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PubMed2005

Non-work-related finger amputations in the United States, 2001-2002.

STUDY OBJECTIVE: We characterize non-work-related finger amputations treated in US hospital emergency departments (EDs) and discuss implications for injury-prevention programs. METHODS: Finger amputation data from 2001 and 2002 were obtained from the National Electronic Injury Surveillance System All Injury Program (a nationally representative sample of 66 US hospital EDs). National estimates are based on weighted data for 948 cases for finger amputations (including partial and complete) that occurred during non-work-related activities (ie, nonoccupational) activities. RESULTS: An estimate of 30,673 (95% confidence interval [CI] 24,877 to 36,469) persons with non-work-related amputations were treated in US hospital EDs annually. Of these persons, 27,886 (90.9%; 95% CI 22,707 to 33,065) had amputations involving 1 or more fingers; 19.1% were hospitalized or transferred for specialized trauma care. Male patients were treated for finger amputations at 3 times the rate of female patients. The rate of persons treated for finger amputations was highest for children younger than 5 years (18.8 per 100,000 population; 95% CI 12.3 to 25.2 per 100,000 population), followed by adults aged 55 to 64 years (14.9 per 100,000 population; 95% CI 9.6 to 20.1 per 100,000 population). For children aged 4 years and younger, 72.9% were injured in incidents involving doors, and for adults aged 55 years or older, 47.2% were injured in incidents involving power tools. CONCLUSION: National estimates of finger amputations among US residents indicate that young children and older adults are at greatest risk. Parents or other responsible adults should be aware of the risk of small children's fingers around doorways, and adults should take safety precautions when using power tools.

Accidents, Home↗
PubMed2007

The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia.

OBJECTIVES: A consequence of delay in the diagnosis of peripheral vascular disease limb loss. This study was undertaken to determine the correlation of low socioeconomic status and race on the severity of ischemic presentation and the subsequent amputation rate. METHODS: Data from the Nationwide Inpatient Sample (NIS) from 1998 to 2002 on patients from urban hospitals with the diagnosis of lower extremity ischemia were evaluated. The population was divided into two groups: the amputation group (AMP) and lower extremity revascularization group (LER). Comorbidities, age, gender, race, ischemic gangrene at presentation, insurance status (no/noncommercial or commercial), and income status at admission were determined. These variables were compared using multivariate logistic regression analyses of the data for risk adjustment. RESULTS: Of 691,833 patients presenting with lower extremity ischemia, 363,193 underwent revascularization (66.3%) or amputation (33.7%). Univariate analysis correlated a statistically significant (P < .0001) higher rate of amputation and multivariate analysis associated significantly higher odds of amputation with the following variables: nonwhites (1.91, 95% confidence interval [CI], 1.65, 2.20), low-income bracket (1.41, 95% CI, 1.18, 1.60), and Medicare & Medicaid (1.81, 95% CI, 1.66, 1.97). Adjusting for other variables of statistical significance, multivariate regression analysis showed a statistically significant risk for amputation based on the nonteaching status of the institution (odds ratio [OR], 1.17, 95% CI, 1.08, 1.30). CONCLUSIONS: Primary amputation was performed with a higher frequency on patients with lower extremity ischemia who were nonwhite, low income, and without commercial insurance. The observed advanced ischemia among these economically disadvantaged patients suggests a delayed diagnosis of peripheral vascular disease, probably due to lack of access to adequate primary care or vascular surgery providers, or both. Better education of the general population and primary care providers to the symptoms and consequences of PVD may reduce the amputation rate in this group.

Aged↗
PubMed1990

Effect of a failed distal reconstruction on the level of amputation.

Controversy exists as to whether the level of amputation is adversely affected by an unsuccessful limb salvage attempt. Two hundred ten amputations following failed reconstruction attempts in 191 patients were studied and compared with 551 amputations in limbs with no prior revascularization. Initially, 147 of those with failed reconstruction attempts underwent below-knee (BK) amputation and 63 underwent above-knee (AK) amputation. One hundred ten of 143 (77%) surviving BK amputations eventually healed. This is in contrast to the eventual healing in 266 of 298 (89%) of the BK amputations performed with no prior attempts at reconstruction. A statistically significant (p less than 0.05) difference in eventual healing favoring those with no prior reconstruction was demonstrated. Successful reconstruction of the ischemic extremity is the goal of vascular surgery and should be attempted when indicated. However, it should be realized that unsuccessful revascularization attempts may adversely affect healing in those limbs initially considered for a BK amputation.

Adolescent↗
PubMed2000

Predictive value of serum immunosuppressive acidic protein for lung metastasis after amputation of murine osteosarcoma of the lower limb.

A spontaneously occurring murine osteosarcoma cell line (POS-1) was inoculated into the footpads of 88 mice. In 59 mice, the tumor-bearing leg was amputated at 1, 3, 5, or 7 weeks after inoculation and the mice sacrificed at 9 weeks. Lung metastasis was observed in 82.6-100% of the mice undergoing leg amputation at 5 or 7 weeks after inoculation. There were no lung metastasis in the mice amputated at 1 or 3 weeks. The serum immunosuppressive acidic protein (IAP) concentration showed a significant increase at 5 or 7 weeks after inoculation (P<0.005 and P<0.0005, respectively). When amputation was done 5 weeks after inoculation, the serum IAP concentration increased further to 5.9 times the pre-amputation level 1 week after the amputation. The IAP concentration increased only 1.3-fold in the control group without inoculation. Thus, a high serum IAP concentration before amputation and a further increase after amputation were indicators of lung metastasis in this mouse model of osteosarcoma.

Amputation, Surgical↗
PubMed1996

Prevention of neuroma in elective digital amputations by utilization of neurovascular island flap.

Following hand surgery, painful neuromas may impair the quality of the functional result. In planned, elective digital amputation, neuroma formation is quasi-unavoidable because the nerve is cut. Several techniques have been proposed to prevent the formation of neuroma but, in our opinion, the only logical way to avoid it, is not to cut the nerve. For this purpose, we proposed, in cases of planned, elective digital amputation, an intervention inspired by the technique described by Littler in 1956. This technique consists of isolating as an island, the pulp of the amputated finger while preserving nerve continuity of both collateral pedicles. Once the amputation is completed, in cases of distal amputation, the pulp flap is used to cover the proximal stump and, in cases of ray amputation, the nerve loop is buried after its deepithelialization between the adjacent metacarpals. Since 1990, this technique has been used for nine-planned, elective amputations in eight patients. Postoperatively, no patient has developed painful neuroma except one patient who had a painful finger preoperatively and in whom the symptoms remained unchanged postoperatively. This simple technique must be part of the therapeutic armamentarium of planned, elective digital amputations in cases with intact collateral nerves.

Amputation, Surgical↗
PubMedDate not supplied

Cost-efficacy issues in the treatment of peripheral vascular disease: primary amputation or revascularization for limb-threatening ischemia.

Controlling rising health care costs represents a major challenge to our society. Due to the aging of the population and the increasing number of patients with vascular disease, vascular specialists will be under mounting pressure by the managed care industry to provide the most cost-effective care for these patients. One particular controversy is whether to attempt revascularization in the patient with limb-threatening ischemia or to proceed directly with primary amputation. Although it has been assumed that the operative risk for revascularization procedures is high in elderly patients with a severely ischemic limb, mortality rates in the sickest patients are actually higher for amputation. It is also incorrect to assume that the duration of hospitalization is shorter for patients undergoing amputation than for patients undergoing revascularization. For both types of procedures, it is complications that prolong the length of hospital stay, and the rate of secondary amputation following a revascularization attempt is low (8.5%), compared with the rate of operative revision in patients following primary below-knee amputation (23%). The costs for revascularization and primary amputation are similar when the costs of a prosthesis and rehabilitative therapy are included in the calculations for amputation. The rationale for primary amputation assumes that patients will ambulate successfully with a prosthesis; however, many do not, and thus costs for institutionalization must be included in the equation. Long-term costs following revascularization were $28,374 in patients with a viable limb, compared with $56,809 in those undergoing secondary revascularization. The key to minimizing health care costs in this population is careful patient selection for initial revascularization, with aggressive long-term surveillance to ensure graft patency and limb viability.

Activities of Daily Living↗
PubMedDate not supplied

Seasonal variations in lower extremity amputation.

The purpose of this study was to examine seasonal variations in nontraumatic amputation among diabetic and nondiabetic adults. We abstracted data from a database supplied by the state of New York for 14,555 amputations performed in 1990 and 1991. We categorized amputations into three different levels (foot, leg, and thigh). The most common season for a patient with diabetes to receive a lower-extremity amputation was spring (27.0%, p < 0.004; odds ratio 1.1, confidence interval 1.0 to 1.2), while winter was the most common in nondiabetic patients (27.3%, p < 0.005; odds ratio 1.1, confidence interval 1.0 to 1.2). When stratified by amputation level, fewer amputations at the level of the foot occurred during winter in patients with diabetes compared with those without diabetes (24.5% vs. 28.2%, p < 0.002; chi 2MM = 193.1, odds ratio = 1.2, confidence interval = 1.1 to 1.4). Fall was the least common season for amputation at nearly every level for both diabetic and nondiabetic groups, and more diabetic patients presented with an admission diagnosis of vascular disease (74.6% vs. 54.9%, p < 0.0001; chi 2MM = 612.3, odds ratio = 2.4, confidence interval = 2.3 to 2.6). In most diabetic patients, a primary etiologic factor for amputation is an infected neuropathic ulceration brought about or exacerbated by increased activity. By limiting activity, cold weather should act as a protective measure. The data in this study seem to support this notion.

Adult↗
PubMed1997

Effects of vascular surgery on amputation rates and mortality.

OBJECTIVES: To study the relation between rates of vascular interventions, amputations and mortality in a defined population. DESIGN: Retrospective comparison between two consecutive 4-year periods. SETTING: Swedish district hospital covering a population of 125,000. MATERIAL: Three hundred and sixty-seven lower limb amputations and 1080 vascular procedures. RESULTS: The number of legs treated for limb-threatening ischaemia with either revascularisation or amputation increased from 269 to 289. The rate of vascular interventions for limb-threatening ischaemia increased from the first to the second period by 65%, while the rate of amputations decreased by 23%. Limb salvage rate at 30 months increased from 37% to 53% (p < 0.0000). The reduced amputation rate was entirely related to primary amputations. The adjusted risk of amputation for patients treated in the second period was half of that for patients treated in the first period (relative risk = 0.49, p = 0.0001), while mortality was similar in both periods. Among survivors, the proportion of patients with intact legs was higher in the second period than in the first, while no difference was found between the two periods among deceased patients. CONCLUSIONS: Increased vascular intervention leads to improved limb salvage rates and reduced amputation rates. It is important for both ethical and economical reasons to identify good responders to revascularisation, because the choice of initial treatment will only influence limb salvage but not survival.

Age Distribution↗
PubMed2000

Arterial intervention and reduction in amputation for chronic critical leg ischaemia.

BACKGROUND: Untreated chronic critical leg ischaemia (CLI) usually leads to an amputation or death of a patient. Surgical and endovascular interventions may improve arterial flow. Long infrainguinal reconstruction may be the most useful method for preventing amputations. The value of different reconstruction methods was assessed by their impact on amputation incidence. METHODS: A nationwide 2-year analysis of the incidence of major amputations and reconstructions for CLI was done in Finland (population 5.1 million). Incidences were compared in hospital regions with more than 150 000 inhabitants. RESULTS: The overall amputation incidence was 216 per million inhabitants per year. The corresponding incidence of arterial reconstructions was 203 per million inhabitants per year. There were large variations in the incidence of amputations and reconstructions; 20-fold differences in infrapopliteal surgical reconstructions and 30-fold differences in endovascular procedures were found. There was a correlation between a high incidence of infrapopliteal surgical reconstructions and a low incidence of amputations. This correlation was found for below-knee amputations only. CONCLUSION: These results suggest that long surgical reconstructions improving perfusion directly to the ischaemic tissue can improve leg salvage.

Amputation, Surgical↗
PubMed2001

Factors related to successful job reintegration of people with a lower limb amputation.

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.

Adolescent↗
PubMed2000

Children with congenital deficiencies or acquired amputations of the lower limbs: functional aspects.

The aim of the study was to evaluate the use of prostheses, some secondary complications and functional aspects among children who had a congenital leg deficiency or an acquired leg amputation. Rehabilitation physicians were asked to refer children, aged 1-18 years, with a leg deficiency or amputation. Mentally retarded children, children who had only had a toe amputated and children within one year after amputation were excluded. A total of 88 children were included; 64 with a congenital deficiency and 24 with an acquired amputation. In 25 of these 88, both legs were affected; 28 children also had an arm deficiency or amputation. A structured interview was held and the Child-HAQ assessed. Five (5) questions from the Child-HAQ, all relating to leg functions, were analysed. All but 7 children had had a prosthesis fitted, most (89%) using it for almost the entire day. In the children with congenital deficiencies, the first prosthesis had been fitted at an average age of approximately 18 months. Four (4) of the 7 children without prostheses used orthopaedic footwear. The 10 children with congenital deficiencies necessitating prostheses with articulated knees had the first knee of this type fitted at an average age of approximately 37 months. Forty-seven (47) of the 88 children had needed one or more (secondary) operations. In the children with congenital deficiencies, this was usually a conversion procedure, while the children with an acquired amputation had usually been operated on for osseous overgrowth. Twenty (20) of the 88 children experienced or had previously experienced phantom sensations, 5 children phantom pain. Skin problems were common. Most children (95%) were able to walk, most of them (93%) more than 100 m and 93% of the children aged 4 years or over were able to cycle. Most children (94%) aged 6 years or over were able to don and doff their prostheses independently. Some 90% of the children aged 4 years or over attended a normal primary or secondary school. Most (93%) of the children were able to take part in the physical education programme at school, although frequently (47%) with some degree of difficulty. The functional abilities of 88 Dutch children with congenital leg deficiencies or leg amputations were found to be generally satisfactory. Most of the children used prostheses in their daily activities. Secondary complications were, however, frequent.

Adolescent↗
PubMedDate not supplied

Psychosocial adjustment to lower-limb amputation: a review.

PURPOSE: To review the existing literature on the social and psychological challenges faced by people with an amputation and to provide a detailed analysis of the literature examining psychological adjustment to these challenges across time. METHOD: Existing papers on psychological adjustment to amputation were analysed according to their results, methodology, and conclusions. RESULTS: Although depression and anxiety are relatively high up to 2 years post-amputation, they appear to decline thereafter to general population norms. However, social discomfort and body-image anxiety have also been found among some people with amputations, and these have been associated with increased activity restriction, depression, and anxiety. Factors associated with positive adjustment to limb loss include greater time since amputation, more social support, greater satisfaction with the prosthesis, active coping attempts, an optimistic personality disposition, a lower level of amputation in the case of lower limbs, and lower levels of phantom limb pain and stump pain. CONCLUSION: The majority of studies on adjustment to amputation are cross-sectional in design and have used noncomparable measures. Furthermore, they have neglected to study many important areas of rehabilitation, including immediate reaction to amputation, adjustment during and shortly after the rehabilitation period, and development of a changed sense of self and identity. In order to address these concerns, more longitudinal and qualitative research is called for. We end by outlining the components of a descriptive phased model of the rehabilitation process.

Activities of Daily Living↗
PubMedDate not supplied

Psychosocial predictors of long-term adjustment to lower-limb amputation and phantom limb pain.

PURPOSE: To evaluate the utility of a biopsychosocial model to predict long-term adjustment to lower-limb amputation and phantom limb pain (PLP). METHOD: One month after lower-limb amputation, 70 participants completed measures of PLP intensity, cognitions (catastrophizing, perceived control over pain), coping (pain-contingent rest), social environment (social support, solicitous responding), and functioning (pain interference, depressive symptoms). The measures of functioning were administered again at 1- and 2-years post-amputation. Multiple regression analyses were used to examine the ability of the psychosocial variables at 1-month post-amputation to predict changes in the functioning measures over time. RESULTS: The psychosocial variables at 1-month post-amputation, controlling for initial PLP intensity, accounted for 21% of the variance in change in depressive symptoms at 1-year (p < 0.05), and 27% and 22% (p's < 0.01 and 0.05, respectively) of the variance in change in pain interference and depressive symptoms, respectively, at 2-years post-amputation. Catastrophizing and social support were associated with decreases (improvement) in both criterion measures, while solicitous responding was associated with increases (worsening) in both measures. DISCUSSION: The findings support a biopsychosocial model of long-term adjustment to amputation and PLP. In addition, results suggest that some psychosocial variables are more important than others for predicting adjustment, providing important implications for early interventions after amputation.

Activities of Daily Living↗
PubMed1997

Salvage of fingertip amputated at nail level: new surgical principles and treatments.

In this study, a new classification of fingertip amputation based on the surgical treatment is reported. Specifically, the necessity for special procedures to prevent venous congestion in fingertip replantation at the nail bed level was studied. There are some reports of successful replantations without venous anastomoses. In order to avoid technical factors, clinical cases operated on by a single surgeon were evaluated to determine what treatment is necessary for amputations at various levels to avoid necrosis due to venous congestion. During the 5-year period from October 1987 to October 1992, 150 replantations in 137 patients were performed, including 49 fingertip replantations in 45 patients who were operated on consecutively by a single surgeon. The distal phalanx (DP) of the finger was classified as zone DP-I, IIA, IIB, and III from distal to proximal. This classification was based not only on the amputation level but also on the difference in surgical treatment. For amputations of zone DP-I, which extends from the fingertip to the most distal dividing point of the digital artery, the amputated fingertip is attached without vascular anastomosis and the whole finger is wrapped in aluminium foil and cooled in ice water for 3 days. For amputations of zone DP-IIA and IIB, anastomosis of the digital artery is performed in the central portion of the palmar region of the finger, but Kirschner wire fixation is not performed so as not to disturb the venous drainage through the medullary cavity. For amputations of zone DP-IIA, special treatment is not necessary for venous congestion, and for those of zone DP-IIB partial resection of the nail is done if necessary. For zone DP-II amputations, venous anastomosis must be performed for salvage. All patients were operated on according to the procedures based on this classification and final survival rate was 91.5%.

Adult↗
PubMed1982

The role of vascular laboratory criteria in the selection of patients for lower extremity amputation.

We evaluated clinical and vascular laboratory data on 126 patients with below-knee or forefoot amputation. Vascular laboratory examination included Doppler systolic blood pressure and arterial wave form analysis using the segmental plethysmograph. Fifty-four patients had below-knee amputation. A calf systolic pressure greater than 70 torr was associated with 97% (33/34) success (p less than 0.005), an ankle systolic pressure greater than 30 torr yielded 91% (39/43) success (p less than 0.025), and an ankle systolic pressure greater than zero yielded an 87% success (p less than 0.005). In the absence of each of the above criteria, the predictive value of a negative test was only 32%, 40%, and 52%, respectively. The presence of a popliteal pulse was associated with 97% success (p less than 0.025); however, 88% of those with an absent popliteal pulse also achieved successful healing of below-the-knee amputations. Prior vascular reconstructive surgery was detrimental to healing of below-knee amputations. with 33% failure rate (p less than 0.025). For the 72 forefoot amputations, an ankle systolic pressure greater than 70 torr yielded a 65% success (p less than 0.025). The sensitivity of an ankle systolic pressure greater than 70 torr was 80% (32/40) and an ankle systolic greater than 35 yielded a sensitivity of 95% (38/40). The specificity was low for both of these reference values. Clinical and vascular laboratory criteria can identify patients who will have a successful below-knee amputation; however, because of the high false negative rate, patients should not be denied below-knee amputation solely on the basis of Doppler systolic pressure. Vascular laboratory criteria for predicting healing of forefoot amputations are also limited by the high rate of false positive and false negative results.

Aged↗
PubMed1999

Replantation of fingertip amputation by using the pocket principle in adults.

There are several treatment modalities for zone 1 or zone 2 fingertip amputations that cannot be replanted by using microsurgical techniques, such as delayed secondary healing, stump revision, skin graft, local flaps, distant flaps, and composite graft. Among these, composite graft of the amputated digit tip is the only possible means of achieving a full-length digit with a normal nail complex. The pocket principle can provide an extra blood supply for survival of the composite graft of the amputated finger by enlarging the area of vascular contact. The surgery was performed in two stages. The amputated digit was debrided, deepithelialized, and reattached to the proximal stump. The reattached finger was inserted into the abdominal pocket. About 3 weeks later, the finger was removed from the pocket and covered with a skin graft. We have consecutively replanted 29 fingers in 25 adult patients with fingertip amputations by using the pocket principle. All were complete amputations with crushing or avulsion injuries. Average age was 33.64 years, and men were predominant. The right hand, the dominant one, was more frequently injured, with the middle finger being the most commonly injured. Of the 29 fingers, 16 (55.2 percent) survived completely and 10 (34.5 percent) had partial necrosis less than one-quarter of the length of the amputated part. The results of the above 26 fingers were satisfactory from both functional and cosmetic aspects. Twenty of the 29 fingers, which had been followed up for more than 6 months (an average of 16 months), were included in a sensory evaluation. Fifteen of these 20 fingers (75 percent) were classified as "good" (static two-point discrimination of less than 8 mm and normal use). From the overall results and our experience, we suggest that the pocket principle is a safe and valuable method in replantation of zone 1 or zone 2 fingertip amputation, an alternative to microvascular replantation, even in adults.

Adolescent↗
PubMed2001

Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction.

Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.

Adolescent↗
PubMed2007

Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies.

PURPOSE: Leg threatening injuries present patients and clinicians with a difficult decision: whether to pursue primary amputation or limb salvage? The purpose of our study was to review the literature in an effort to inform this management decision. METHODS: We systematically searched and selected observational studies that reported on individuals presenting with leg threatening injuries comparing outcomes of limb salvage versus primary amputation. We searched MEDLINE, CINAHL, and EMBASE. We reported on the following outcomes, and pooled data across trials when possible: length of hospital stay, total rehabilitation time, cost, clinical outcomes, failure rate for limb salvage, function & quality of life, pain, return to work, factors associated with poor outcome, and patient preference. RESULTS: Nine observational studies contributed data to our systematic review. The current evidence suggests that while length of hospital stay is similar for limb salvage and primary amputation, length of rehabilitation and total costs are higher for limb salvage patients. Salvage patients requires greater additional surgery and are significantly more likely to undergo re-hospitalization. Long-term functional outcomes (up to 7 years post injury) are equivalent between limb salvage and primary amputation; both forms of management are associated with high rates of self-reported disability (40%; to 50%;), and functional status continues to worsen over time. Report of pain following limb salvage or primary amputation is similar. Return to work is essentially the same between limb salvage and primary amputation groups, with approximately half of such patients returning to competitive employment at 2 years post injury. Both clinical and psychosocial factors are associated with poorer functional outcomes. At the time of injury patients prefer limb salvage, but the majority of failed salvage patients would opt for early amputation if they could decide again. CONCLUSION AND SIGNIFICANCE: Functional outcome among patients who present with leg-threatening injuries are not significantly different, at least up to 7 years, whether they are managed with limb salvage or primary amputation. Research to optimize triage decisions to avoid failed limb salvage as well as on interventions targeting important psychosocial prognostic variables should be considered a priority.

Amputation, Surgical↗