKenzie EJ, Kellam JF. et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347 (24) 1924-1931
    CrossrefPubMedGoogle Scholar
  • 6 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 (04) 1212-1220
    CrossrefPubMedGoogle Scholar
  • 7 MacKenzie EJ, Bosse MJ, Pollak AN. et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005; 87 (08) 1801-1809
    PubMedGoogle Scholar
  • 8 Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil 2000; 81 (03) 292-300
    CrossrefPubMedGoogle Scholar
  • 9 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 (04) 329-334
    CrossrefPubMedGoogle Scholar
  • 10 MacKenzie EJ, Bosse MJ, Kellam JF. et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000; 14 (07) 455-466
    CrossrefPubMedGoogle Scholar
  • 11 Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg 2005; 115 (06) 1618-1624
    CrossrefPubMedGoogle Scholar
  • 12 Elsharawy MA, Maher K, Elsaid AS. Limb salvage in a child with severely injured mangled lower extremity and muscle rigor. Vascular 2012; 20 (06) 321-324
    CrossrefPubMedGoogle Scholar
  • 13 Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001; 108 (04) 1029-1041 , quiz 1042
    CrossrefPubMedGoogle Scholar
  • 14 MacKenzie EJ, Bosse MJ, Kellam JF. et al; LEAP Study Group. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002; 52 (04) 641-649
    CrossrefPubMedGoogle Scholar
  • 15 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 (12) 2601-2608
    PubMedGoogle Scholar
  • 16 Prasarn ML, Helfet DL, Kloen P. Management of the mangled extremity. Strateg Trauma Limb Reconstr 2012; 7 (02) 57-66
    CrossrefPubMedGoogle Scholar
  • 17 Lange RH, Bach AW, Hansen Jr ST, Johansen KH. Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 1985; 25 (03) 203-208
    CrossrefPubMedGoogle Scholar
  • 18 Daigeler A, Fansa H, Westphal T, Schneider W. [Replantation at lower leg level]. Chirurg 2003; 74 (11) 1040-1046
    CrossrefPubMedGoogle Scholar
  • 19 Cavadas PC, Landín L, Ibáñez J, Roger I, Nthumba P. Infrapopliteal lower extremity replantation. Plast Reconstr Surg 2009; 124 (02) 532-539
    CrossrefPubMedGoogle Scholar
  • 20 Momoh AO, Kumaran S, Lyons D. et al. An argument for salvage in severe lower extremity trauma with posterior tibial nerve injury: the ganga hospital experience. Plast Reconstr Surg 2015; 136 (06) 1337-1352
    CrossrefPubMedGoogle Scholar
  • 21 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
    CrossrefPubMedGoogle Scholar
  • 22 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89 (03) 478-487 , discussion 488–489
    CrossrefPubMedGoogle Scholar
  • 23 Korompilias AV, Lykissas MG, Vekris MD, Beris AE, Soucacos PN. Microsurgery for lower extremity injuries. Injury 2008; 39 (Suppl. 03) S103-S108
    CrossrefPubMedGoogle Scholar
  • 24 Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (Suppl. 01) 228S-238S
    CrossrefPubMedGoogle Scholar
  • 25 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 26 Haykal S, Roy M, Patel A. Meta-analysis of Timing for microsurgical free-flap reconstruction for lower limb injury: evaluation of the Godina principles. J Reconstr Microsurg 2018; 34 (04) 277-292
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (08) 632-634
    CrossrefPubMedGoogle Scholar
  • 28 Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 2018; 52 (05) 259-264
    CrossrefPubMedGoogle Scholar
  • 29 Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg 2010; 125 (02) 582-588
    CrossrefPubMedGoogle Scholar
  • 30 Ilizarov GA, Lediaev VI, Shitin VP. [The course of compact bone reparative regeneration in distraction osteosynthesis under different conditions of bone fragment fixation (experimental study)]. Eksp Khir Anesteziol 1969; 14 (06) 3-12
    PubMedGoogle Scholar
  • 31 Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, Jennings R, Marsh DR. Ilizarov principles of deformity correction. Ann R Coll Surg Engl 2010; 92 (02) 101-105
    CrossrefPubMedGoogle Scholar
  • 32 Chim H, Sontich JK, Kaufman BR. Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity. Plast Reconstr Surg 2011; 127 (06) 2364-2372
    CrossrefPubMedGoogle Scholar
  • 33 Tekin L, Safaz Y, Göktepe AS, Yazýcýodlu K. Comparison of quality of life and functionality in patients with traumatic unilateral below knee amputation and salvage surgery. Prosthet Orthot Int 2009; 33 (01) 17-24
    CrossrefPubMedGoogle Scholar
  • 34 Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical and economic impact of severely injured lower extremities. J Trauma 1988; 28 (08) 1270-1273
    CrossrefPubMedGoogle Scholar
  • 35 Melcer T, Sechriest VF, Walker J, Galarneau M. A comparison of health outcomes for combat amputee and limb salvage patients injured in Iraq and Afghanistan wars. J Trauma Acute Care Surg 2013; 75 (02) (Suppl. 02) S247-S254
    CrossrefPubMedGoogle Scholar
  • 36 Ladlow P, Phillip R, Coppack R. et al. Influence of immediate and delayed lower-limb amputation compared with lower-limb salvage on functional and mental health outcomes post-rehabilitation in the U.K. Military. J Bone Joint Surg Am 2016; 98 (23) 1996-2005
    CrossrefPubMedGoogle Scholar
  • 37 Dahl B, Andersson AP, Andersen M, Andersen GR, Ebskov LB, Reumert T. Functional and social long-term results after free tissue transfer to the lower extremity. Ann Plast Surg 1995; 34 (04) 372-375
    CrossrefPubMedGoogle Scholar
  • 38 Penn-Barwell JG. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. Injury 2011; 42 (12) 1474-1479
    CrossrefPubMedGoogle Scholar
  • 39 Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am 1976; 58 (01) 42-46
    CrossrefPubMedGoogle Scholar
  • 40 Stinner DJ, Burns TC, Kirk KL, Ficke JR. Return to duty rate of amputee soldiers in the current conflicts in Afghanistan and Iraq. J Trauma 2010; 68 (06) 1476-1479
    CrossrefPubMedGoogle Scholar
  • 41 Fleming ME, O'Daniel A, Bharmal H, Valerio I. Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length. Ann Plast Surg 2014; 73 (02) 183-189
    CrossrefPubMedGoogle Scholar
  • 42 Fioravanti M, Maman P, Curvale G, Rochwerger A, Mattei JC. Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study. Orthop Traumatol Surg Res 2018; 104 (02) 277-281
    CrossrefPubMedGoogle Scholar
  • 43 Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 1996; 10 (04) 223-229
    CrossrefPubMedGoogle Scholar
  • 44 Fairhurst MJ. The function of below-knee amputee versus the patient with salvaged grade III tibial fracture. Clin Orthop Relat Res 1994; (301) 227-232
    PubMedGoogle Scholar
  • 45 Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 2007; 21 (01) 70-76
    CrossrefPubMedGoogle Scholar
  • 46 Patel KM, Economides JM, Franklin B, Sosin M, Attinger C, Ducic I. Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients. Microsurgery 2014; 34 (01) 1-4
    CrossrefPubMedGoogle Scholar
  • 47 van Dongen TT, Huizinga EP, de Kruijff LG. et al. Amputation: not a failure for severe lower extremity combat injury. Injury 2017; 48 (02) 371-377
    CrossrefPubMedGoogle Scholar
  • 48 Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A meta-analysis of amputation versus limb salvage in mangled lower limb injuries--the patient perspective. Injury 2011; 42 (11) 1194-1197
    CrossrefPubMedGoogle Scholar
  • 49 Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008; 122 (06) 1796-1805
    CrossrefPubMedGoogle Scholar
  • 50 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 (01) 3-14
    CrossrefPubMedGoogle Scholar
  • 51 McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A. LEAP study group. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am 2003; 85 (09) 1689-1697
    CrossrefPubMedGoogle Scholar
  • 52 Bernhoff K, Björck M, Larsson J, Jangland E. Patient experiences of life years after severe civilian lower extremity trauma with vascular injury. Eur J Vasc Endovasc Surg 2016; 52 (05) 690-695
    CrossrefPubMedGoogle Scholar
  • 53 O'Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ. LEAP Study Group. Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Joint Surg Am 2008; 90 (06) 1206-1211
    CrossrefPubMedGoogle Scholar
  • 54 Hutchins PM. The outcome of severe tibial injury. Injury 1981; 13 (03) 216-219
    CrossrefPubMedGoogle Scholar
  • 55 MacKenzie EJ, Jones AS, Bosse MJ. et al. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007; 89 (08) 1685-1692
    Google Scholar
  • 56 Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009; 124 (06) 1965-1973
    CrossrefPubMedGoogle Scholar
  • 57 Sabino JM, Slater J, Valerio IL. Plastic surgery challenges in war wounded i: flap-based extremity reconstruction. Adv Wound Care (New Rochelle) 2016; 5 (09) 403-411
    CrossrefPubMedGoogle Scholar
  • 58 Valerio I, Sabino J, Heckert R. et al. Known preoperative deep venous thrombosis and/or pulmonary embolus: to flap or not to flap the severely injured extremity?. Plast Reconstr Surg 2013; 132 (01) 213-220
    CrossrefPubMedGoogle Scholar
  • 59 Valerio IL, Campbell P, Sabino J. et al. TXA in combat casualty care--does it adversely affect extremity reconstruction and flap thrombosis rates?. Mil Med 2015; 180 (3, Suppl) 24-28
    CrossrefPubMedGoogle Scholar
  • 60 Connolly M, Ibrahim ZR, Johnson III ON. Changing paradigms in lower extremity reconstruction in war-related injuries. Mil Med Res 2016; 3: 9
    PubMedGoogle Scholar
  • 61 Chattar-Cora D, Perez-Nieves R, McKinlay A, Kunasz M, Delaney R, Lyons R. Operation Iraqi freedom: a report on a series of soldiers treated with free tissue transfer by a plastic surgery service. Ann Plast Surg 2007; 58 (02) 200-206
    CrossrefPubMedGoogle Scholar
  • 62 Kumar AR. Standard wound coverage techniques for extremity war injury. J Am Acad Orthop Surg 2006; 14 (10 Spec No.): S62-S65
    CrossrefPubMedGoogle Scholar
  • 63 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg 2009; 123 (01) 218-229
    CrossrefPubMedGoogle Scholar
  • 64 Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR. The mangled foot and leg: salvage versus amputation. Foot Ankle Clin 2010; 15 (01) 63-75
    CrossrefPubMedGoogle Scholar
  • 65 Hierner R, Berger AK, Frederix PR. Lower leg replantation--decision-making, treatment, and long-term results. Microsurgery 2007; 27 (05) 398-410
    CrossrefPubMedGoogle Scholar
  • 66 Gayle LB, Lineaweaver WC, Buncke GM. et al. Lower extremity replantation. Clin Plast Surg 1991; 18 (03) 437-447
    CrossrefPubMedGoogle Scholar
  • 67 Schmidhammer R, Nimmervoll R, Pelinka LE. et al. Bilateral lower leg replantation versus prosthetic replacement: long-term outcome of amputation after an occupational railroad accident. J Trauma 2004; 57 (04) 824-831
    CrossrefPubMedGoogle Scholar
  • 68 Daigle JP, Kleinert JM. Major limb replantation in children. Microsurgery 1991; 12 (03) 221-231
    CrossrefPubMedGoogle Scholar
  • 69 Beris AE, Soucacos PN, Malizos KN, Mitsionis GJ, Soucacos PK. Major limb replantation in children. Microsurgery 1994; 15 (07) 474-478
    CrossrefPubMedGoogle Scholar
  • 70 Zubairi AJ, Hashmi PM. Long term follow-up of a successful lower limb replantation in a 3-year-old child. Case Rep Orthop 2015; 2015: 425376
    PubMedGoogle Scholar
  • 71 Durban CM, Lee SY, Lim HC. Above-the-knee replantation in a child: a case report with a 24-year follow-up. Strateg Trauma Limb Reconstr 2015; 10 (03) 189-193
    CrossrefPubMedGoogle Scholar
  • 72 Mamakos MS. Lower extremity replantation-two and a half-year follow-up. Ann Plast Surg 1982; 8 (04) 305-309
    CrossrefPubMedGoogle Scholar
  • 73 Jones NF, Shin EK, Mostofi A, Oppenheim WL. Successful replantation of the leg in a pre-ambulatory infant. J Reconstr Microsurg 2005; 21 (06) 359-364
    Article in Thieme ConnectPubMedGoogle Scholar
  • 74 Usui M, Minami M, Ishii S. Successful replantation of an amputated leg in a child. Plast Reconstr Surg 1979; 63 (05) 613-617
    CrossrefPubMedGoogle Scholar
  • 75 Masuda K, Usui M, Ishii S. A 17-year follow-up of replantation of a completely amputated leg in a child: case report. J Reconstr Microsurg 1995; 11 (02) 89-92
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Battiston B, Tos P, Pontini I, Ferrero S. Lower limb replantations: indications and a new scoring system. Microsurgery 2002; 22 (05) 187-192
    CrossrefPubMedGoogle Scholar
  • 77 Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986; 78 (03) 295-299
    CrossrefPubMedGoogle Scholar
  • 78 Wang JN, Wang SY, Wang ZJ, Liu D, Zhao GQ, Zhang F. Temporary ectopic implantation for salvage of amputated lower extremities: case reports. Microsurgery 2005; 25 (05) 385-389
    CrossrefPubMedGoogle Scholar
  • 79 Higgins JP. Ectopic banking of amputated parts: a clinical review. J Hand Surg Am 2011; 36 (11) 1868-1876
    CrossrefPubMedGoogle Scholar
  • 80 Kayikçioğlu A, Ağaoğlu G, Nasir S, Keçik A. Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation. Plast Reconstr Surg 2000; 106 (04) 868-873
    CrossrefPubMedGoogle Scholar
  • 81 Cavadas PC, Thione A, Landín L. Elective cross-over transfer of the foot: case report. J Plast Reconstr Aesthet Surg 2010; 63 (10) 1744-1746
    CrossrefPubMedGoogle Scholar
  • 82 Fansa H, Frerichs O, Schneider W. Heterotopic replantation after bilateral lower leg amputation [article in German]. Chirurg 2001; 72 (11) 1369-1372
    CrossrefPubMedGoogle Scholar
  • 83 Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003; 361 (9368): 1545-1551
    CrossrefPubMedGoogle Scholar
  • 84 Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366 (9498): 1719-1724
    CrossrefPubMedGoogle Scholar
  • 85 Connor H. Some historical aspects of diabetic foot disease. Diabetes Metab Res Rev 2008; 24 (Suppl. 01) S7-S13
    CrossrefPubMedGoogle Scholar
  • 86 Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 2010; 52 (3, Suppl): 17S-22S
    CrossrefPubMedGoogle Scholar
  • 87 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
    CrossrefPubMedGoogle Scholar
  • 88 Hashimoto I, Abe Y, Morimoto A, Kashiwagi K, Goishi K, Nakanishi H. Limb salvage and vascular augmentation by microsurgical free flap transfer for treatment of neuropathic diabetic foot ulcers. J Med Invest 2014; 61 (3-4): 325-332
    CrossrefPubMedGoogle Scholar
  • 89 Randon C, Jacobs B, De Ryck F, Van Landuyt K, Vermassen F. A 15-year experience with combined vascular reconstruction and free flap transfer for limb-salvage. Eur J Vasc Endovasc Surg 2009; 38 (03) 338-345
    CrossrefPubMedGoogle Scholar
  • 90 Attinger CE, Brown BJ. Amputation and ambulation in diabetic patients: function is the goal. Diabetes Metab Res Rev 2012; 28 (Suppl. 01) 93-96
    CrossrefPubMedGoogle Scholar
  • 91 Attinger CE, Ducic I, Neville RF, Abbruzzese MR, Gomes M, Sidawy AN. The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient. Plast Reconstr Surg 2002; 109 (04) 1281-1290 , discussion 1291–1292
    CrossrefPubMedGoogle Scholar
  • 92 Janhofer DE, Lakhiani C, Kim PJ. et al. The Utility of preoperative arteriography for free flap planning in patients with chronic lower extremity wounds. Plast Reconstr Surg 2019; 143 (02) 604-613
    CrossrefPubMedGoogle Scholar
  • 93 DeFazio MV, Han KD, Akbari CM, Evans KK. Free tissue transfer after targeted endovascular reperfusion for complex lower extremity reconstruction: setting the stage for success in the presence of mutlivessel disease. Ann Vasc Surg 2015; 29 (06) 1316.e7-1316.e15
    CrossrefPubMedGoogle Scholar
  • 94 Hobbs SD, Yapanis M, Burns PJ, Wilmink AB, Bradbury AW, Adam DJ. Peri-operative myocardial injury in patients undergoing surgery for critical limb ischaemia. Eur J Vasc Endovasc Surg 2005; 29 (03) 301-304
    CrossrefPubMedGoogle Scholar
  • 95 Giswold ME, Landry GJ, Sexton GJ. et al. Modifiable patient factors are associated with reverse vein graft occlusion in the era of duplex scan surveillance. J Vasc Surg 2003; 37 (01) 47-53
    CrossrefPubMedGoogle Scholar
  • 96 Chien SH, Huang CC, Hsu H, Chiu CH, Lin CM, Tsai JP. Free tissue transfers for limb salvage in patients with end-stage renal disease on dialysis. Plast Reconstr Surg 2011; 127 (03) 1222-1228
    CrossrefPubMedGoogle Scholar
  • 97 Faglia E, Clerici G, Frykberg R. et al. Outcomes of chopart amputation in a tertiary referral diabetic foot clinic: data from a consecutive series of 83 hospitalized patients. J Foot Ankle Surg 2016; 55 (02) 230-234
    CrossrefPubMedGoogle Scholar
  • 98 Evans KK, Attinger CE, Al-Attar A. et al. The importance of limb preservation in the diabetic population. J Diabetes Complications 2011; 25 (04) 227-231
    CrossrefPubMedGoogle Scholar
  • 99 Stone PA, Back MR, Armstrong PA. et al. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg 2005; 19 (06) 805-811
    CrossrefPubMedGoogle Scholar
  • 100 Elsharawy MA. Outcome of midfoot amputations in diabetic gangrene. Ann Vasc Surg 2011; 25 (06) 778-782
    CrossrefPubMedGoogle Scholar
  • 101 Frykberg RG, Abraham S, Tierney E, Hall J. Syme amputation for limb salvage: early experience with 26 cases. J Foot Ankle Surg 2007; 46 (02) 93-100
    CrossrefPubMedGoogle Scholar
  • 102 Hahn HM, Jeong KS, Park MC, Park DH, Lee IJ. Free-flap transfer for coverage of transmetatarsal amputation stump to preserve residual foot length. Int J Low Extrem Wounds 2017; 16 (01) 60-65
    CrossrefPubMedGoogle Scholar
  • 103 Suckow BD, Goodney PP, Cambria RA. et al; Vascular Study Group of New England. Predicting functional status following amputation after lower extremity bypass. Ann Vasc Surg 2012; 26 (01) 67-78
    CrossrefPubMedGoogle Scholar
  • 104 Wukich DK, Raspovic KM. What role does function play in deciding on limb salvage versus amputation in patients with diabetes?. Plast Reconstr Surg 2016; 138 (3, Suppl)): 188S-195S
    CrossrefPubMedGoogle Scholar
  • 105 Fisher Jr DF, Clagett GP, Fry RE, Humble TH, Fry WJ. One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. J Vasc Surg 1988; 8 (04) 428-433
    CrossrefPubMedGoogle Scholar
  • 106 Sanchez LA, Goldsmith J, Rivers SP, Panetta TF, Wengerter KR, Veith FJ. Limb salvage surgery in end stage renal disease: is it worthwhile?. J Cardiovasc Surg (Torino) 1992; 33 (03) 344-348
    PubMedGoogle Scholar
  • 107 Moran SL, Salgado CJ, Serletti JM. Free tissue transfer in patients with renal disease. Plast Reconstr Surg 2004; 113 (07) 2006-2011
    Google Scholar
  • 108 Simsir SA, Cabellon A, Kohlman-Trigoboff D, Smith BM. Factors influencing limb salvage and survival after amputation and revascularization in patients with end-stage renal disease. Am J Surg 1995; 170 (02) 113-117
    CrossrefPubMedGoogle Scholar
  • 109 Johnson BL, Glickman MH, Bandyk DF, Esses GE. Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg 1995; 22 (03) 280-285 , discussion 285–286
    CrossrefPubMedGoogle Scholar
  • 110 Edwards JM, Taylor Jr LM, Porter JM. Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD. Arch Surg 1988; 123 (09) 1164-1168
    CrossrefPubMedGoogle Scholar
  • 111 Illig KA, Moran S, Serletti J. et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001; 33 (01) 17-23
    CrossrefPubMedGoogle Scholar
  • 112 Nehler MR, Coll JR, Hiatt WR. Functional outcome in a series of major lower extremity amputations. J Vasc Surg 2003; 38 (01) 7-14
    CrossrefPubMedGoogle Scholar
  • 113 Chopra A, Azarbal AF, Jung E. et al. Ambulation and functional outcome after major lower extremity amputation. J Vasc Surg 2018; 67 (05) 1521-1529
    CrossrefPubMedGoogle Scholar
  • 114 Andrews KL. Rehabilitation in limb deficiency. 3. The geriatric amputee. Arch Phys Med Rehabil 1996; 77 (3, Suppl): S14-S17
    CrossrefPubMedGoogle Scholar
  • 115 Uustal H. Prosthetic rehabilitation issues in the diabetic and dysvascular amputee. Phys Med Rehabil Clin N Am 2009; 20 (04) 689-703
    CrossrefPubMedGoogle Scholar
  • 116 Reiber GE, Ledoux WR. Epidemiology of diabetic foot ulcers and amputations: evidence for prevention. In: Williams R, Herman W, Kinmonth A, Wareham NJ. eds. The Evidence Base for Diabetes Care. London: Wiley; 2003: 641-665
    Google Scholar
  • 117 Kucan JO, Robson MC. Diabetic foot infections: fate of the contralateral foot. Plast Reconstr Surg 1986; 77 (03) 439-441
    CrossrefPubMedGoogle Scholar
  • 118 Choi MS, Jeon SB, Lee JH. Predictive factors for successful limb salvage surgery in diabetic foot patients. BMC Surg 2014; 14: 113
    CrossrefPubMedGoogle Scholar
  • 119 Lu J, DeFazio MV, Lakhiani C. et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg 2019; 35 (02) 117-123
    Article in Thieme ConnectPubMedGoogle Scholar
  • 120 Falola RA, Lakhiani C, Green J. et al. Assessment of function after free tissue transfer to the lower extremity for chronic wounds using the lower extremity functional scale. J Reconstr Microsurg 2018; 34 (05) 327-333
    Article in Thieme ConnectPubMedGoogle Scholar
  • 121 Suh HS, Oh TS, Lee HS. et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016; 138 (04) 702e-709e
    CrossrefPubMedGoogle Scholar
  • 122 Franklin H, Rajan M, Tseng CL, Pogach L, Sinha A, Mph M. Cost of lower-limb amputation in U.S. veterans with diabetes using health services data in fiscal years 2004 and 2010. J Rehabil Res Dev 2014; 51 (08) 1325-1330
    CrossrefPubMedGoogle Scholar
  • 123 Ollendorf DA, Kotsanos JG, Wishner WJ. et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998; 21 (08) 1240-1245
    CrossrefPubMedGoogle Scholar
  • 124 Goldner MG. The fate of the second leg in the diabetic amputee. Diabetes 1960; 9: 100-103
    CrossrefPubMedGoogle Scholar
  • 125 Armstrong DG, Lavery LA, Harkless LB, Van Houtum WH. Amputation and reamputation of the diabetic foot. J Am Podiatr Med Assoc 1997; 87 (06) 255-259
    CrossrefPubMedGoogle Scholar
  • 126 Lavery LA, Van Houtum WH, Armstrong DG. Institutionalization following diabetes-related lower extremity amputation. Am J Med 1997; 103 (05) 383-388
    CrossrefPubMedGoogle Scholar
  • 127 Ecker ML, Jacobs BS. Lower extremity amputation in diabetic patients. Diabetes 1970; 19 (03) 189-195
    CrossrefPubMedGoogle Scholar