SLR - July 2021 - Caleb P. Thomas

Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation 

Reference: Major Extremity Trauma Research Consortium (METRC). Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am. 2021 May 12. doi: 10.2106/JBJS.20.01320. Epub ahead of print. PMID: 33979309. 

Level of Evidence: II

Scientific Literature Review 

Reviewed By: Caleb P. Thomas, DPM 
Residency Program: Geisinger Community Medical Center – Scranton, PA 

Podiatric Relevance: Limb salvage is an integral part of the podiatric profession, and podiatric surgeons are often presented with difficult decisions when it comes to the surgical management of their limb salvage patients. The mere ability to successfully perform a certain procedure must not be a deciding factor when it comes to choosing the right procedure for our patients. Depending on the nature and location of their deformity, some patients would be better served forgoing the limb salvage process altogether and having an early amputation instead.  
Methods: A level II observational study was performed on 581 patients, of whom 84 percent underwent limb salvage and 16 percent underwent early amputation, which was defined as a transtibial or Syme amputation performed within three months after the injury. Of the limb salvage procedures, 17 involved partial foot amputations and 10 were followed by late amputation. The study included patients 18 to 60 years of age with an a) Type-III pilon fracture, b) Tyle-IIIB C ankle fracture, c) Type-III talar or calcaneal fracture, or d) open or closed blast/crush injury. Subjects had either been treated with limb salvage (n=488) or early amputation (n=151). Each of the subjects were followed for 18 months. The primary outcome measure was the Short Musculoskeletal Functional Assessment (SMFA) score, which provides a quantitative method for assessing functional status following orthopaedic trauma. Causal effect estimates of the improvement which early amputation would have provided had it been performed in lieu of limb salvage were calculated using the following variables: SMFA score, physical performance, pain level, participation level in vigorous activities, and return to work. 

Results: The SMFA is a 46-item questionnaire consists of two main indices: The Dysfunction Index, which assesses function (or lack thereof), and The Bother Index, which is designed to detect how much patients are bothered by functional deficits. In this study, SMFA scores were consistently higher across all subgroups favoring early amputation over limb salvage. This means that these patients tend to have greater function and are less bothered by what they cannot do. The improvement in SMFA score was most notable among subjects with pilon/complex ankle fractures.  
Conclusions: Depending on the injury type and complexity, early amputation should be considered as a legitimate early treatment option rather than last resort. Early amputation becomes a more viable early treatment option with increasingly complex fracture patterns. While this can be a hard sell to our patients, it is important to for us as podiatric surgeons to help them to not only achieve an optimal functional level, but also to help what function they lack be less bothersome to them. 

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