Limb Salvage vs Amputation
A badly damaged limb with a complex fracture is one of the most challenging situations for an orthopaedic surgeon. Many patients who present with such injuries are young people of working age, for whom the loss of a limb would be catastrophic. Advances in reconstructive surgery allow salvage attempts to be made on limbs that in the past could only have been dealt with by amputation. However, salvage does not necessarily guarantee a return to full functionality. In this article, Mr Aswinkumar Vasireddy, Orthopaedic Trauma Surgeon, explores the factors that are taken into consideration when assessing limb salvage vs amputation and the medicolegal challenges involved.
The main goal of treatment is to achieve the best possible outcome for the patient, but it is not always clear whether this should involve an attempt to salvage the limb or whether amputation might actually be a better option. Factors to consider when contemplating amputation include severe soft tissue damage, severe vascular injury and significant nerve damage. Amputation should also be performed where the injured limb is the source of uncontrollable bleeding which may threaten the patient’s life, or where any attempt at salvaging the limb would also present an unacceptable risk to life.
Whilst limb salvage, if at all possible, should always be the preferred option, this course of treatment does potentially leave the patient at greater risk of long-term complications, such as infection, non-union of broken bones and functional limitations. There may also be a psychological cost, particularly if the affected limb becomes more of a liability than an asset. It has been reported that nearly 50% of patients with a salvaged lower leg required an assistive device in order to walk, and walking with crutches actually requires around 15% more energy than a below-knee prothesis. Furthermore, long-term employment rates in patients with salvaged limbs are only half those of patients undergoing early amputation. Interestingly, the factors which determine a successful return to work appear to be related to the patient, rather than the injury. Thus, patients aged less than 40 years who are highly educated and employed in a white-collar job are more likely to return to work, while those who cannot afford a long absence from work and who have a poor social support network are less likely to do so. For some patients then, returning to their pre-injury level of functioning may actually be better achieved by early amputation. However, the crucial issue is identifying exactly which patients would benefit in this way.
In order to assist clinicians in making a decision on whether to amputate, particularly in borderline cases, numerous scoring systems have been developed. The most commonly used of these is the Mangled Extremity Scoring System (MESS), which assesses soft tissue injury, limb ischemia, presence and duration of shock and the age of the patient. However, studies have shown that none of these systems is completely accurate at predicting outcomes, meaning that in some patients, salvage is attempted only for it to fail, while other patients undergo amputations. Part of this inaccuracy stems from inter-observer variations in the classification of injury severity. In addition, these systems do not consider factors related to the institution and surgical team involved in the case. The availability of resources and specialist staff, as well as the experience of the surgeon, are all important factors to consider. It is therefore not surprising that NICE guidelines specifically stipulate that a decision to amputate should not be based on the result of a scoring system alone.
Instead, the decision should be centred around a multidisciplinary assessment of the limb. Discussions should involve, at least, an orthopaedic surgeon, a plastic surgeon and a rehabilitation specialist, along with the patient and their family or carers. As well as objective assessments of the patient’s injury and physical condition, other more subjective factors which need to be taken into account include their wishes, attitude, support system, lifestyle, occupation and financial resources, although it is clear that some of these potentially influential factors may not be measurable on admission to hospital. If the decision to amputate is made, the surgery should be performed within 72 hours of injury to lessen the risk of deep infection.
The question of limb salvage vs amputation presents some particularly complex medicolegal challenges. Losing a limb will clearly have a huge impact on a patient, but while limb reconstruction may be psychologically more acceptable, the physical outcome is similar for salvage and amputation. If the decision to salvage the limb turns out to be wrong, and results in a secondary amputation, this will be to the detriment of the patient, physically, psychologically, financially and socially. However, once a limb has been amputated, it is impossible to argue that it could have been salvaged. Thus, it can be difficult to prove that a course of treatment was negligent. This is reflected by the fact that medical negligence claims involving amputation are relatively rare. The most common reason for a claim to be made is a delay in the diagnosis or treatment of arterial ischemia, although claims also arise from delays in the diagnosis and/or mismanagement of injuries, such as fractures, or infection in a limb, resulting in subsequent amputation.
To discuss a case or instruct Mr Vasireddy, please contact firstname.lastname@example.org or call 020 7118 0650.
National Institute for Health and Care Excellence. Fractures (complex): assessment and management [Internet]. [London]: NICE; 2016 [updated 2017 Nov; cited 2019 Dec 11]. (NICE guideline [NG37]). Available from: https://www.nice.org.uk/guidance/ng37/evidence/full-guideline-pdf-2359957649
Hiatt, M.D., Farmer, J.M., Teasdall R.D. (2009). The decision to salvage or amputate a severely injured limb. J South Orthop Assoc; 9(1): 1-7.