Review Question - QID 215791

This patient has an open fracture of the lower leg with significant soft tissue injury. If amputation is performed, the ability to return to work is the strongest predictor of postoperative outcome.

The absence of plantar sensation has historically been cited as an indication for amputation after lower extremity trauma. The absence of plantar sensation, however, is not an absolute contraindication to reconstruction and it can recover by long-term follow-up. SIP (Sickness Impact Profile) and return to work are not significantly different between amputation and reconstruction at 2 years in limb-threatening injuries. Current literature suggests that the strongest predictor of patient-reported outcomes after trauma-related lower extremity amputation is the patient's ability to return to work.

Bosse et al. retrospectively reviewed limb salvage following severe trauma. They report that at two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups, and patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. They concluded that patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.

O'Toole et al. prospectively reviewed patient satisfaction following limb-threatening lower-extremity injuries at eight level-I trauma centers. They reported that only measures of physical function, psychological distress, clinical recovery, and return to work correlated with patient satisfaction at two years. They concluded that patient satisfaction after surgical treatment of lower-extremity injury is predicted more by function and pain at two years than by any underlying characteristic of the patient, injury, or treatment.

Figure A is the clinical image of an open tibial shaft fracture with extensive soft tissue injury. Figure B is the corresponding radiograph demonstrating comminuted mid-shaft tibia and fibula fractures.

Incorrect Answers
Answer 2: Amputation and limb salvage have similar results in Sickness Impact Profile at 2 years
Answer 3: The absence of plantar sensation has the second-highest impact on a surgeon's decision-making process. The degree of soft tissue injury has the highest impact on surgeon's decision-making process
Answer 4: Amputation and limb salvage have similar results in functional outcome at 2 years
Answer 5: Psychological distress is predictive of the outcome but is not the strongest predictor. The ability to return to work is the strongest predictor of outcome following amputation