Section 2: Limb Salvage and Amputation After Major Lower Limb Trauma

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Major, high-energy lower extremity trauma is common in the military and civilian settings. Although mechanisms of injury are different, many of the challenges in the treatment of these injuries are similar. Early, acute management of the trauma is critical and often involves consideration of both amputation and limb salvage options. Whereas significant medical and surgical advances have improved the technical ability to reconstruct severely injured lower extremities, concurrent development of bioengineering advances in below-the-knee prosthetics can result in good function for those undergoing amputation. These advances have contributed to a therapeutic dilemma for the treating surgeon. Although results from the Lower Extremity Assessment Project (LEAP) suggest that limb salvage is advisable for most patients with severe lower extremity trauma, there is growing evidence to suggest that for some patients, limb salvage may not always be the best option. It is important to determine early in the course of treatment which patients may do better with an amputation versus reconstruction and to maximize long-term outcomes regardless of the treatment pathway. This section describes 4 METRC studies that address these challenges.
One major challenge in the early management of patients with major lower limb trauma is the diagnosis of acute compartment syndrome (ACS).1,2 No validated criteria exist to reliably diagnose the presence of the condition. The Predicting Acute Compartment Syndrome (PACS) Study was designed to develop a clinical decision rule to predict the likelihood of developing ACS. Once translated into clinical practice guidelines, better prediction can improve care by avoiding unnecessary fasciotomies and ensuring that patients with compartment syndrome are not missed. This study will improve our understanding of the natural history of compartment syndrome and specifically examine the utility of early and continuous monitoring of intramuscular pressure and muscle oxygenation using near-infrared spectroscopy in the timely diagnosis of ACS.
Significant soft tissue injury or degloving of the mid to hind foot, structural damage to the foot, vascular injury, and major joint dislocations are recognized in the orthopedic trauma community as indicators for possible amputation.3,4 Patients with these injuries are faced with a long recovery period and have difficulty with weight bearing.5,6 A subanalysis of the LEAP study suggested that patients with severe distal tibia, ankle and/or foot injuries requiring a free flap or ankle arthrodesis experienced significantly worse functional outcomes when compared with patients who underwent transtibial amputation.6 Although the sample size was small, the results of this study and others' suggest that there may be subgroups of patients for whom transtibial amputation may provide better long-term functional outcome than limb salvage. Building on this substudy, the Outcomes of Severe Lower Extremity Trauma (OUTLET) study was designed to compare 18 month outcomes of patients undergoing salvage versus early amputation after severe foot and ankle injuries in a large prospective, multicenter observational cohort. The intent is to identify subgroups of salvage patients who would have done better had they undergone amputation. Study results will help the surgeon and patient make informed decisions about treatment.
Although rehabilitative and prosthetic care for individuals with amputation has advanced, major improvements in orthotics and rehabilitation for limb salvage patients have not kept pace, likely contributing to poor overall outcomes after limb salvage of major foot and ankle trauma. The military recognized this challenge and developed the Intrepid Dynamic Exoskeletal Orthosis (IDEO), a custom, energy-storing carbon fiber orthosis specifically developed to improve ankle biomechanics and power allowing for high-end physical performance after severe lower extremity injury.7,8 Early evaluations suggest that the IDEO may be a game changer for limb salvage patients who are young, high functioning individuals with a desire to return to active duty.

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