In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Obesity and age as factors in leg amputations in fatal motorcycle crashes

The autopsy files at Forensic Science South Australia were searched over an 11-year period from January 2008 to December 2018 for all cases of motorcycle fatalities in which there had been lower-limb amputations. Six cases were identified, consisting of five male riders and one female pillion passenger. The age range was 48–67 years (average 59 years), which was significantly older than the control group (40.6 years; p < 0.01). All the decedents were overweight, with a body mass index (BMI) of 28.7–43.5 kg/m2 (average 34.9 kg/m2), which again was significantly greater than the control group (28.8 kg/m2; p < 0.05). Five of the incidents involved a collision between a motorcycle and a motor vehicle; the remaining case involved a collision with a tree. Five of the amputations were on the right side in the motorcycle-vehicle impacts, and they varied in severity from loss of a foot to a hind-quarter amputation. There was a single left lower-leg amputation which occurred during the collision with a tree, which was beside the road on the motorcyclist’s left. This study has shown that motorcyclists at greatest risk of lower-limb/pelvis amputations are older than the average rider with higher BMIs. This may be significant information given the increase in both BMI and age in many populations.

Predictors of Acute Complications Following Traumatic Upper Extremity Amputation

Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009-2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113-118, 2018).

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data

INTRODUCTION

Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.

METHODS

The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ² and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.

RESULTS

We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).

CONCLUSION

Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

Traumatic extremity amputation in a Nigerian setting: patterns and challenges of care

PURPOSE

We aimed to determine the epidemiological pattern and highlight challenges of managing traumatic amputation in our environment.

METHOD

This was a ten-year retrospective study of all the patients with traumatic extremity amputation seen in Ebonyi State University Teaching Hospital and Federal Medical Centre Abakaliki from January 2001 to December 2010.

RESULT

There were 53 patients with 58 amputations studied. There was a male to female ratio of 3:1 and the mean age was 32.67 ± 1.54 years. Amputations were more prevalent in the rainy season. Road traffic accident was the predominant causative factor and accounted for about 57% of amputations. A majority of the patients (81.4%) had no pre-hospital care and none of the amputated parts received optimum care. Three patients underwent re-attachment of amputated fingers and one was successful. Wound infection (in 56.6% of patients) was the most common complication observed. Overall mortality was 7.5% and all were due to complications of amputations.

CONCLUSION

Appropriate injury prevention mechanisms based on the observed patterns are needed. Educational campaigns for prevention should be intensified during the rainy season and directed toward young men. Measures aimed at improving pre-hospital care of patients and optimum care of amputated parts is an important aspect to be considered in any developmental programme of replantation services in the sub-region.

An economic analysis of hand transplantation in the United States

BACKGROUND

Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations.

METHODS

One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY.

CONCLUSIONS

Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

The use of vacuum assisted closure (VAC™) in soft tissue injuries after high energy pelvic trauma

BACKGROUND

Application of vacuum-assisted closure (VAC) in soft tissue defects after high-energy pelvic trauma is described as a retrospective study in a level one trauma center.

MATERIALS AND METHODS

Between 2002 and 2004, 13 patients were treated for severe soft tissue injuries in the pelvic region. All musculoskeletal injuries were treated with multiple irrigation and debridement procedures and broad-spectrum antibiotics. VAC was applied as a temporary coverage for defects and wound conditioning.

RESULTS

The injuries included three patients with traumatic hemipelvectomies. Seven patients had pelvic ring fractures with five Morel-Lavallee lesions and two open pelviperineal trauma. One patient suffered from an open iliac crest fracture and a Morel-Lavallee lesion. Two patients sustained near complete pertrochanteric amputations of the lower limb. The average injury severity score was 34.1 +/- 1.4. The application of VAC started in average 3.8 +/- 0.4 days after trauma and was used for 15.5 +/- 1.8 days. The dressing changes were performed in average every 3 days. One patient (8%) with a traumatic hemipelvectomy died in the course of treatment due to septic complications.

CONCLUSION

High-energy trauma causing severe soft tissues injuries requires multiple operative debridements to prevent high morbidity and mortality rates. The application of VAC as temporary coverage of large tissue defects in pelvic regions supports wound conditioning and facilitates the definitive wound closure.

Major amputations in Nigeria: a plea to educate traditional bone setters

A study was made of 100 major amputations performed on 96 patients in two regional hospitals in a 10-year period in Nigeria. The objective of the study was to evaluate the outcome of major amputations in Nigeria. The median age of patients was 30 years with male to female ratio 3:1. Ninety of the 100 major amputations involved the lower limbs with the above-the-knee/elbow-the-knee ratio of 0.5. Trauma was the leading indication for 70 amputations, of these 60 were iatrogenic resulting from mismanaged fractures by the traditional bone setters. The non-traumatic indications were: diabetic limb gangrene (20); bone malignancies (9); and vascular insufficiency (1). Provisional amputation was offered in 60 cases, of these 10 had reamputation. There were eight (8.5%) mortalities. The functional outcome for this group was discouraging. Only 25 amputees affording successful prosthetic fitting and social rehabilitation. Major amputation in Nigeria foreshadows a dismal existence and emphasizes the need for health policies which are effective in controlling the risk factors.

Ten-year survival of Finnish lower limb amputees

Data on mortality for the ten years following lower limb amputation were obtained from all the 16 surgical units in Southern Finland and the National Social Insurance Institution. In Southern Finland during the period 1984-1985, amputations of the lower limb were performed on 705 patients, of whom 382 (54%) were women and 323 (46%) men. The majority of the amputations, 47% were performed for vascular diseases and 41% were performed for diabetes mellitus. The overall survival was 62% at one year after amputation, 49% at two years, 27% at five years and 15% at ten years. The median survival after amputation was 1 yr 5 mth for the women and 2 yr 8 mth for the men. Of the arteriosclerotics, 43% died within one postoperative year while 43% lived longer than two years and 23% longer than five years. The median survival of arteriosclerotics was 1 yr 6 mth. The corresponding figure for patients with diabetes was 1 yr 11 mth. Of the diabetics, 38% died within one postoperative year while 47% lived longer than two years and 20% longer than five years. Of the trauma patients, 86% lived longer than five years and 71% longer than ten years. Of the trans-femoral amputees, 54% lived longer than one year, 36% over two years, 18% over five years and 8% over ten years. The corresponding figures for trans-tibial amputees were 70%, 53%, 21% and 4%. Many elderly vascular and diabetic patients undergoing amputation have a reduced physiological reserve and high mortality. The more proximal the amputation, the greater the risk that the patient will never be able to walk or that the duration of use of the prosthesis will be short. If a prosthesis seems to be a reasonable option for the elderly amputee, any delays in prosthetic fitting should be avoided in older age groups.

The status of lower-limb amputation in Bangladesh: a 6-year review

We conducted a review of 450 single lower-limb amputations performed in our hospital in Bangladesh between July 1982 and June 1987. The incidence of amputation in the specific area of 1000000 inhabitants covered by the hospital was 0.75/10(3) per year. The indications for amputation were: limb ischemia in 366 patients (81%), traumatic crush injury in 45 (10%), diabetes-associated complications in 20 (5%), severe limb infection in 10 (2%), and neoplasm growth in 10 (2%). The ratio of above-knee (AK) to below-knee (BK) amputation was 1:65, and 36 patients (8%) required reamputation, 22 of whom had undergone BK amputation previously. Thus, the number of patients with a final amputation at AK level was 302 (67%). The operative mortality was 21% and the uncomplicated primary wound healing rate was 89% within the survivors. Among the 355 patients who survived the amputation, 265 (75%) were given a prosthesis, 50 (14%) refused a prosthesis, and the remaining 40 (11%) were unfit for a prosthesis. Rehabilitation was successful in 44% of the AK and 86% of the BK amputees. In conclusion, when amputation is inevitable, maximum consideration should be given to the type of surgery performed to avoid rehabilitation failure.

[Traumatic hemipelvectomy. Experiences with 11 cases]

With further improvements of the prehospital rescue systems, an increasing number of patients with extreme injuries such as traumatic hemipelvectomy are admitted to trauma centers alive. The accepted definition of traumatic hemipelvectomy is: unstable ligamentous or osseous hemipelvic injury with rupture of the pelvic neurovascular bundle (open or closed integuments). A review of the literature up to 1995 yielded on 48 surving cases with such an injury. A review of 2002 consecutive patients after pelvic fractures treated from 1972-1994 at the Medical School Hannover, resulted in the identification of 11 traumatic hemipelvectomies with four survivors. The purpose of the study was the analysis of the early clinical course of the patients after traumatic hemipelvectomy and the evaluation of the late outcome of the survivors. All accessible clinical and radiological data were reviewed for the preclinical and primary clinical treatment, concomitant injuries, cause of death and complications. The survivors are under continuous follow-up at our institution and were evaluated on average 5.5 years (range 2-7 years) after trauma. All patients were managed with early and aggressive shock therapy by an emergency physician, hemorrhage control with manual compression of the wound and a short transit time to a trauma center. Immediate surgical hemostasis was attempted in all cases. Despite this, four patients died within the first 4 h secondary to uncontrollable bleeding. Another three died between 2 days and 5 weeks after accident from complications of septic or hemorrhagic shock. In four patients a limb-saving procedure was attempted. Three of these died early, and in the remaining case secondary hemipelvectomy was necessary due to sepsis and paralyses. After primary surgical completion of the hemipelvectomy, three of four patients survived. The late result was good in two children and moderate in one adult (ambulatory and socially reintegrated). A bad result occurred in one male after secondary surgical completion of the hemipelvectomy (social deterioration and drug abuse). A strict protocol has to be set for the primary treatment of a traumatic hemipelvectomy. It includes immediate prehospital hemostasis by local pressure, advanced shock therapy and prompt transfer to a trauma center. In-hospital procedures include immediate surgical hemostasis and debridement. When the criteria or traumatic hemipelvectomy are fulfilled, surgical completion of the hemipelvectomy is mandatory. Limb-saving procedures endanger the patient's life. Early and frequent second-look operations minimize wound healing problems. Early psychological support for the patient and family is advantageous for personal well-being and social reintegration.

[Amputation injuries of large extremity segments. Clinical management]

Amputating injuries are often combined with multiple trauma. The management of these serious traumas has to consider survival more than restoration of function and extremity preservation. Out of 51 patients with 60 macroamputation injuries only one case was successful in replantation. The leading rule in the treatment of macroamputation still must be life before limb, as our series of the years 1988 up to 1991 clearly shows.

Amputees in a hospital of the International Committee of the Red Cross

The object of this study is to describe the treatment of patients with an amputation in terms of causes and distribution of injuries, mortality and drain on surgical resources. A group of patients with war injuries, who did not undergo an amputation (1796) and a group of war-injured patients with an amputation (245) were analysed retrospectively. All these patients were treated in the hospital for Afghan war wounded of the International Committee of the Red Cross. The most common amputation was below-knee amputation (BKA). In more than 90 per cent of the patients a BKA was the result of a mine explosion. About 80 per cent of amputations of the lower limb were caused by antipersonnel mines. The upper limb amputations were mainly caused by mines or by fragments. War-injured patients with an amputation face more serious problems than non-amputated patients. Their mortality is higher, they stay longer in the hospital, the risk of infection is higher, they need more blood and they undergo more surgical interventions. The high percentage of non-combatants stresses the need to give civilians better protection against the indiscriminate use of mines.

Traumatic amputation by explosive blast: pattern of injury in survivors

Explosive blast causes a pattern of injury including primary blast lung, secondary fragment injury and traumatic amputation of limbs. Major traumatic amputation is rare in survivors of bomb blast but common in those who die. The mechanism of such injury has not been previously determined, but must be established if protective measures are to be developed for members of the armed forces. The nature of 41 traumatic amputations in 29 servicemen who survived to reach medical care after blast injury was investigated to determine the anatomical level of amputation and the pattern of soft tissue damage. Joints were an infrequent site of amputation and the tibial tuberosity was a particularly frequent site of lower-limb severance. Comparison of the pattern of injury was made with that seen in ejecting fast-jet pilots, who frequently suffer major flailing injury; there appears to be a substantially different injury distribution. The accepted mechanism of traumatic amputation, avulsion by the dynamic overpressure, is challenged; it is suggested that the shockwave resulting from an explosion is capable of causing at least bone disruption in a limb.

[Not a tourniquet, but compressive dressing. Experience from 68 traumatic amputations after injuries from mines]

In autumn 1991, 68 patients with traumatic amputations after injuries caused by mines were evacuated to the United Nation's field hospital in the demilitarized zone between Iraq and Kuwait. Most were seen during a three week period when civilians harvested mines. During the first days of this period, continuous bleeding distally to applied tourniquets was frequently observed. Orders were issued to remove any tourniquets and cover the wounds with a very tight elastic bandage. Prehospital intravenous infusions were decreased. Three out of 18 patients died prior to the change of routine compared with one out of 50 afterwards. The new directives led to visibly less haemorrhage. Haemoglobin on admission was mean 8.6 g/100 ml during the first part of the observation period compared with mean 10.5 g/100 ml with the new routine. 23 patients received blood transfusions. Fewer patients needed transfusions after the use of tourniquets was discontinued. A tourniquet should not be used in the treatment of bleeding extremity injuries. In extensive crush injuries and traumatic amputations a compressive dressing should be used, applied from the end of the extremity in a proximal direction.

Salvage of limbs with vascular trauma

In an eight-year period we treated 51 cases of vascular injury associated with fractures and/or dislocations or soft-tissue injuries of the limbs. We relied on a clinical diagnosis and immediate exploration of blood vessels rather than the time-consuming procedure of arteriography. All patients were operated on by the orthopaedic residents on duty and not by vascular surgeons. Only 17 (33%) were repaired within six hours of injury. Limb viability with good function was obtained in 38. Complications included six deaths, four amputations, two renal failures and delayed occlusion in one case.

Terrorist bombings. Lessons learned from Belfast to Beirut

Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall "critical mortality" rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.

Current procedures in China on replantation of severed limbs and digits

Since the first successful replantation of a severed right hand was reported in 1963, surgeons in China have performed more than 3735 replantations of limbs and digits with increasing improvement in the survival rate. Of special interest is that local hospitals have reported numerous successful cases revealing a popularization of this kind of operation in China. The replantation survival rate is related to the type of injury and duration of anoxia. The types of injury include avulsion or crush amputation, severed distal segments of fingers, immersion conditions, amputated limbs or digits in children, and segmental resection of diseased tissues. The results are analyzed by a special system of functional evaluation.

Treatment in serious lower limb injuries: amputation versus preservation

A study of patients with serious lower limb injuries is presented. With these injuries it is important to decide whether the limb should be salvaged at the risk of losing a life. Seventy-six patients are described and compared with a group of patients with similar injury severity scores but without serious lower limb injury. It is concluded that it is often preferable to amputate the limb rather than to risk the patient's life. Attempts at preservation of a limb were unsuccessful in 20 of the 54 patients in whom this was attempted. Secondary amputation was often performed in unsatisfactory conditions because of general complications that had resulted from the delay.