Study compares outcomes of amputation and limb salvage surgery following lower extremity trauma

Issue: February 2011

According to a congressional research service report, there were 1,621 amputations performed due to Operation Iraqi Freedom, Operation Enduring Freedom and unaffiliated conflicts.

The Department of Defense-funded military extremity trauma limb salvage study (METALS) examined and compared the experiences of service members who underwent amputation vs. those who opted for limb salvage surgery.

For the study, major limb trauma was defined as having a traumatic amputation or one or more of the following: revascularization, bone graft or bone transport, local or free flap coverage, complete deficit of a major nerve, or a complete compartment injury or syndrome. According to Col. (Ret.) William Doukas, Walter Reed Army Medical Center, who spoke at the 2010 Orthopaedic Trauma Association Annual Meeting, 37% of reported amputations were transfemoral and 52% were transtibial.

The retrospective cohort study of 298 U.S. service members who sustained a major lower limb injury while serving in Iraq or Afghanistan revealed that major lower limb trauma sustained in the military results in significant long-term disability. In fact, one-fifth reported pain that interfered with their daily activities and 35% were not working, on active duty or currently enrolled in school. The short musculoskeletal functional assessment (SMFA) was used to measure overall function. Symptoms of depression, post-traumatic stress and chronic pain were also studied. Although there were no significant differences when comparing depressive symptoms, post-traumatic stress or pain interference, those who underwent at least one major amputation had better SMFA scores than those who opted for limb salvage.

He said in SMFA function scoring, unilateral amputees did significantly better than unilateral limb salvage patients and those with at least one amputation did better than those with two salvaged limbs.

“When the patients were asked if they were involved in sports and activities such as hiking, those who had undergone amputation were much more likely to be involved than those who had undergone limb salvage,” Doukas said. – by Anthony Calabro

References:

Doukas W, et al. The Military Extremity Trauma Association/limb salvage (METALS) study: Comparing outcomes for amputation versus limb salvage following major lower extremity trauma. Paper #72. Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association. Oct. 13-16, 2010. Baltimore.

Disclosure: Doukas has no relevant financial disclosures.

I think the big surprise of the study is that when we looked at functional outcomes, the amputees seemed to perform better than the limb salvage patients. One would think the results would be similar or even the other way around. We have done work in the past with the civilian sector that showed the outcomes between amputation and limb salvage were similar. Unfortunately, this study was limited and we really were not able to answer that important question — why? We have to do to more work to find out the reasons for these differences.

It is important not to take away the message that amputation is better than limb salvage. There are a lot of factors going on here and we really have to find out why we are seeing this difference.

– Ellen MacKenzie, PhD
Chair, Fred and Julie Soper professor in health policy and management, Johns Hopkins Bloomberg School of Public Health
Disclosure:She has no relevant financial disclosures.