Limb Salvage or Early Amputation

Publication Date: December 6, 2019

RECOMMENDATIONS

BURDEN OF INJURY

Other Injury Burden

Time0 and Time1
A. The Physician team should evaluate overall burden of injury and patient physiology when considering if initial limb salvage is advisable. (M)
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B. In the absence of reliable evidence, the workgroup suggests the physician team should prioritize patient survival in the limb reconstruction vs. amputation decision. Limb specific damage control (i.e. temporizing) measures or immediate amputation should be considered when further attempts at definitive salvage will increase risk of mortality. (M)
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Severe HELET Injury

Time1 and Beyond
C. Physicians should consider the cumulative injury burden (soft tissue, vascular, nerve, bone, joint) of the limb when counseling patients on anticipated outcomes of and making recommendations on when to pursue limb salvage or amputation treatment. (M)
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PSYCHOSOCIAL FACTORS

Clinicians should screen all patients with high energy lower extremity trauma for psychosocial risk factors (e.g. depression, PTSD, anxiety, low self-efficacy, poor social support) affecting patient outcomes. (S)
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REHABILITATION

Clinicians should recommend patients with high energy lower extremity trauma injuries participate in a rehabilitation program (e.g. PT, OT, behavioral health) to improve psychological and functional outcomes. (M)
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NERVE INJURY

The evidence suggests plantar sensation or an observed nerve transection is not a factor in the decision for limb salvage vs. amputation. (L)
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MASSIVE SOFT TISSUE AND MUSCLE DAMAGE

Time1
Limited evidence suggests that these etiologies may lead to increased risk of adverse events or decreased functional outcomes:
  • Crush
  • Blunt
  • Blast
  • Penetrating
  • Degloving
  • Volumetric muscle loss/soft tissue loss
(L)
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VASCULAR INJURY/LIMB ISCHEMIA

The evidence suggests that neither hard signs of vascular injury nor duration of limb ischemia are absolute factors in the decision for limb salvage vs. amputation. However, the panel recognizes that prolonged ischemia is detrimental and the interval to reperfusion should be kept to a practical minimum. The duration of lower extremity ischemia is directly correlated with adverse events. (L)
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SMOKING

Physicians should not consider a patient’s smoking/nicotine use as a critical decision making factor at time zero; Physicians should recommend nicotine education/cessation (abstinence of nicotine) for all patients with high energy lower limb trauma as there is moderate evidence to suggest that smoking/nicotine use has a detrimental effect on outcomes for both amputation and limb salvage. (M)
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LOWER EXTREMITY INJURY SCORES

Physicians should not utilize extremity specific scores to select limb salvage vs. amputation, or to predict outcomes for patients with high energy lower extremity trauma. (M)
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AMPUTATION/LIMB SALVAGE

Injury patterns requiring ankle arthrodesis or foot free tissue transfer may be an indication for amputation in the non-acute phase and should be addressed in shared decision making with the patient. (L)
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Recommendation Grading

Disclaimer

Overview

Title

Limb Salvage or Early Amputation

Authoring Organization

Endorsing Organization

Publication Month/Year

December 6, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Physical therapist, nurse, nurse practitioner, physician, physician assistant

Scope

Rehabilitation, Management, Treatment

Keywords

amputation, limb salvage, limb reconstruction, lower extremity trauma, trauma

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
36
Literature Search Start Date
June 1, 2018
Literature Search End Date
June 1, 2019