Injured limb – Amputation or salvage?

Bakota Bore

General Hospital Karlovac, Department of Traumatology, Zagreb, Croatia

University of Zagreb, School of Medicine, Zagreb, Croatia (2)

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Despite a borderline Mangled Extremity Severity
Score in some cases reconstruction can be attempted
considering the overall health status of the patient and
local clinical status, with preserved plantar sensitivity
and satisfactory capillary perfusion.
In conclusion, management of mangled extremity
treatment should refer to evidence-based literature in
correlation with clinical evaluation of every individual
patient. Scores are helpful but should not be taken as
a sole indication for amputation.
Mangled extremity is a consequence of high ener-
gy trauma which result in combined bone and soft tis-
sue injury associated with severe bone and soft tissue
loss or destruction (1).Treatment of a mangled lower
extremity represents a major challenge. The decision-
whether to amputate or attempt reconstruction is cur-
rently based upon surgical evaluation (1).
soft tissue loss with tibial nerve transsection (2,3). Rel-
ative criteria are elderly patients in shock with a man-
gled limb, massive soft tissue loss associated with bone
loss, Mangled Extremity Severity Score (MESS) ≥ 7
(especially with absent plantar sensation), severe ipsi-
lateral foot trauma, polytrauma, and patients who are
not expected to tolerate reconstruction (4).
However, these criteria should not be considered
strict rules, but rather guidelines, due to many pa-
tient and wound-related variables(5). A patient with
a mangled extremity that matches criteria for amputa-
tion can successfully have a salvaged limb with restora-
tion of full function due to an individualized approach
to treatment and consideration of many other patient
and wound variables (1).
Discussion

Criteria Decision making in a clinical situation of mangled

extremity is complex (6). Due to the development of
Until now, the absolute criteria for amputation have surgical techniques and technologies, comprehensive
been non-reconstructablevascular injury, crush injury reconstructions are possible today in limb salvage pro-
with warm ischemia over 6 hours, and severe bone and cedures (7–12).



405


t Suomen Ortopedia ja Traumatologia Vol. 36

Figure 1a and 1b. Running train - Foot and ankle subamputation

Figure 2. Corn Machine separator injury

Figure 3a and 3b. Explosion Injury - Hand bomb fuse

Suomen Ortopedia ja Traumatologia Vol. 36 
t


405



 However, uncritical limb salvage attempts ex-
pose patients to increased morbidity and mortal-
ity, prolonged and costly treatment and often result
in dysfunctional extremity and disappointment (4).
Although in many cases based solely on clinical exam-
ination the decision to amputate or attempt salvage is
clear, in borderline cases the decision requires the uti-
lization of different tools, such as scoring systems, that
may help differentiate salvageable from non-salvage-
able extremities (1).
There is a variety of different scoring systems de-
signed to aid clinical decision-making, such as the
MESS, the Limb Salvage Index (LSI), the Predictive
Salvage Index (PSI), the Nerve Injury, Ischemia, Soft-
Tissue Injury, Skeletal Injury, Shock, and Age (NISS-
SA) Score, the Hannover Fracture Scale-97 (HFS-
97) and many others(4,13–17). The purpose of these
scores is to allow accurate prediction of either the need
for amputation or the possibility of salvage. Ideally, a
trauma limb-salvage score should have a perfect ac-
curacy with a sensitivity of 100% (all amputated
limbs with trauma limb-salvage scores at or above the
threshold) and specificity of 100% (all salvaged limbs
with scores below the threshold). Several clinical trials
were conducted in order to determine the exact cut-
off point for these scores that could be used in deci-
sion making (1). Johansen et al. reported that a MESS
score greater or equal to 7 predicted amputation with
100% accuracy (4). Since delayed amputation in that
study resulted in over 20% mortality from sepsis as
compared to no mortality in primary amputation (4),
the importance of accurate decision making is obvi-
ously of paramount importance. MESS, NISSSA, and
HFS-97 scores are greatly influenced by the results of
initial neurological examination, with the assumption
that an acute sensory debilitation correlates with de-
creased limb-salvage potential and that the initial ex-
amination demonstrates the final deficiency (1).
Still, ischemia, contusion, stretch, or compression
can cause transitory neurological deficit. When the
LSI is used, the neurological impairment is scored on
the basis of anatomical nerve findings. Howe et al. re-
ported a sensitivity of 78% and a specificity of 100%
for the PSI. On the other hand, Bosse et al. found the
sensitivity and specificity of the PSI for patients with
an ischemic limb injury were 56% and 79% when
immediate amputations were included in the analy-
sis and 40% and 79% when immediate amputations
were excluded.
Performance was not improved when only open


405


t
tibial fractures were considered. Given the large num-
ber of different scoring systems, a prospective, ob-
servational, multicenter evaluation of patients with
Gustillo IIIB and IIIC open tibia fractures (Lower Ex-
tremity Assessment Project – LEAP study) was per-
formed (16). However, the results of this study failed
to validate clinical utility of any scoring system in pre-
dicting the need for amputation. On the other hand,
it demonstrated the important role of psycho-social
issues in long-term outcomes. Furthermore, an initial
absence of plantar sensation was not a reliable indica-
tor of the need for amputation as 55% of patients with
no plantar sensation initially reported plantar sensa-
tion at 24 months. A repeat of the LEAP study con-
firmed these previous results, emphasizing the inabili-
ty of scoring systems to accurately predict the need for
amputation, although low scores may predict salvage
potential (18,19).
Furthermore, there is also not enough evidence
in the literature that supports the necessity of ur-
gent temporary vascular shunting followed by ortho-
pedic stabilization in combined orthopedic and vas-
cular foot and ankle injuries with borderline MESS
scores (20). The sequence of procedures and patient
care should be adjusted to the specific needs of ev-
ery patient in order to minimize the rate of amputa-
tion. Early soft tissue coverage of a mangled foot and
ankle with Vacuum Asisted Closure (VAC) combined
with silver hydrofiber dressings is very convenient and
results in fewer complications, earlier mobilization
and return to work. VAC is also an excellent bridg-
ing solution in situations where due to the absence of
specialized surgical teams (late at night surgery, local
community hospital, etc.) definite treatment (21,22)
cannot be immediately performed. Delaying soft-tis-
sue reconstruction beyond 7 days has been associat-
ed with increased flap complications and an increased
risk of infection (23,24). Gopal et al. found a deep
infection rate of 6% for fractures covered within 72 h,
and an infection rate of 29% for fractures covered af-
ter 72 hours. The authors concluded that provided an
adequate debridement has been performed, immedi-
ate internal fixation and healthy soft tissue cover with
a muscle flap is safe (25). However, early aggressive
fracture fixation and definitive soft-tissue reconstruc-
tion may be favorable for isolated extremity fractures
but may not be the safest option for the majority of
patients with complex extremity fractures, many of
whom have severe additional injuries (26).
Bone and joint infections represent an important
Suomen Ortopedia ja Traumatologia Vol. 36
problem which consists of three components: the ex- amputation should not be considered as a treatment
tent of tissue involvement, the microorganism and failure, but rather as a means of meeting the goal of
the host. Management is based on radical debride- treatment (37). As Hansen pointed out, we should not
ment, skeletal stabilization, microbial-specific antibi- let the heroism triumph over reason (38).
otics, soft tissue coverage, and reconstruction of bone
defects. Direct blunt trauma or open wounds of the Conclusion
distal tibia, the ankle joint and the foot often lead to
tissue loss and subsequent bacterial colonization. Re- When treating mangled extremity, it is necessary to
sistant microorganisms may further complicate the include all other patient and wound variables (1) in
situation, meaning that systemically compromised pa- addition to scoring systems in order to allow improved
tients are in a less favorable position (27–29). treatment outcomes using an individualized approach
Necrotizing fasciitis is a special problem which to patients with mangled extremities. Consequently,
represents a rapidly progressive infection with necrosis there is an obvious need for comprehensive criteria
of the fascia and surrounding tissues and has a mor- proposal of mangled extremity treatment for border-
tality rate up to 76% (30). Important clinical find- line cases (1) that will take into account not only scor-
ings are pain, hyperpyrexia, chills, cellulitis, edema, ing systems, but also important patient and wound
warmth, induration, fluctuance, crepitus, skin necro- characteristics (39).
sis and bullae (31). Immediate aggressive surgical de-
bridement (skin, subcutaneous tissue, muscle debride- References
ment, fasciotomy) and administration of high doses of 
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