SLR - December 2018 - Richard R. Bruno
Complications and Revision Amputation Following Trauma-Related Lower Limb Loss
Reference: Eric Edison Low, Elizabeth Inkellis, Saam Morshed. Complications and Revision Amputation Following Trauma-Related Lower Limb Loss. Injury-International Journal of the Care of the Injured, 48, 364–370, February 2017.
Scientific Literature Review
Reviewed By: Richard R. Bruno, DPM
Residency Program: Eastern Virginia Medical School, Virginia Beach, VA
Podiatric Relevance: Limb salvage is key to the podiatric profession. In most instances, it involves people living with diabetes, although it may also pertain to limb salvage following trauma. Trauma injuries introduce a different aspect as one must respect the unique deformity based on its soft-tissue characteristics as well. The main proponent of this retrospective study was to investigate the epidemiology of lower-extremity amputations secondary to traumatic injury, to assess predictors of postsurgical complications versus revision amputation and length of hospitalization.
Methods: This level IV retrospective study performed secondary data analysis from 2011–2012 research. They searched 900 trauma centers with 1,617,999 incidents. Searches conducted by ICD-9 codes were for LE amputation, toe and foot amputation, ankle disarticulation or amputation through tibia and fibular, knee disarticulation, trans-tibial, trans-femoral, hip disarticulation and abdominopelvic amputations. They refined down to 4,343 subjects by removing those undergoing minor toe amputations or with unspecified ICD-9s. They hoped to research factors to evaluate predictors for major postsurgical complications, revision amputation, length of hospitalization and in-hospital mortality. Major complications were classified as graft/flap failure, deep infection, decubitus ulcer, osteomyelitis, DVT, PE, acute kidney injury, respiratory distress syndrome and sepsis. The need for revision was classified as needing an irrigation, debridement, closure of a stump or more proximal amputation. Injury severity score was also implemented for analysis. They associated these groups with logistic regression models fit to the Hosmer-Lemeshow test.
Results: There were 2,879 patients who underwent LE amputation following trauma. MVAs were the most common cause at 61.7 percent. Most frequent amputations were trans-tibial (46 percent) with injury severity score of 14.6 and 20.8 days for length of stay, trans-femoral (37.5 percent) and foot (7.6 percent). The most common code identified was unilateral amputation below the knee at 7.3 percent then open tibia/fibula shaft fracture at 5.4 percent. Of all patients, 67.6 percent were treated at a level 1 trauma center. Within the cohort, 21.8 percent had neurovascular injury with 7.2 percent having compartment syndrome and crush injuries at 11.4 percent. There were 27.5 percent of amputees who had major postsurgery complications. Patients with neurovascular issue had 35 percent higher odds of major postsurgery complication. For every increase in the injury severity score of one point, hospital course increased by 12 hours. The average length of stay in hospital was 22.7 days. Individuals with a revision stayed 5.5 days longer. There were 1,204 patients (41.8 percent) who required at least one revision. Revisional amputation was predicted and seen as a common outcome in patients with larger injury severity scores, age, hospital teaching status (WB/PT), crush injuries, fracture areas, compartment syndrome and complications. They cited the cost of amputation by year 2 and lifetime course are $91,106 and $509,275. The discovered high ratios of revision amputations at university hospitals.
Conclusions: Trauma-related amputations are situations requiring advanced efforts to preserve the soft tissue and proximal limb with high risk of complications. These situations are often costly and demanding on the patient and surgeon. Limitations included refined search to only hospital stay and not readmittance or revisions once discharged and no subjective information.