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Limb salvage versus primary amputation in Gustilo–Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The last systematic review on this topic was published in 2008. With advances in surgical techniques, patients with mangled extremities may now be potentially salvageable with comparable outcomes. This review aims to evaluate the outcomes of limb salvage compared to primary amputation in patients with severe open tibial fractures.

Materials and methods

A comprehensive search on PubMed, MEDLINE, Embase, Web of Science, Scopus, CENTRAL and CINAHL was performed from inception to 19 January 2022. The primary outcome was to evaluate clinical and functional outcomes. Secondary outcomes were to evaluate pain, patient preference, quality of life, and patient preferences. Methodological quality was evaluated using the MINORS criteria. Pooled estimates of relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) were used as a summary statistic for dichotomous variables and continuous variables, respectively.

Results

Sixteen studies with 645 patients met inclusion criteria. The methodological quality was moderate based on the MINORS score. The majority were male. Mean age was 36.3 years. There was no significant differences in the length of hospitalization (n = 8), return to work rates (n = 9), return to sport rates (n = 4) and quality of life scores (n = 4). Patients with primary amputation had a significantly lower risk of total complications (RR 0.21, 95% CI 0.08–0.53, p = 0.001) (n = 10), infections (RR 0.46, 95% CI 0.25–0.85, p = 0.01) (n = 9), and number of surgeries (MD – 4.17, 95% CI − 6.49 to − 1.85, p = 0.0004) (n = 6). Patients with primary amputation were able to ambulate significantly earlier (MD − 4.06, 95% CI − 7.65 to − 0.46, p = 0.03) (n = 3). Three studies found a significantly higher cost of hospitalization in limb salvage patients. Functional outcomes were similar in both groups.

Conclusion

While patients with primary amputation had better clinical outcomes in the short-term, functional outcomes were not significantly different in both groups. Despite the heterogenicity of the results in this review, surgeons need to contextualize the decision making for their patients and incorporate these findings.

Level of evidence

III.

Trial registration

PROSPERO CRD42022303357.

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Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AKA:

Above knee amputation

BKA:

Below knee amputation

CI:

Confidence interval

LEFS:

Lower-extremity functional scale

MCS:

Mental component score

MD:

Mean difference

MINORS:

Methodological Index for Randomized Studies

PCS:

Physical component score

ROM:

Range of motion

RR:

Relative risk

SD:

Standard deviation

SF-12:

12-Item Short Form Survey

SF-36:

36-Item Short Form Survey

WOMAC:

Western Ontario and McMaster Universities Arthritis Index

References

  1. Patel MB, Richter KM, Shafi S (2015) Mangled extremity: amputation versus salvage. Curr Trauma Rep 1:45–49. https://doi.org/10.1007/s40719-014-0003-6

    Article  Google Scholar 

  2. Harris AM, Althausen PL, Kellam J et al (2009) Complications following limb-threatening lower extremity trauma. J Orthop Trauma 23:1–6. https://doi.org/10.1097/BOT.0b013e31818e43dd

    Article  PubMed  Google Scholar 

  3. Huh J, Stinner DJ, Burns TC et al (2011) Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma. J Trauma 71:S47-51. https://doi.org/10.1097/TA.0b013e318221181d

    Article  PubMed  Google Scholar 

  4. Chung KC, Shauver MJ, Saddawi-Konefka D, Haase SC (2011) A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives. Ann Plast Surg 66:185–191. https://doi.org/10.1097/SAP.0b013e3181cbfcce

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Schirò GR, Sessa S, Piccioli A, Maccauro G (2015) Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord 16:372. https://doi.org/10.1186/s12891-015-0832-7

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Akula M, Gella S, Shaw CJ et al (2011) A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—the patient perspective. Injury 42:1194–1197. https://doi.org/10.1016/j.injury.2010.05.003

    Article  PubMed  Google Scholar 

  7. Black CK, Ormiston LD, Fan KL et al (2021) amputations versus salvage: reconciling the differences. J Reconstr Microsurg 37:32–41. https://doi.org/10.1055/s-0039-1696733

    Article  PubMed  Google Scholar 

  8. Rossiter ND, Higgins TF, Pallister I (2014) (ii) The mangled extremity: limb salvage versus amputation. Orthop Trauma 28:137–140. https://doi.org/10.1016/j.mporth.2014.05.002

    Article  Google Scholar 

  9. Busse JW, Jacobs CL, Swiontkowski MF et al (2007) Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 21:70–76. https://doi.org/10.1097/BOT.0b013e31802cbc43

    Article  PubMed  Google Scholar 

  10. Saddawi-Konefka D, Kim HM, Chung KC (2008) A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the Tibia. Plast Reconstr Surg 122:1796–1805. https://doi.org/10.1097/PRS.0b013e31818d69c3

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700–b2700. https://doi.org/10.1136/bmj.b2700

    Article  PubMed  PubMed Central  Google Scholar 

  12. Higgins J, Thomas J, Chandler J et al (2022) Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane

  13. OCEBM Levels of Evidence Working Group The Oxford Levels of Evidence 2

  14. Slim K, Nini E, Forestier D et al (2003) Methodological index for non-randomized studies (MINORS): development and validation of a new instrument: methodological index for non-randomized studies. ANZ J Surg 73:712–716. https://doi.org/10.1046/j.1445-2197.2003.02748.x

    Article  PubMed  Google Scholar 

  15. Yeung M, Kowalczuk M, Simunovic N, Ayeni OR (2016) Hip arthroscopy in the setting of hip dysplasia: a systematic review. Bone Jt Res 5:225–231. https://doi.org/10.1302/2046-3758.56.2000533

    Article  CAS  Google Scholar 

  16. Walter SD, Yao X (2007) Effect sizes can be calculated for studies reporting ranges for outcome variables in systematic reviews. J Clin Epidemiol 60:849–852. https://doi.org/10.1016/j.jclinepi.2006.11.003

    Article  CAS  PubMed  Google Scholar 

  17. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. https://doi.org/10.1186/1471-2288-5-13

    Article  PubMed  PubMed Central  Google Scholar 

  18. Higgins JPT (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  19. Aravind M, Shauver MJ, Chung KC (2010) A qualitative analysis of the decision-making process for patients with severe lower leg trauma. Plast Reconstr Surg 126:2019–2029. https://doi.org/10.1097/PRS.0b013e3181f4449e

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Chung KC, Saddawi-Konefka D, Haase SC, Kaul G (2009) A cost-utility analysis of amputation versus salvage for gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 124:1965–1973. https://doi.org/10.1097/PRS.0b013e3181bcf156

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Dagum AB, Best AK, Schemitsch EH et al (1999) Salvage after Severe Lower-Extremity Trauma: Are the Outcomes Worth the Means? Plast Reconstr Surg 103:1212–1220. https://doi.org/10.1097/00006534-199904010-00017

    Article  CAS  PubMed  Google Scholar 

  22. Dahl B, Andersson AP, Andersen M et al (1995) Functional and social long-term results after free tissue transfer to the lower extremity. Ann Plast Surg 34:372–375. https://doi.org/10.1097/00000637-199504000-00005

    Article  CAS  PubMed  Google Scholar 

  23. Fioravanti M, Maman P, Curvale G et al (2018) Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study. Orthop Traumatol Surg Res 104:277–281. https://doi.org/10.1016/j.otsr.2017.12.013

    Article  CAS  PubMed  Google Scholar 

  24. Frisvoll C, Clarke-Jenssen J, Madsen JE et al (2019) Long-term outcomes after high-energy open tibial fractures: Is a salvaged limb superior to prosthesis in terms of physical function and quality of life? Eur J Orthop Surg Traumatol 29:899–906. https://doi.org/10.1007/s00590-019-02382-x

    Article  CAS  PubMed  Google Scholar 

  25. Georgiadis GM, Behrens FF, Joyce MJ et al (1993) Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Jt Surg 75:1431–1441. https://doi.org/10.2106/00004623-199310000-00003

    Article  CAS  Google Scholar 

  26. Hertel R, Strebel N, Ganz R (1996) Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 10:223–229. https://doi.org/10.1097/00005131-199605000-00001

    Article  CAS  PubMed  Google Scholar 

  27. Hutchins PM (1981) The outcome of severe tibial injury. Injury 13:216–219. https://doi.org/10.1016/0020-1383(81)90242-4

    Article  CAS  PubMed  Google Scholar 

  28. Lange RH, Bach AW, Hansen ST, Johansen KH (1985) Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 25:203–208. https://doi.org/10.1097/00005373-198503000-00006

    Article  CAS  PubMed  Google Scholar 

  29. Penn-Barwell JG, Myatt RW, Bennett PM et al (2015) Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation. Injury 46:288–291. https://doi.org/10.1016/j.injury.2014.12.004

    Article  CAS  PubMed  Google Scholar 

  30. Puno RM, Grossfeld SL, Henry SL et al (1996) Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia. Microsurgery 17:167–173. https://doi.org/10.1002/(SICI)1098-2752(1996)17:3%3c167::AID-MICR14%3e3.0.CO;2-Y

    Article  CAS  PubMed  Google Scholar 

  31. Ritchie AJ, Small JO, Hart NB, Mollan RAB (1991) Type III tibial fractures in the elderly: results of 23 fractures in 20 patients. Injury 22:267–270. https://doi.org/10.1016/0020-1383(91)90003-W

    Article  CAS  PubMed  Google Scholar 

  32. Sethuraman AS, Devendra A, Rajasekaran RB et al (2021) Is lower limb salvage worthwhile after severe open tibial fractures in a developing country? An analysis of surgical outcomes, quality of life and cost implications. Injury 52:996–1001. https://doi.org/10.1016/j.injury.2020.12.027

    Article  PubMed  Google Scholar 

  33. Sügün TS (2013) Limb salvage and amputation in Type 3C tibial fractures. Acta Orthop Traumatol Turc 47:19–26. https://doi.org/10.3944/AOTT.2013.2823

    Article  PubMed  Google Scholar 

  34. Tekin L, Safaz Ý, Göktepe AS, Yazýcýođlu K (2009) Comparison of quality of life and functionality in patients with traumatic unilateral below knee amputation and salvage surgery. Prosthet Orthot Int 33:17–24. https://doi.org/10.1080/03093640802482542

    Article  PubMed  Google Scholar 

  35. Schade AT, Khatri C, Nwankwo H et al (2021) The economic burden of open tibia fractures: a systematic review. Injury 52:1251–1259. https://doi.org/10.1016/j.injury.2021.02.022

    Article  PubMed  Google Scholar 

  36. Rees S, Tutton E, Achten J et al (2019) Patient experience of long-term recovery after open fracture of the lower limb: a qualitative study using interviews in a community setting. BMJ Open 9:e031261. https://doi.org/10.1136/bmjopen-2019-031261

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ribeiro D, Cimino SR, Mayo AL et al (2021) 3D printing and amputation: a scoping review. Disabil Rehabil Assist Technol 16:221–240. https://doi.org/10.1080/17483107.2019.1646825

    Article  PubMed  Google Scholar 

  38. Nightingale J, Shu’anScammell KLBE et al (2022) What is important to patients who are recovering from an open tibial fracture? a qualitative study. Clin Orthop 480:263–272. https://doi.org/10.1097/CORR.0000000000002031

    Article  PubMed  Google Scholar 

  39. Errasti-Ibarrondo B, Jordán JA, Díez-Del-Corral MP, Arantzamendi M (2018) Conducting phenomenological research: Rationalizing the methods and rigour of the phenomenology of practice. J Adv Nurs 74:1723–1734. https://doi.org/10.1111/jan.13569

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, 1 Jurong East Street 21, Singapore, 609606, Singapore

    Hannah Jia Hui Ng

  2. Department of Anaesthesia, Ng Teng Fong General Hospital, Singapore, 1 Jurong East Street 21, Singapore, 609606, Singapore

    Ernest Jin Guang Ang

  3. Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, 90 Yishun Central, Singapore, 768828, Singapore

    Antony Xavier Rex Premchand & Vaikunthan Rajaratnam

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Correspondence to Hannah Jia Hui Ng.

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Ng, H.J.H., Ang, E.J.G., Premchand, A.X.R. et al. Limb salvage versus primary amputation in Gustilo–Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 143, 4961–4976 (2023). https://doi.org/10.1007/s00402-023-04804-2

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