Association of clinical characteristics with decision making in patients with severe lower extremity trauma

1. Introduction

Severe lower limb trauma represents a challenge for both emergency department physicians and surgeons [1]. These injuries are associated with a significant incidence of limb loss [2]. The patients may present with a Gustilo-Type 3C open fracture with vascular compromise, or an amputated limb. It is not uncommon for the treating physician to make the hard decision between limb salvage, amputation or stump closure for a patient in critical condition. The critical condition of a hemodynamically unstable patient may preclude attempting to perform a long reimplantation procedure. Limb salvage should be considered for non-life-threatening mangled extremities, only if this lengthy procedure does not decrease patient survival [3].

Distinguishing between a Type IIIC open fracture and subtotal amputation may be challenging. The widely accepted classification by Biemer [4] defines subtotal amputation as a severe injury where the soft tissue connection of the distal part of the limb is less than one-quarter of the circumference and there is no evidence of perfusion. In total amputations, the entire connection with the proximal limb is lost. In all cases, a multidisciplinary approach is required to assess the salvagability of a mangled extremity and manage patient resuscitation.

Fortunately, the incidence of traumatic amputations is relatively rare, compared to ischemic or diabetic amputations [5]. Still, it has a significant burden on an individiuals’ life and society. All patients who sustain traumatic amputations, reimplanted or not, will have permanent impairment. These patients are generally younger, with longer life expectancy and a higher activity level prior to injury. Because of their longer survival, traumatic amputees comprise nearly 50% of amputees [6]. Recent advances in surgical techniques made the replantation or reconstruction of mangled extremities possible which were once considered designated for amputation [1, 7, 8]. The studies on limb salvage versus primary amputation have revealed conflicting results [2, 7]. A successful replantation is generally defined as a viable salvaged limb. Patients who undergo replantation or limb salvage are prone to complications and more likely to require additional surgeries or re-hospitalization, compared to primary amputations [8, 9].

Several scoring and grading systems are described to assist the surgeon to decide whether to attempt limb salvage or proceed with a primary amputation [10]. The results of studies on the validation of these scoring systems are far from uniform, and the clinical judgment of the surgeon still has an important role [2, 11, 12]. A Mangled Extremity Severity Score was proposed as a guide to predict the success and adequacy of limb salvage, taking into account both the systemic and extremity-related factors [13]. Generally, a score less than 7 means that the extremity has a higher chance of salvage and the patient’s overall condition is good enough to permit a relatively long reconstructive surgery.

In our clinical practice, we realized that patients with traumatic amputations, even those with clear indications for amputation, are almost always referred to higher-tier centers. This is generally because of the fear of litigation and the patient’s or patient relatives’ desire for a limb salvage procedure. The effect of delays caused by referrals and consultations on patient resuscitation and outcomes are not reported in the literature. The only study evaluating the delays to treatment of orthopedic injuries was performed by Pouramin et al., on behalf of the INORMUS investigators. This multinational, multicenter study involves a large cohort of patients, and focuses on delays to hospital admission, caused mainly by geographic or socioeconomic factors [14]. Even in comprehensive studies such as the Lower Extremity Assessment Project (LEAP) [8] or the study by de Mestral et al. [15], data on the process from admission to definitive treatment is missing. We performed this retrospective study to evaluate the epidemiology of traumatic lower extremity amputations and to analyze those factors and parameters prior to surgery, which affect patient resuscitation, limb salvage and expedite patient management.

2. Materials and methods

Following approval from the institutional review board (Decision number 2020-13/6), patients who were admitted to our institution’s emergency department for traumatic lower extremity amputation over an 8 years’ period (2012 to 2020) were retrospectively analyzed. The hospital records of patients with severe lower limb trauma and a mangled extremity were retrieved and analyzed using ICD codes registered during the emergency department admission. Records of 114 patients were available for the initial evaluation. 20 cases had inaccurate or missing records and were removed from the study group. Of the remaining 94 patients, 42 patients with type IIIC open fractures, 10 cases with type IIIB open fractures and 21 patients with isolated toe amputations were excluded. 21 cases with total/subtotal amputations were available for final analysis and included in the study (Fig. 1). Patient demographics, the mechanism of trauma, the initial status of the patient, severity of the injury, details of resuscitation and patient monitoring, the number of consulted departments and the time it took to complete the consultations were recorded. Factors that might influence the decision to proceed with reimplantation, the number of consulted departments, the time till operation and the patients’ vital signs were evaluated.

Fig. 1.Flow chart for patient inclusion and performed treatment.

In our institution, the standard of care in traumatic amputation cases is to initiate aggressive fluid resuscitation upon admission to the emergency department. The patients’ general condition and ABC is closely monitored. The patient is examined for visceral injuries and appropriate consultations are obtained. The bleeding from the mangled extremity is managed with compressive bandages. A temporary thigh tourniquet is applied if compression is not enough to provide hemostasis and major vessels are ligated with suture to prevent unexpected bleeding during wound irrigation. All the traumatic amputations of the lower extremity are approached as contaminated wounds and wide-spectrum antibiotic therapy (1st generation cephalosporin, aminoglycoside and metronidazole) is initiated as soon as possible. All patients receive anti-tetanus prophylaxis and an immunoglobulin is administered when necessary. The wound is meticulously irrigated with 10 L of saline and foreign debris is removed. The stump is cleansed further with an povidine-iodide solution and a sterile compressive bandage is applied.

3. Results

4. Discussion

The rate of re-hospitalization and additional surgeries is higher in patients with a salvaged limb, and the functional results at 2 years are not superior to amputation [8]. Nevertheless, the idea of losing a limb is not easy to accept, and many patients are willing to undergo a lengthy reconstruction and rehabilitation period no matter how small the chance of success. Patients undergoing amputation following an injury are usually younger, with higher functional demands and a longer life expectancy. This creates a fear of future litigation before performing an irreversible procedure such as an amputation or stump closure. Therefore, even patients with a clear indication for amputation are referred to 3${}^{rd}$ tier trauma centers for consultation regarding reconstructive procedures. Time spent during patient transport and repeated medical examination and consultations increase the time till definite treatment can occur. Even though this delay in treatment may have detrimental effects on patient resuscitation and outcomes, our study did not support these concerns [16].

Higher MESS scores and longer admission time did not cause a significant decrease in initial MAP during admission. We had expected that patients with higher MESS scores would have lower MAP, since a higher MESS score indicates a more severe trauma that might cause increased blood loss, and lower blood pressure which is an integrated component of the scoring system. A possible explanation is that blood loss from the severed extremity is prevented during patient transportation and the patients’ fluid resuscitation is managed properly.

In 6 cases, it took between 2 and 3 hours for the laboratory tests and imaging studies in the emergency department to be concluded. Similarly, the mean time from emergency admission to transfer to the operating theater was 184.5 minutes. Although it may seem long and inappropriate for a patient with an amputated limb to wait that long in the ER, it is vital to exclude visceral injuries. Blood loss from an amputation can be managed with a simple tourniquet, whereas missed visceral bleeding may result in a mortality. In our clinical practice, we encountered cases where patients who were initially deemed stable by general surgeons and admitted to the orthopedics ward; subsequently required an emergency laparotomy. Nevertheless, unnecessary delays that prolong the warm ischemia time and reduce the chance of a successful repimlantation should be avoided.

There was no correlation between higher MESS scores and the number of consultations. The increased number of consultations did not cause an increase in time spent until definitive surgery. This was in contrast to our expectation that a patient with a more serious injury would have more concomitant injuries and would require a higher number of consultations, resulting in a significant delay. A possible explanation is that, no matter the condition of the patient, a minimum of two consultations are made; orthopedics for stump closure and plastic surgery for a possible reimplantation. Furthermore, the results of final laboratory tests and studies ordered by emergency department doctors tend to come back after the consultation is completed.

All patients whose lower extremities were reimplanted had an initial MESS score $<$ 7. The typical clinical decision making algorithms proposed by different authors have two crucial considerations in the early treatment stages [17, 18]. Is the warm ischemia time less than 6-8 hours, and does the patient’s general status allow a long and extensive reconstruction procedure? By default, a traumatic amputation patient who is in critical condition or who has a long ischemia time will have a MESS score $>$ 7, since these two criteria are taken into consideration during the calculation. Clinical judgement is still the cornerstone of decision making, and scores cannot be used as the sole criteria for an amputation [3].

In our series, survival of the reimplanted limb (100%) was higher and the need for a major secondary procedure (50%) was lower than that reported by Battiston et al. [19]. In their study, 35% of the reimplanted lower extremities required amputation, and 78% of the remaining cases underwent complex soft tissue surgeries such as free flaps or ostetomies. In the literature, the success rate of lower extremity reimplantation differs between 37-89% [17]. Although all patients in our study who had undergone reimplantation were dishcarged with a viable limb, a relatively low number of cases makes a direct comparison impossible.

This study has several limitations. Consultation times were analyzed based on inputs in the electronic patient records. It is likely that many of the consultations were performed orally or discussed among consulting and treating physicians in the emergency ward prior to closing their electronic notes. The time spent during each consultation may be shorter than that appearing in the official documents. However, any future medico-legal liability will be evaluated based on electronic patient records, not on conversations. There are several procedures such as “verbal order” defined to speed-up the patient management during an emergency. However, there is no defined “verbal consultation” in the institution where this study was conducted. The importance of an accurate medical record in an irreversible procedure cannot be over-emphasized. The surgeon should state in the electronic medical record that they proceeding with an amputation after consulting with the appropriate colleagues and taking into account their verbal recommendations.

5. Conclusions

The final decision for performing a traumatic amputation should be based on sound clinical knowledge and patient consent. Reimplantation should be avoided to prevent increased morbidity and mortality in those cases where reimplantation is unlikely to be successful. A multidisciplinary approach is necessary to determine if the limb can be reimplanted; however, this does not justify a delay in treatment. The time spent obtaining the necessary consultations does not have negative effects on patient outcomes as long as the patient is closely monitored and properly resuscitated in the emergency department.

Ethics approval and consent to participate

Ethical approval was taken from the Clinical Researches Ethical Commitee of the University (2020-13/6).

Acknowledgements

The authors thank Adnan Çakar for his help in preparation of this manuscript.

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Human rights

Human rights permissions are taken for our study.

Availability of data and materials

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