Late amputation resulted in poorer outcomes

Only 14% of patients with an amputation three months after injury returned to work.

Issue: November 2003

OTA 2003: Salt Lake City, Utah [logo] SALT LAKE CITY — Patients whose amputations were performed more than three months after injury had significantly higher disability levels than patients whose amputations were done earlier.

“Surgeons have long hypothesized that individuals with initial salvage attempts who ultimately come to amputation have worse outcomes than those with initial amputation,” said Douglas G. Smith, MD, here at the Orthopaedic Trauma Association 19th Annual Meeting. “However, evidence to really document this belief has been lacking in the literature.”

Smith and colleagues prospectively followed 173 high-energy trauma patients to analyze the effect of the timing of amputation on functional outcome at two years. All patients had been admitted to level I trauma centers.

The researchers split the patients into four groups: group 1 (n=91), with amputation performed within 24 hours of hospital admission; group 2 (n=57), with amputation performed after 24 hours but within the initial hospitalization; group 3 (n=13), with amputation performed after first hospitalization but within three months of injury; and group 4 (n=12), with amputation done more than three months after injury.

Smith and colleagues used multivariate regression models to adjust for amputation level, sex, race, age, education, insurance, income level, smoking status, previous conditions, ISS, ipsilateral and contralateral injuries and self-efficacy score.

To gauge outcomes, the investigators measured the Sickness Impact Profile (SIP), which includes an overall disability score as well as physical and psychosocial components, return to work, ability to achieve a walking speed of greater than four feet per second and a visual pain scale.

SIP scores much lower

Results showed that late amputations yielded significantly poorer outcomes. The mean overall SIP scores for patients in group 2 was 10.7 vs. 18.1 for patients in group 4 (P<.05). Mean physical SIP scores were 8.1 for group 2 and 16.3 for group 4 (P<.01).

Outcomes of early vs. late amputation
	Group 1 Within 24 hours of injury	Group 2 Within first hospitalizationbut after 24 hours	Group 3 After first hospitalizationbut within three months	Group 4 >Three months after injury
Mean overall SIP	13.9	10.7	11.5	18.1
Mean physical SIP	11.5	8.1	10.3	16.3
Mean psychosocial SIP	11.9	10.8	8.8	12.7
Return to work	40%	57%	71%	14%
Success at walking speed	48%	57%	67%	36%
Mean pain score	23.1	22.9	33.1	22.1
Percent with infection	10%	12%	77%	58%
Mean number of surgeries	1.6	2.9	4.1	5.3

Fifty-seven percent of patients in group 2 returned to work compared to 14% in group 4, (P<.05). The scores for walking speed (more than four feet per second) were 22.9 for group 2 and 22.1 for group 4 (P<.1).

The mean pain scores, however, were not significantly different. Those scores were 22.9 for group 2 and 22.1 for group 4 (P<.4).

Infections were a problem in group 4 (58% vs. 12%, P<.001). According to Smith, the rates for osteomyelitis and nonunion were also high. In addition, the number of patients who requested amputation was high.

“I believe the major contributing factors to late amputation are infection, osteomyelitis, nonunion and patient request,” Smith said. “And I believe there is value in making this very difficult decision in a timely fashion.”

For more information:

Smith D, Castillo R, MacKenzie E, et al. Functional outcomes of patients who have late amputation after trauma is significantly worse than for those who have early amputation. Symposium: Scientific papers from the LEAP study. Presented at the Orthopaedic Trauma Association 19th Annual Meeting. Oct. 9-11, 2003. Salt Lake City.