Page 18 - Read Online

Page 4 of 11 Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117

[18]
engagement in care, and social support should be considered . A culturally competent team should also
explore the patient’s values during this process - some patients may wish to retain a functionally useless
limb for psychological, cultural, social, religious, and other reasons [19-21] .

Conversely, the orthoplastics team should consider the resources required to attempt limb salvage. The
clinical complexity of these cases frequently requires intensive care for flap monitoring, blood products, and
specialized surgical equipment. The clinical course may require infectious disease, vascular surgery,
prosthetic and orthotic, and other consultations, as well as coordinated co-surgeries to minimize adverse
outcomes as well as urgent operating room availability to manage complications. Therefore, the authors
recommend that these procedures be performed by personnel with training and experience in limb salvage
at tertiary or quaternary trauma centers.

Amputation is particularly worth discussing early for a “mangled extremity”. A mangled extremity has been
defined as a limb with injuries to a minimum of three of four musculoskeletal systems (blood vessels,
nerves, bone, and soft tissue) [22,23] . Mangled limbs more commonly occur in military conflict than civilian
trauma, may be life-threatening and associated with other life-threatening injuries, and require immediate
surgical attention. The mangled extremity severity score was proposed in 1990 to guide the choice to
amputate, though its efficacy has been called into question due to advances in orthopedic, vascular, and
plastic management of severe limb trauma [24-26] . Current guidelines recommend against the use of lower
extremity severity scores in both predicting outcomes and deciding on primary amputation .
[2]

The LEAP study was a multi-centered, multivariate, prospective observational study that sought to identify
patient and injury factors that might be associated with a better outcome with limb salvage vs. amputation.
While LEAP provided evidence to guide clinical reasoning and identified objective measures of treatment
success, the study failed to identify criteria available at injury associated with the long-term outcome that
could guide the decision to amputate or attempt limb salvage . However, LEAP and other investigations
[4]
have identified injury characteristics, including the severity and size of traumatic bone defects, the severity
of wound contamination, the extent of soft tissue injuries, neurologic injury, and vascular integrity as
predictors of limb salvage failure [4,27-31] and factors that should be weighed when considering amputation.
Additionally, comorbid conditions including tobacco use, immunosuppression, metabolic disease,
nutrition, and age are associated with poor skeletal and soft tissue healing and thus predict limb salvage
[2,4]
failure .
The METALS study provided robust, long-term documentation of disability and functional outcomes in
[5]
combat veterans who sustained severe extremity injuries . They found limb salvage to be more efficacious
in upper extremities than lower extremities, likely due to less functional upper extremity prostheses .
[5]
Amputation perhaps provided superior outcomes than salvage in the lower extremity, although the authors
expressed concern that selection bias may have influenced these results . Due to the development of
[5]
advanced lower extremity prostheses, these patients have improved limb functionality and quality of life .
[32]
Both METALS and LEAP identified the importance of social support during the clinical recovery from
severe extremity trauma . These studies reported high rates of depression and post-traumatic stress
[4,5]
[4,5]
disorder independent of treatment by limb salvage or amputation . Self-efficacy, or the patient’s
perception of and engagement in their recovery, was consistently the most reliable outcome predictor in the
LEAP study . Through emotional support and motivation, the care team may be able to improve both the
[4]
psychological well-being of the patient as well as their perceptions of surgical results.