Limb salvage vs amputation final

LIMB SALVAGE
Vs.
AMPUTATION
Dr.Sagar A. Savsani ,
Junior Resident , Dept of Orthopaedics ,
JSS Medical College and Hospital ,
Mysuru , Karnataka

Limb Complex Multisystem Injury
( Mangled Extremity )
• A limb with an injury to at least three out of four systems
( soft tissue, bone, nerves, and vessels )
Mangled Extremity
Skin/Soft tissue loss
Fracture/Bone loss
Vascular Injury
Nerve Injury

Limb Complex Multisystem Injury
( Mangled Extemity )
High Energy Trauma
• Blunt trauma
• Motor Vehicle Accidents
• Industrial / Farm Accidents
• Falls from a height
• High Velocity Gunshots
• Explosion Injuries

INJURY EVALUATION
What we are dealing with
1. FRACTURE CLASSIFICATION
2. SKIN INJURY
Closed fractures (IC) 5 grades
Open fractures (IO) 5 grades
3. NEUROVASCULAR INJURY
(NV) 5 grades
4. MUSCLE / TENDON INJURY
(MT) 5 grades

PERSONALITY OF THE INJURY
Global vs Key hole vision
(The Injured Limb)
Soft tissue envelope
Infection
Vascular status : Perfusion , Doppler , CT angiogram
Nerve function : Sensation , Motor
Location and size of the defect
(The Patient)
General condition of the patient
(The Hospital)
Hardware , Equipments & Trained surgical staff
(The Resources)
Psychosocial & Economic

A DECISION HAVE TO BE DONE
Amputation + Prosthesis
Vs
Limb Salvage Procedure

AMPUTATION VS. SALVAGE
GUIDELINES - OUTCOME
• Immediate amputation
• Attempted salvage with early amputation
• Successful salvage
• Unsuccessful salvage with late amputation

AMPUTATION VS. SALVAGE
GUIDELINES - OUTCOME
• How we decide on salvage versus amputation ?
1. Predictive Salvage Index (PSI)
2. Mangled Extremity Severity Score (MESS)
3. Limb Salvage Index (LSI)
4. Nerve Injury, Ischaemia, Soft-tissue Injury, Skeletal Injury,
Shock, and Age (NISSSA)
5. Hannover fracture Scale – 97 (HFS-97)
Trauma scores :
Do not correlate well with final limb function

Classifications And Scoring Systems

• Issues with G & A classification :
1. Under representation of IIIB injuries
2. Varying inter observer variability
3. No guidelines an be drawn using the classi. For
either management or outcome
4. The classification does not address the question
of salvage
5. Gustilo’s grading can change with debridement
and again if the wound requires re-debridement

• The suggested MESS threshold score for amputation is 7.
• Only prediction not indication
• Cautiously decision base on clinical
• Thus using the MESS, for example,
In a 30-year-old patient (1 point) with
a high-energy open tibia fracture (3 points), with
normal perfusion but a diminished pulse secondary to spasm
or compression (1 point), who has
persistent hypotension before laparotomy related to a spleen
injury (2 points)
would undergo amputation at the conclusion of the
laparotomy despite the fact that the limb perfusion will likely
return to normal and splenectomy and appropriate
resuscitation will resolve the patient’s hypotension.

• Since the time of their initial publication, various
other authors have attempted to validate several
of the proposed scoring systems.
• In a later study Lin et al.91 suggested attempted
salvage should be done for MESS scores of ≤9
because of improvements that have been made
in clinical techniques and patient care.

• If MESS -10 points, primary amputation is suggested
given the universally poor functional prognosis.
• If the patient has MESS =<6 points, a 95% salvage rate
is expected, and limb salvage should be attempted.
• If the patient has an equivocal MESS (between 7 and
9 points), the ISS should be applied to assess for the
presence of concomitant systemic injury.
• When the patient with MESS between 7 and 9 has ISS <
18, limb salvage can be attempted with an expected
60% salvage rate.
• On the other hand, if ISS >18,expected salvage rate falls
to approximately 25%, and primary amputation should
be considered .

• Reference :
The effect of systemic injury score on the decision making of
mangled lower extremities
Hsuan-keng Yeh, Frank Fang, Yu-Te Lin ,Cheng-Hung Lin, Chih-
Hung Lin,Chung-Chen Hsu,
Injury, Int. J. Care Injured 47 (2016) 2127–2130

• To further clarify the clinical utility of any of the limb
salvage scores, the LEAP study prospectively captured all of
the elements of the MESS, LSI, PSI, NISSSA, and the HFS145
at the time of each patient’s initial assessment and critical
decision making.

Ganga Hospital
Open Injury
Severity Score
for Open Type
IIIB fractures

• Advantage of Ganga Score over other scores
1. This score acts as a predictable scoring system for limb slavage and
also prognosticating outcome measure of requirement of
a) Flap Procedures
b) No. of inpatient days
c) Union time
d) Rate of Infection
e) No. of surgical procedures required
2. The score is based on well defined objective criteria and has an
average inter-observer agreement rate of 98.4% .

3. It evaluates the severity of injury to all components of the injured
limbs separately and collectively and takes into account the
importance of co-morbid factors which influence the treatment and
outcome .
4. It can be used effectively to compare the result of different
modalities of treatment and the results from different centers as the
nature of injury to each component is assessed very objectively .
• Reference :
Rajasekaran S. Ganga hospital open injury severity score –
A score to prognosticate limb salvage and outcome
measures in type IIIb open tibial fractures; indian J Orthop.
[ serial online ] 2005 [ cited 2015 Aug 3 ] 39:4-13

• Interpretation:
Minimum score: 0
Maximum score: 29
• The higher the score the more severe the trauma.
• Rajasekaran et al. emphasized that injuries with a score of 14
and below should be attempted for salvage, those with
the score of 17 and above should be considered for primary
amputation, and those in between must be assessed by an
experienced team on a case-to-case basis.
• References:
Rajasekaran S, Raja Sabapathy S. A philosophy of care of
open injuries based on the Ganga hospital score. Injury (Int
J Care Injured). 2007; 38: 137-146.

• GHOISS was found to compare favorably with the
MESS in --
Sensitivity (98% vs 99%),
Specificity (100% vs 17%)
Positive predictive value (100% vs 97.5%), and
Negative predictive value (70% vs 50%).
• The scoring system was found to be simple in
application and reliable in prognosis for salvage
and outcome measures.

• Ideally, a trauma limb salvage index would be 100% sensitive
(all amputated limbs will have scores at or above the threshold)
and 100% specific (all salvaged limbs will have scores below
the threshold).
• In the decision to amputate, high specificity is important to ensure
that only a small number (ideally, none) of salvageable limbs are
incorrectly assigned a score above the amputation decision
threshold.
• A high sensitivity is also important to guard against inappropriate
delays in amputation when the limb is ultimately not salvageable.
• Unfortunately, few clinical scoring systems perform ideally and the
limb salvage scoring systems have proved to be no exception.
Ultimately it falls to the treating physicians in consultation
with the patient and their family to come to a decision
regarding when to salvage and when to amputate.

Historically
Mangled Extremities
Have been associated with
Very high amputation rates
Nowadays
Advances in evaluation , resuscitation , wound care , free flap –
soft tissue transfer , and internal fixation make it nowadays
possible to salvage limbs that would have been amputated in the
past

PRINCIPLES OF MANAGEMENT
1. Initial Evaluation
• ATLS principle
• Evaluate perfusion of injured limb
• ATB and Tetanus prophylaxis
• Removed gross contamination
• Reduction of Fracture and Joint+Splint
• Check distal neurovascular before and after
• Look for Compartment syndrome
• Plain film: 2 orthogonal views

• Photographs of the extremity should be obtained
whenever possible with permission of the patient
or legal representative if possible.
• These can provide invaluable documentation of the
extent of the initial injury and, during the course of
treatment, serve as a visual record of progress to or
away from a functional salvaged extremity as long
as the patient’s right to privacy is not violated.

SOFT TISSUE
• How big is the laceration ?
• Is there loss of skin , muscle ?
• How much contaminated it is ?
• What environement did the injury occur in ?

VASCULAR ASSESSMENT
• Palpable pulses ? Asymetry ?
• Doppler pulses ? Asymmetry ? Wave form ?
• Color and temperature of limb ?
• Signs of Compartment syndrome ?
• Expanding haematoma , pulsatile bleeding ?
NEUROLOGICAL ASSESSMENT
• Sciatic  Tibial + Peroneal component
• Femoral  Saphenous

PRINCIPLES OF MANAGEMENT
1. Patient with a pulseless but perfused limb
- Stable Fracture
Vascular repair before EF
- Unstable Fracture
EF before vascular repair
2. Ischemic limb
- Temporary intraluminal vascular shunting first
- Debridement+EF
- Vascular repair
3. Fasciotomy in all pts prevent compartment
syndrome

OPERATIVE DEBRIDEMENT
• Placed Tourniquet but not inflate (Inflate
when bloody field)-prevent further ischemic
injury
• Irrigation and debridement -most important
step
• Zone of injuries
◦ central zone of necrotic tissue-non viable tissue
◦ zone of marginal stasis+/-viable tissue
◦ the periphery zone of the injury

• Extend open wound and remove all necrotic
tissue in central zone
• Serial debridement require(zone of marginal
stasis)

SKELETAL STABILIZATION
• Prevents ongoing soft tissue damage .
• Promotes wound healing .
• Thought to protect against infection .
• Most managed with temporizing external fixation
◦ applied relatively quickly
◦ without the use of fluoroscopy
◦ providing excellent stability and alignment
◦ allows for redisplacement of the fracture fragments
for a more thorough evaluation and debridement of
the soft tissues during any repeat procedures .

HYPERBARIC OXYGEN THERAPY
• Thought to enhance oxygen delivery to
injured tissues affected by vascular disruption
– Improve wound healing.
• Most beneficial in the peripheral zone of
injury.

Mangled Extremity : Primary Amputation

SUMMARY
• The decision to amputate or salvage a severely
injured lower extremity is a difficult one, which
relies not only on the expertise of the orthopedic
surgeon but also on the input of subspecialty
colleagues (general trauma surgeons, vascular
surgeons, and plastic surgeons) as well as the
patient.

• The decision to reconstruct or amputate an extremity
cannot depend on limb salvage scores, as all have
proved to have little clinical utility .
• Using current technology and level I trauma center
orthopedic clinical experience, combined with
multispecialty support, current data appear to suggest
that the results of limb reconstruction are equal to
those of amputation following severe lower
extremity trauma, and this observation should
encourage the continued efforts to reconstruct severely
injured limbs.

• Ideally,
the patient with a mangled extremity should be
directed to an experienced limb injury center,
where strategies to minimize complications, address
related posttraumatic stress disorder, improve the
patient’s self-efficacy, and target early vocational
retraining may improve the long-term outcomes in
patients with these life-altering injuries.

Limb salvage vs amputation final

Limb salvage vs amputation final

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