Bennett, PM et. al. (2018) performed a study of 114 combat-wounded patients followed for a median of 5 years who sustained 90 fractures. The authors report that, “The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction. […] Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees.”
Bevevino, AJ, et. al performed a study of 155 open calcaneus fractures treated with a “median follow-up 3.5 years and an amputation rate 44%.” Authors employed an “artificial neural network designed to estimate likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. […] Decision curve analysis indicated the artificial neural network resulted in higher benefit across the broadest range of threshold probabilities compared to the logistic regression model.”
Ellington and his colleagues in the LEAP Study Group evaluated the 2-year results of patients with mangled foot and ankle injuries that were treated with “limb salvage surgery that required free tissue flaps for wound closure compared with a similar [group of patients with foot and ankle injury who] underwent early below-knee amputation (BKA).” They evaluated the SIP score (the higher the score, the greater is the disability) and other functional outcome measures such as walking speed, number of rehospitalizations for injury-related complications, time to full weight bearing, the visual analog pain scale, and return to work at 2 years. Their conclusion was that patients with severe foot and ankle injuries who require free tissue transfer or ankle fusion have SIP outcomes that are significantly worse than BKA with the typical skin flap design closure.
Dickens, JF et. al. performed a “retrospective review of 102 combat-related open calcaneal fractures.” Multivariate Cox proportional-hazards regression identified that “blast” being the mechanism of injury and the location and larger size of the open wound, “were predictive of eventual amputation.”
BENEFITS & HARMS:
Desirable anticipated effects are large: the lifetime costs and quality of life for accurate and predictable decision-making are substantial. The undesirable effects consist of amputation OR limb salvage decisions that increase costs, reduce quality, but are largely mitigated with shared decision-making and are lower relative to the desirable effects. Precision in decision making somewhat clearly outweighs the risks.
Shared decision making has very little downside, and this question is foundational to the entire Practice Guideline; Evidence is sufficient for this relatively discrete set of injury variables to improve arrival at data-based decision making.
COST EFFECTIVENESS/RESOURCE UTILIZATION:
Consideration of prolonged treatment processes includes implant and surgical costs; hospitalizations; recovery duration as well as lifetime disability; emotional and behavioral care costs as well as prostheses/ orthoses.
There will continue to be stakeholders who will refute the available literature for risk to benefit ratio, the costs, and the importance of outcomes.
Potential moral objections to intervention are low in that autonomy and shared decision-making mitigates other ethical principles such as no maleficence, beneficence, or justice.
Development of a decision tool is feasible to implement and highly important to surgeons and facilities where these injuries are only occasional. This is a sustainable intervention and permits autonomy for providers as well as patients. Barriers include dissemination across various specialties and disciplines
Foremost will be implementation and validation of this toolkit/ guideline approach. Generalizability and acceptance criteria can be readily developed/ modified and need to be part and parcel of the roll out.
Additional Rationale References:
Bevevino, A.J., Dickens, J.F., Potter, B.K., Dworak, T., Gordon, W., Forsberg, J.A. A model to predict limb salvage in severe combat-related open calcaneus fractures. Clin Orthop Relat Res. 2014; 472(10): 3002-9.
- Bennett, P. M., Stevenson, T., Sargeant, I. D., Mountain, A., Penn-Barwell, J. G. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018; 2: 131-138
- Bevevino, A.J., Dickens, J.F., Potter, B.K., Dworak, T., Gordon, W., Forsberg, J.A. A model to predict limb salvage in severe combat-related open calcaneus fractures Clin Orthop Relat Res 2014; 10: 3002-9
- Dickens, J. F., Kilcoyne, K. G., Kluk, M. W., Gordon, W. T., Shawen, S. B., Potter, B. K. Risk factors for infection and amputation following open, combat-related calcaneal fractures. J Bone Joint Surg Am 2013; 5: e24
- Ellington, J. K., Bosse, M. J., Castillo, R. C., MacKenzie, E. J. The mangled foot and ankle: results from a 2-year prospective study. J Orthop Trauma 2013; 1: 43-8