Nerve Injury
The evidence suggests plantar sensation or an observed nerve transection is not a factor in the decision for limb salvage vs. amputation.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA

Rationale

RATIONALE:

The evidence suggests that plantar sensation or an observed tibial nerve transection is not an absolute, major, or unique factor for early amputation. In 2005, Bosse et al. (as part of the LEAP study) identified 55 patients with an insensate extremity (lack of plantar sensation) after lower extremity trauma. They found the presence of an insensate foot at the time of presentation did not adversely affect limb salvage at both 12- and 24-months post injury. More recently Bennett et al. in 2018, found in a cohort of 77 patients’ neurologic deficit also did not impact functional recovery.

BENEFITS & HARMS:

Given the available procedures for nerve reconstruction and/or innervated free tissue transfer, nerve injury alone should not predicate salvage versus amputation. However, a known nerve injury (e.g. transection, avulsion, crush, segmental injury) identified at presentation will result in a more complicated reconstructive process for the patient with lower limb trauma. The work group recommends future salvage decisions outside of the acute presentation should be shared with the patient incorporating the risks and benefits of salvage versus amputation. Possible negative sequelae of salvage include lack of motion, lack of sensation and debilitating neuropathic pain.

IMPORTANT/PRIORITY OUTCOMES:

Priority outcomes include a sensate, mobile, stable and nonpainful limb.

COST EFFECTIVENESS/RESOURCE UTILIZATION:

As an independent factor, there is no direct impact on cost effectiveness/resource utilization.

ACCEPTABILITY:

High (not sure)

FEASIBILITY:

High (not sure)

FUTURE RESEARCH:

High powered studies evaluating the impact of the level of nerve injury (with or without reconstruction) on functional outcomes are needed. Long-term outcome studies determining the return of sensation and motor function after reconstructive nerve procedures (e.g. nerve repair, graft, transfer and free soft tissue transfer) are also needed to help set patient and physician expectations in the care of the threatened limb.


LEARN MORE ABOUT AAOS

The Future of OrthoGuidelines

FIND OUT MORE

The OrthoGuidelines Process