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Treatment in serious lower limb injuries: amputation versus preservation
Injury
(1987) 18,21-23
Printedin Great Britain
21
Treatment in serious lower limb injuries: amputation versus preservation C. Her&, M. Gaillard, P. Andrivet, F. Roujas, C. Kauer and P. Huguenard Henri Moncior Hospital, University of Paris Summary 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.
INTRODUCTION SERIOUS lower limb injury can be characterized by complex fractures with serious cutaneous, muscular and vascular damage. Such injuries are becoming more common. They are frequently associated with other major injuries and we have not found any other papers describing the conflict between treating the more local lesion at the risk of dying from the other injuries. A severely injured limb also raises the question whether there should be immediate amputation or an attempt to preserve the limb. The following study aims to give a number of prognostic indices which would help in making this decision. MATERIAL AND METHOD Seventy-six severely injured lower limbs treated in the same surgical intensive care unit from 1972 to 1984 are reported after retrospective review. ‘The 76 limbs all had an Abbreviated Injury Score (AIS) of 4 or 5 (Committee on Medical Aspects of Automobile Safety, 1971, 1972). These patients were then further evaluated on the Injury Severity Score (ISS) as described by Baker et al. (1974). In the control group the weighted injury severity score (wISS) is used excluding the part referring to lower limb lesions. All studies used the chi squared test. Three groups were distinguished: group I-the ISS is ~25, wISS=O; group II-ISS between 25 and 50, wISS<25; group III: ISSa50, wISS>25. There were 66 men (87 per cent) and 10 women (13 per cent) with a mean age of 28.5 (7-72 years). Sixty-six per cent were adults between l&and 40 years old and 30 per cent between 16 and 20. These patients were compared with a control group of 570 injured subjects with
Tab/e 1. Evolution of the lesions according to the period (no. of injured patients spread over three groups of increasing severity over two periods: 1972-1976 and 1977-l 984)
ISS
Group
Group
Period
(median)
I
II
1972-l 976 (N=21) 1977-l 984 (N=55) 1972-l 984 (N=76)
25
14 (66%)
5 (24%)
2 (10%)
29
25 (45%)
23 (41%)
7 (14%)
29
39 (51%)
28 (37%)
9 (12%)
Group
111
Tab/e II. Fractures in serious lower limb injury Fracture
No. of cases
Tibia1 fractures
53
Femoral fractures
30
Associated fractures
23
41 45 14 14
comminuted open comminuted open
similar Injury Severity Scores who were in the hospital between 1980 and 1982. RESULTS The patients were grouped as follows: group I, 39 patients (51 per cent); group II, 28 patients (37 per cent); group III, 9 patients (12 per cent). Most of the responsible accidents were road traffic accidents (46 patients). The frequency and severity of the accidents show an increase of 53-8 per cent after January 1977 (P
Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 1
22
Table 111.Anatomical location and macroscopic aspect of the vascular lesions described in 31 patients
Table VI. Evolution according to initial Modalities
Anatomical
location
No.
Thrombosis Spasm Thrombosis Spasm
7
2 4 1
Spasms Thrombosis Complete rupture
14
1 3 8 1 1
Spasm Thrombosis Complete ruptures Complete section Undetermined
; 1 2
Thrombosis Complete ruptures Undetermined Spasms
3
Superficial femoral artery
4;
Popliteal artery
Anterior tibia1 artery
”
Amputation (N=22)
Tab/e IV. Initial surgery attitude within the three groups (with the exception of traumatic amputations) Group
Group
Group
I
II
III
4 (17%) 20 (83%)
I (14%) 6 (86%)
5 (15%) 28 (85%)
Table V. Final evolution hospitalization period
Mortality Amputation Preservation
Survival
Preservation (N=54)
Traumatic (N=l2) Therapeutic (N=lO)
3
9
1
9
Secondary amputation (N=20) Preservation (N=34)
2
18
15
19
21
55
Total
Tab/e VII. Final evolution of the victims of traumatic amputation and of the patients undergoing immediate therapeutic amputation; distribution of patients in the ISS groups Traumatic amputation
Immediate amputation Preservation
Mortality
aspect
2 1
External iliac artery
Posterior tibia1 artery
Macroscopic
surgery treatment
according
immediate therapeutic amputation
1 (10%)
Mortality Group I Group II Group III
3 (25%) 1 2 0
0 0 1
Survival Group I Group II Group Ill
9 (75%) 5 4 0
9 (90%) 5 4 0
to the ISS of each group;
mean
Group I
Group II
Group III
Mean hospitalization period
4 (10%) 23 (59%) 12 (31%)
9 (32%) 13 (46%) 6 (22%)
8 (89%)
2 days 7-5 months II.5 months
with complete transection of the lower limb (6 at thigh level, 4 at leg level and 2 at foot level). Forty-six patients (60 per cent) had other serious injuries: there were 27 of the head, 13 in upper limbs, 16 of the pelvis, 9 of the chest, 8 of the abdomen, 5 of nerve roots and 6 of the face. Twenty-two patients (29 per cent) underwent primary amputation and 12 of these occurred at the time of injury. Six were formerly amputated through the midfemur and 4 through the tibia. Preservation of the limb was attempted in 54 patients (84 per cent). Table N shows that the initial decision whether to perform amputation or to preserve the limb did not take into account the overall ISS. In each of groups I, II and III the same percentage of patients underwent immediate amputation. Table V shows that there was a considerable difference in mortality between the three groups (P
1 (11%)
Table VI shows that traumatic amputations were associated with a 25 per cent death rate whereas therapeutic amputation showed a 10 per cent death rate. In 54 cases of initial preservation of the limb there were 20 secondary amputations. Seventeen of these 20 patients had severe arterial damage and only 3 of these had an operation for revascularization. In 31 patients with serious vascular lesions there were 25 attempts at preservation of the limb, of which only 6 had attempts at revascularization. In only 3 of these patients was the limb saved, and 3 died. There were 20 patients with secondary amputation following gangrene due to aerobic bacteria in 13 cases and to anaerobic bacteria (gas gangrene) in 5 cases. In 13 of these patients their general condition was very poor due to cardiovascular impairment and renal dysfunction. Two of these 20 secondary amputated patients died. Continued attempts to preserve the limb were followed by 15 deaths and 19 survivals. There is a marked difference between the mortality rate of the patients in whom an initial attempt was made to preserve their limbs but who eventually underwent an
Herv6
et al.: Lower limb amputation vs preservation
Tab/e
VI//.
Comparison
ISS groups
of mortality
23
rates according
to the
between our series and the test group
Test series Our series
Group I
Group II
27%
33%
55%
10%
32%
89%
Group III
amputation and those (Table VI) who had their limb successfully preserved (P
reprints
should
be addressed
94010 Creteil, France.
to:
Docteur
al. (1978) advocating the need for such surgery in patients presenting with associated emergency lesions (cranial, thoracic, etc.). 2. If attempts are made to preserve the limb without revascularization, secondary amputation has to be performed frequently (25 out of 31 cases). This has already been observed by De Bakey and Simeone (1946) and Robbs and Baker (1978). 3. In all severity groups there is a tendency towards attempting preservation of the limb. It would seem that this decision is made in isolation without regard to the severity of other multiple injuries. Excessive attempts at preservation result in an increased mortality rate (3142 vs 15/34) and morbidity (7.5 vs 1l-5 months for mean hospitalization period). CONCLUSION Serious lower limb injury is a serious condition especially when associated with multiple injuries. With a high ISS attempts to preserve a seriously injured lower limb lead to an increased mortality rate. It is thus important to take into account the ISS when considering whether to preserve the limb. In most cases of severe multiple injuries with an ISS of more than 50 it is preferable to sacrifice the limb in order to preserve the patient’s life.
REFERENCES Baker S., O’Neill B., Haddon W. et al. (1974) The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14, 187. Committee on Medical Aspects of Automobile Safety Rating the Severity of Tissue Damage (1971) The Abbreviated Scale. JAMA 215, 277. Committee on Medical Aspects of Automobile Safety Rating the Severity of Tissue Damage. (1972) The Comprehensive Scale. JAMA 220, 712. De Bakey M. E. and Simeone F. R. (1946) Battle injuries of the arteries in World War Two: an analysis of 2471 cases. Ann. Surg. 123, 534. O’Reilly M., Hood J., Livingston R. et al. (1978) Penetrating injuries of the popliteal artery. Br. J. Surg. 65, 789. Rich N., Baugh J. and Hughes C. (1970) Acute arterial injuries in Vietnam-1000 cases. J. Truumn 10, 359. Robbs J. and Baker C. (1978) Major arterial trauma: review of experience with 267 injuries. Br. J. Surg. 65, 532. Paper accepted 27 February
Christian Her&
Dtpartement
1986.
d’AnesthCsic et Rkanimation
N“ 1, HBpital
(1987) 18,21-23
Printedin Great Britain
21
Treatment in serious lower limb injuries: amputation versus preservation C. Her&, M. Gaillard, P. Andrivet, F. Roujas, C. Kauer and P. Huguenard Henri Moncior Hospital, University of Paris Summary 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.
INTRODUCTION SERIOUS lower limb injury can be characterized by complex fractures with serious cutaneous, muscular and vascular damage. Such injuries are becoming more common. They are frequently associated with other major injuries and we have not found any other papers describing the conflict between treating the more local lesion at the risk of dying from the other injuries. A severely injured limb also raises the question whether there should be immediate amputation or an attempt to preserve the limb. The following study aims to give a number of prognostic indices which would help in making this decision. MATERIAL AND METHOD Seventy-six severely injured lower limbs treated in the same surgical intensive care unit from 1972 to 1984 are reported after retrospective review. ‘The 76 limbs all had an Abbreviated Injury Score (AIS) of 4 or 5 (Committee on Medical Aspects of Automobile Safety, 1971, 1972). These patients were then further evaluated on the Injury Severity Score (ISS) as described by Baker et al. (1974). In the control group the weighted injury severity score (wISS) is used excluding the part referring to lower limb lesions. All studies used the chi squared test. Three groups were distinguished: group I-the ISS is ~25, wISS=O; group II-ISS between 25 and 50, wISS<25; group III: ISSa50, wISS>25. There were 66 men (87 per cent) and 10 women (13 per cent) with a mean age of 28.5 (7-72 years). Sixty-six per cent were adults between l&and 40 years old and 30 per cent between 16 and 20. These patients were compared with a control group of 570 injured subjects with
Tab/e 1. Evolution of the lesions according to the period (no. of injured patients spread over three groups of increasing severity over two periods: 1972-1976 and 1977-l 984)
ISS
Group
Group
Period
(median)
I
II
1972-l 976 (N=21) 1977-l 984 (N=55) 1972-l 984 (N=76)
25
14 (66%)
5 (24%)
2 (10%)
29
25 (45%)
23 (41%)
7 (14%)
29
39 (51%)
28 (37%)
9 (12%)
Group
111
Tab/e II. Fractures in serious lower limb injury Fracture
No. of cases
Tibia1 fractures
53
Femoral fractures
30
Associated fractures
23
41 45 14 14
comminuted open comminuted open
similar Injury Severity Scores who were in the hospital between 1980 and 1982. RESULTS The patients were grouped as follows: group I, 39 patients (51 per cent); group II, 28 patients (37 per cent); group III, 9 patients (12 per cent). Most of the responsible accidents were road traffic accidents (46 patients). The frequency and severity of the accidents show an increase of 53-8 per cent after January 1977 (P
Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 1
22
Table 111.Anatomical location and macroscopic aspect of the vascular lesions described in 31 patients
Table VI. Evolution according to initial Modalities
Anatomical
location
No.
Thrombosis Spasm Thrombosis Spasm
7
2 4 1
Spasms Thrombosis Complete rupture
14
1 3 8 1 1
Spasm Thrombosis Complete ruptures Complete section Undetermined
; 1 2
Thrombosis Complete ruptures Undetermined Spasms
3
Superficial femoral artery
4;
Popliteal artery
Anterior tibia1 artery
”
Amputation (N=22)
Tab/e IV. Initial surgery attitude within the three groups (with the exception of traumatic amputations) Group
Group
Group
I
II
III
4 (17%) 20 (83%)
I (14%) 6 (86%)
5 (15%) 28 (85%)
Table V. Final evolution hospitalization period
Mortality Amputation Preservation
Survival
Preservation (N=54)
Traumatic (N=l2) Therapeutic (N=lO)
3
9
1
9
Secondary amputation (N=20) Preservation (N=34)
2
18
15
19
21
55
Total
Tab/e VII. Final evolution of the victims of traumatic amputation and of the patients undergoing immediate therapeutic amputation; distribution of patients in the ISS groups Traumatic amputation
Immediate amputation Preservation
Mortality
aspect
2 1
External iliac artery
Posterior tibia1 artery
Macroscopic
surgery treatment
according
immediate therapeutic amputation
1 (10%)
Mortality Group I Group II Group III
3 (25%) 1 2 0
0 0 1
Survival Group I Group II Group Ill
9 (75%) 5 4 0
9 (90%) 5 4 0
to the ISS of each group;
mean
Group I
Group II
Group III
Mean hospitalization period
4 (10%) 23 (59%) 12 (31%)
9 (32%) 13 (46%) 6 (22%)
8 (89%)
2 days 7-5 months II.5 months
with complete transection of the lower limb (6 at thigh level, 4 at leg level and 2 at foot level). Forty-six patients (60 per cent) had other serious injuries: there were 27 of the head, 13 in upper limbs, 16 of the pelvis, 9 of the chest, 8 of the abdomen, 5 of nerve roots and 6 of the face. Twenty-two patients (29 per cent) underwent primary amputation and 12 of these occurred at the time of injury. Six were formerly amputated through the midfemur and 4 through the tibia. Preservation of the limb was attempted in 54 patients (84 per cent). Table N shows that the initial decision whether to perform amputation or to preserve the limb did not take into account the overall ISS. In each of groups I, II and III the same percentage of patients underwent immediate amputation. Table V shows that there was a considerable difference in mortality between the three groups (P
1 (11%)
Table VI shows that traumatic amputations were associated with a 25 per cent death rate whereas therapeutic amputation showed a 10 per cent death rate. In 54 cases of initial preservation of the limb there were 20 secondary amputations. Seventeen of these 20 patients had severe arterial damage and only 3 of these had an operation for revascularization. In 31 patients with serious vascular lesions there were 25 attempts at preservation of the limb, of which only 6 had attempts at revascularization. In only 3 of these patients was the limb saved, and 3 died. There were 20 patients with secondary amputation following gangrene due to aerobic bacteria in 13 cases and to anaerobic bacteria (gas gangrene) in 5 cases. In 13 of these patients their general condition was very poor due to cardiovascular impairment and renal dysfunction. Two of these 20 secondary amputated patients died. Continued attempts to preserve the limb were followed by 15 deaths and 19 survivals. There is a marked difference between the mortality rate of the patients in whom an initial attempt was made to preserve their limbs but who eventually underwent an
Herv6
et al.: Lower limb amputation vs preservation
Tab/e
VI//.
Comparison
ISS groups
of mortality
23
rates according
to the
between our series and the test group
Test series Our series
Group I
Group II
27%
33%
55%
10%
32%
89%
Group III
amputation and those (Table VI) who had their limb successfully preserved (P
reprints
should
be addressed
94010 Creteil, France.
to:
Docteur
al. (1978) advocating the need for such surgery in patients presenting with associated emergency lesions (cranial, thoracic, etc.). 2. If attempts are made to preserve the limb without revascularization, secondary amputation has to be performed frequently (25 out of 31 cases). This has already been observed by De Bakey and Simeone (1946) and Robbs and Baker (1978). 3. In all severity groups there is a tendency towards attempting preservation of the limb. It would seem that this decision is made in isolation without regard to the severity of other multiple injuries. Excessive attempts at preservation result in an increased mortality rate (3142 vs 15/34) and morbidity (7.5 vs 1l-5 months for mean hospitalization period). CONCLUSION Serious lower limb injury is a serious condition especially when associated with multiple injuries. With a high ISS attempts to preserve a seriously injured lower limb lead to an increased mortality rate. It is thus important to take into account the ISS when considering whether to preserve the limb. In most cases of severe multiple injuries with an ISS of more than 50 it is preferable to sacrifice the limb in order to preserve the patient’s life.
REFERENCES Baker S., O’Neill B., Haddon W. et al. (1974) The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 14, 187. Committee on Medical Aspects of Automobile Safety Rating the Severity of Tissue Damage (1971) The Abbreviated Scale. JAMA 215, 277. Committee on Medical Aspects of Automobile Safety Rating the Severity of Tissue Damage. (1972) The Comprehensive Scale. JAMA 220, 712. De Bakey M. E. and Simeone F. R. (1946) Battle injuries of the arteries in World War Two: an analysis of 2471 cases. Ann. Surg. 123, 534. O’Reilly M., Hood J., Livingston R. et al. (1978) Penetrating injuries of the popliteal artery. Br. J. Surg. 65, 789. Rich N., Baugh J. and Hughes C. (1970) Acute arterial injuries in Vietnam-1000 cases. J. Truumn 10, 359. Robbs J. and Baker C. (1978) Major arterial trauma: review of experience with 267 injuries. Br. J. Surg. 65, 532. Paper accepted 27 February
Christian Her&
Dtpartement
1986.
d’AnesthCsic et Rkanimation
N“ 1, HBpital