To determine the outcome of the mangled foot and ankle undergoing limb salvage surgery that required free tissue flaps for wound closure compared with a similar patient foot and ankle injury group that underwent early below knee amputation (BKA).

: Prospective longitudinal study.

: Eight level 1 trauma centers.

LEAP (Lower Extremity Assessment Project) study. One hundred seventy-four open severely injured hindfoot or ankle injuries (116 had salvage; 58 had a BKA).

Patients either required immediate amputation or salvage was attempted.

The Sickness Impact Profile (SIP) was the principal measure of outcome (higher SIP scores equal greater disability). Secondary outcomes included walking speed, number of rehospitalizations for injury-related complications, time to full weight-bearing, the visual analog pain scale, and return to work at 2 years.

When compared to patients treated with standard BKA, salvage patients who required free flaps and/or ankle arthrodesis had significantly worse 2-year outcomes. They had overall SIP scores that were 2.5 points higher and psychosocial SIP scores that were 8.4 points higher at 24 months (P = 0.014 and P = 0.013, respectively). Physical SIP scores were 3.7 points higher in the free flap and/or arthrodesis group but only approached statistical significance (P = 0.10). After adjusting for the need for free flap and/or arthrodesis, the salvage pathway had clinically, but not statistically, significantly better overall and psychosocial SIP scores than the standard BKA patients (P = 0.34 and P = 0.20, respectively).

: Patients with severe foot and ankle injuries who require free tissue transfer or ankle fusion have SIP outcomes that are significantly worse than BKA with typical skin flap design closure.

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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