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Page 4 of 10 Crystal et al. Plast Aesthet Res 2019;6:1 I http://dx.doi.org/10.20517/2347-9264.2018.69

Table 1. Indications for amputation vs. limb salvage following mass casualty incidents
Amputation Limb salvage
Life-threatening hemorrhage or refractory hypotension Minimal-to-no distal sensation, peripheral nerve disruption [13]
Warm lower limb and upper limb ischemia for > 6 or > 8 h, Stable distal extremity vascular assessment
respectively [49]
Severe partial traumatic amputation and/or multi-level soft tissue, Limited access to prosthesis centers or limited potential for rehabilitation in
osseous, and vascular defects [31,49] the patient (i.e., access or functional capacity) [50]
Resource and infrastructure constraints Viable, non-injured donor sites for tissue transfer
Uniformly: patient preference, age, and comorbidities should be considered

[10]
bony and soft-tissue origin necessitating joint orthoplastic involvement . The most frequently performed
procedures included wound dressing changes, surgical debridements, and split thickness skin grafts.
Notably, 10% of patients received pedicled flaps for local reconstruction and coverage of exposed bone, as
[10]
free flaps were technically impossible within the field hospital . Ultimately, there were six amputations in
this series, three below-the-knee, one above-the-knee, and two digital amputations. Of these amputations,
[10]
only two were in cases of failed limb salvage .

DISCUSSION
The aforementioned case profiles highlight the significant reality that MCIs are an ever-possible occurrence
in our society. Of particular concern is the high prevalence of extremity wounds following disasters such as
[2,3]
earthquakes or bombings . Subsequent decisions regarding limb salvage in this setting are complex and
are impaired by resource availability [Table 1].

Following resuscitation, early assessment of distal neurovascular stability is critical to appraise the utility of
reconstruction [Figure 1]. Vascular assessment and doppler ultrasound interrogation should be performed
prior to considering CT-angiography. As evidenced by reports from French terror attacks, peripheral nerve
[12]
injuries are common in MCIs , however they do not definitively preclude reconstruction. Data from the
Lower Extremity Assessment Project (LEAP) challenged historical beliefs that a lack of plantar sensation
is an indicator for amputation. The authors found that those with insensate lower limbs who underwent
reconstruction had proportionally similar plantar sensation on testing at two years when compared to those
[13]
who had intact plantar sensation prior to reconstruction . Adding complexity to the situation, delayed
access to patients at the location of disasters interrupts transport and evaluation and lengthens ischemia
time, thereby increasing risk of compartment syndrome and rates of amputation [6,14] .

As our case profiles depict, amputation in the setting of MCIs should be reserved for those with life
threatening hemorrhage and severe wounds beyond that of conceivable reconstruction. Further complicating
decisions of mangled extremity limb salvage, a prospective study from the LEAP found that no single
[15]
extremity trauma scoring system can effectively guide amputation decisions . The limiting factors for
salvage in the described MCIs were patient stability, wound severity, and resource availability. Life-saving
amputations must be made definitively, however, as noted at the Bégin Military Teaching Hospital following
[16]
terror attacks in Paris, stable amputations should always involve discussion with the patient .

The utility and quality of life following amputation is subject to significant debate when compared to
[17]
reconstruction. A large prospective series by Bosse et al. identified similar self-reported functional
outcomes at two years between those who underwent amputation or lower extremity reconstruction.
Comparatively, a 2008 systematic review reported that the mean percentage of patients returning to work
[18]
was higher in those who received amputation compared to reconstruction . More recently, cost-utility
[19]
analyses of lower extremity trauma found that amputation was significantly more expensive , and yielded
[19]
slightly less quality-adjusted life years , when compared to reconstruction.