Comorbidities
In the absence of reliable evidence, it is the opinion of the work group that pre-existing comorbid conditions should be considered in the decision of 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:

Consensus opinion was reached by the work group based on the argument that limiting surgical exposures (early amputation) would likely minimize complications and increase cost-effectiveness in patients with severe and/or multiple comorbidities (COPD, PVD, CHF, valvular disease, ESRD, liver failure, dementia, etc.) who may not tolerate multiple surgeries when pursuing limb salvage.

BENEFITS & HARMS:

Minimizing the numbers of surgeries in patients with severe comorbidities will potentially minimize the risk of perioperative complications including, but not limited to death, re-admissions, increased length-of-stay (LOS), wound complications, infection/sepsis, VTE, and serious cardiopulmonary and renal complications. Certainly, overestimating the number and/or severity of comorbidities at time zero could lead to premature amputation outside the purview of life-over-limb scenarios.

IMPORTANT/PRIORITY OUTCOMES:

Death, re-admissions, increased LOS, wound complications, infection/sepsis, VTE, and serious cardiopulmonary and renal complications are all well-known negative outcomes that surgeons seek to avoid in attempting to provide high quality care and increased quality of life for their patients. Additionally, they have become well-known metrics by which health care organizations are benchmarked for quality of care.

COST EFFECTIVENESS/RESOURCE UTILIZATION:

Literature supports that lifetime costs of amputation are higher for young patients with diminishing costs approaching that of limb salvage when performed in patients with decreased life expectancy. Under the assumption that patients with severe and/or multiple comorbidities would more likely be older and experience more complications with attempted limb salvage, appropriate early amputation may be the more cost-effective strategy among these patients.

ACCEPTABILITY:

Some people groups may approach the limb salvage versus amputation dilemma with a “limb salvage at all cost” philosophy. However, it is believed that most patients will choose an interactive, rationalized decision-making approach when presented with reasonable evidence and medical facts about their pre-existing health by their surgeon in order to make the most appropriate choice for them.

FEASIBILITY:

Outside of the life-over-limb scenario, informed medical decision-making is the standard of care. Taking into account the type, number, combination, and/or severity of comorbidities and their potential effects on outcomes will promote this process.

FUTURE RESEARCH:

Studies focused on understanding the specific type, number, combination, and/or severity of comorbidities effects on a multitude of outcomes will allow us to make more definitive future recommendations with regards to their influence on the decision for limb salvage versus amputation.


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