This discussion focuses on limb salvage versus limb amputation. The authors address decision-making and outcomes that relate to the following questions: “Which patients would benefit from limb salvage as opposed to an amputation?” “Does the level of injury make a difference?” “Are there surgical or patient factors outside of the injury that have an impact on a patient’s ultimate function and quality of life?” “Are there injury-related factors that have an impact on patient-reported outcomes?” “How satisfied are patients postoperatively?” and “What are the financial implications of these treatment strategies?”
Key points
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Preoperative lower extremity injury scoring systems to aid with surgical decision-making are limited in their ability to clearly predict the need for amputation.
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Patient-reported outcomes after limb salvage and amputation play a critical role in assessing the quality and efficacy of surgical strategies used.
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Patients with severe lower extremity injuries have significant levels of disability following limb salvage and amputations.
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Limb salvage procedures are successful but are associated with higher rates of complication than amputations.
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Long-term functional outcomes are similar in patients with salvaged and amputated lower extremities, with no difference in their ability to return to work.
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Level of amputation does not affect a patient’s perceptions of their results.
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The absence of plantar sensation at initial presentation is not a predictor of the need to amputate.
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Delays in the initial wound debridement beyond 24 hours are associated with higher rates of amputation.
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Self-efficacy is one of the strongest predictors of a patient’s ability to return to work.
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Postoperative self-management interventions have the potential to improve overall function and quality of life in these patients.
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Satisfaction is not influenced by treatment strategy but by postoperative function, pain, and the presence or absence of depression.
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Limb salvage has a higher utility value and costs less than amputation.
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Results from studies in the trauma population are not generalizable to other patient groups.
Introduction
Limb salvage requires persistent effort for patients with aggressive lower extremity tumors or severe peripheral vascular disease with tissue loss, and in patients who have sustained traumatic complex lower extremity injuries. Important reconstructive considerations in all patients regardless of the cause of their limb disease are limb vascularity, tissue components involved that require replacement or stabilization, and the potential for restoration of function with limb salvage. Our ability to salvage the severely injured lower extremity has improved with technical advances over the years. As would be expected, the question of whether salvage is beneficial to certain patients with severe injuries has been raised and some have justifiably suggested that early amputation and rehabilitation with prosthesis provide a better outcome in select patients. In contrast, others have found that most of their patients with severe lower extremity injuries preferred their salvaged extremity to an amputation, even when they ultimately required a delayed amputation. Although appealing, limb salvage may not always be in the best interest of patients because limb viability and function do not always go hand in hand.
Given that the decision to amputate or salvage an extremity is one of the first decisions made in managing patients with severe lower extremity injuries, preoperative scoring systems to aid with the decision-making process would be useful and have been developed. However, the utility of existing scoring systems has been called into question, because they have been found to be effective at identifying patients who would benefit from salvage but are incapable of identifying patients who would ultimately require amputation. This incapability is a significant flaw because amputations performed in a timely fashion can potentially provide patients with a shorter recovery and return to a relatively high level of function with the use of prostheses. Without a clear consensus on preoperative findings that guide decisions, surgeons in practice have to make decisions based on their clinical judgment, sometimes with little or no supporting evidence.
An understanding of outcomes after salvage is also critical to guiding the surgical decision-making process when considering the choice of limb salvage versus amputation. Surgical outcomes focused on complications and function from the physician’s viewpoint provide valuable information but do not provide a complete picture. To this end, as in other areas of health care, considerations of patient-reported outcomes have become an integral part of assessing the quality and efficacy of care delivered. The term patient-reported outcomes broadly includes functional assessments and health-related quality-of-life outcomes. Outcomes are assessed from the patient’s viewpoint and they have the potential to be distinctly different from those perceived by the treating physician. These outcomes ideally should provide some clarity to questions, such as: Is it more beneficial to salvage or amputate an extremity? Which patients would benefit from limb salvage as opposed to an amputation? Does the level of injury make a difference? Are there surgical or patient factors outside of the injury that have an impact on a patient’s ultimate function and quality of life? Are there injury-related factors that have an impact on patient-reported outcomes? How satisfied are patients postoperatively? and What are the financial implications of these treatment strategies?
Introduction
Limb salvage requires persistent effort for patients with aggressive lower extremity tumors or severe peripheral vascular disease with tissue loss, and in patients who have sustained traumatic complex lower extremity injuries. Important reconstructive considerations in all patients regardless of the cause of their limb disease are limb vascularity, tissue components involved that require replacement or stabilization, and the potential for restoration of function with limb salvage. Our ability to salvage the severely injured lower extremity has improved with technical advances over the years. As would be expected, the question of whether salvage is beneficial to certain patients with severe injuries has been raised and some have justifiably suggested that early amputation and rehabilitation with prosthesis provide a better outcome in select patients. In contrast, others have found that most of their patients with severe lower extremity injuries preferred their salvaged extremity to an amputation, even when they ultimately required a delayed amputation. Although appealing, limb salvage may not always be in the best interest of patients because limb viability and function do not always go hand in hand.
Given that the decision to amputate or salvage an extremity is one of the first decisions made in managing patients with severe lower extremity injuries, preoperative scoring systems to aid with the decision-making process would be useful and have been developed. However, the utility of existing scoring systems has been called into question, because they have been found to be effective at identifying patients who would benefit from salvage but are incapable of identifying patients who would ultimately require amputation. This incapability is a significant flaw because amputations performed in a timely fashion can potentially provide patients with a shorter recovery and return to a relatively high level of function with the use of prostheses. Without a clear consensus on preoperative findings that guide decisions, surgeons in practice have to make decisions based on their clinical judgment, sometimes with little or no supporting evidence.
An understanding of outcomes after salvage is also critical to guiding the surgical decision-making process when considering the choice of limb salvage versus amputation. Surgical outcomes focused on complications and function from the physician’s viewpoint provide valuable information but do not provide a complete picture. To this end, as in other areas of health care, considerations of patient-reported outcomes have become an integral part of assessing the quality and efficacy of care delivered. The term patient-reported outcomes broadly includes functional assessments and health-related quality-of-life outcomes. Outcomes are assessed from the patient’s viewpoint and they have the potential to be distinctly different from those perceived by the treating physician. These outcomes ideally should provide some clarity to questions, such as: Is it more beneficial to salvage or amputate an extremity? Which patients would benefit from limb salvage as opposed to an amputation? Does the level of injury make a difference? Are there surgical or patient factors outside of the injury that have an impact on a patient’s ultimate function and quality of life? Are there injury-related factors that have an impact on patient-reported outcomes? How satisfied are patients postoperatively? and What are the financial implications of these treatment strategies?
Patient-reported outcomes measures
Patient-reported outcomes measures (PROMs) are obtained by way of patient-completed questionnaires that assess a host of health-related outcomes relating to patient function and quality of life after undergoing surgery. In general, these outcomes measures can be used to evaluate the quality of care delivered, to assess the efficacy and cost-effectiveness of multiple treatment modalities, and to guide patient choice. Findings from these instruments allow surgeons to better understand salient aspects of a patient’s experience after major limb operations, including but not limited to their ability to walk, care for themselves, work, and participate in recreational activities, as well as the effect of these operations on social interactions and sexual function. Ultimately, information gathered based on patient-rated outcomes can be used to improve surgical management choices in patients with significant lower extremity injuries. Functional assessments are a key component of health and well-being in the lower extremity trauma patient. Self-reported measures rely on a patient’s perception of mobility status and performance of activities of daily living. These measures aim to assess a patient’s activity restrictions, performance difficulties, or the need for assistance with functional activities.
Health-related quality-of-life outcomes are the other component of well-being measured by PROMs. This outcomes measure essentially is an assessment of what health status is worth to a patient, from the patient’s perspective after an injury or intervention. Generic measurement instruments cover areas of relevance to multiple disorders and are applicable to the general population to compare among different groups. Specific instruments, in contrast, are tailored to particular disease processes. As PROMs present data solely from the patient’s perspective, patient factors such as poor cognitive function, culture, language, and education can have an influence on outcomes reported.
Multiple questionnaires for lower extremity outcomes have been developed ( Table 1 ), with the more commonly used questionnaires in recent years including the Sickness Impact Profile (SIP), the Toronto Extremity Salvage Score, and the Musculoskeletal Tumor Society Score. The SIP has been used the most in recent studies on lower extremity trauma, whereas instruments such as the Toronto Extremity Salvage Score and Musculoskeletal Tumor Society Score questionnaires were developed specifically for oncologic patients. Generic questionnaires also used in lower extremity trauma studies include the Short Form-36 and the Nottingham Health Profile.
| Instrument | Measure | Scoring | Primary Outcomes Evaluated |
|---|---|---|---|
| The Sickness Impact Profile (SIP) | Generic, behaviorally based, health status measure | Scores range from 0 to 100; scores >10 represent severe disability | Health-related dysfunction in 12 categories—ambulation, mobility, body care and movement, social interaction, alertness, emotional behavior, communication, sleep and rest, eating, work, home management, and recreation |
| Musculo-Skeletal Tumor Society (MSTS) | Disease-specific instrument (musculoskeletal tumors) | Scores range from 0 to 30; value of 0 to 5 is assigned to each of 6 categories. Higher scores indicate better function | Pain, function, emotional acceptance, supports, walking, and gait |
| Toronto Extremity Salvage Score (TESS) | Disease-specific instrument (extremity sarcoma) | Scores range from 0 to 100; 30 items are rated on a 5-point Likert scale | Activity limitations, restrictions in mobility, restrictions in self care, and restrictions in performing daily tasks and routines |
| Nottingham Health Profile (NHP) | Generic health status measure | Scores range from 0 to 100; higher numbers indicate greater disability | Part I: Subjective health status—mobility, energy level, pain, sleep, emotional reactions, social isolation Part II: Influence of health problems on—employment, housework, family life, social life, sexual function, recreation, and enjoyment of holidays |
| Short Form (36) Health Survey (SF-36) | Generic health-related quality of life measure | Scores range from 0 to 100; higher numbers indicate a better health state | 8 scales assessed resulting in scores relating to patients’ perceived physical and mental status—vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, mental health |
| Western Ontario and McMaster University Osteoarthritis Index (WOMAC) | Disease specific (arthritis) | Scores range from 0 to 96; higher numbers indicate greater disability | 24 items in 3 dimensions—stiffness, pain, and physical function |
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