The Mangled Extremity


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The Mangled Extremity


Tiffany Huynh MD1 and Ted V. Tufescu MD FRCSC1


University of Manitoba, Winnipeg, MB, Canada


Clinical scenario



  • A motorcyclist collides with a car at high speed. He is brought to the Emergency Department with a severe open injury to his leg.
  • He has been experiencing financial difficulties and would like to return to work (RTW) as soon as possible. With this goal in mind, he asks whether amputation or limb salvage would be the best option for him.
  • He looks at his mangled leg and wonders about the long‐term consequences of his injury.

Top three questions



  1. In patients with a mangled extremity injury, does limb salvage necessitate greater resource investment than amputation?
  2. In patients with a mangled extremity injury, what patient factors influence the success of therapy and the rate of RTW?
  3. In patients with a mangled extremity injury, is limb salvage associated with better long‐term outcomes when compared to amputation?

Question 1: In patients with a mangled extremity injury, does limb salvage necessitate greater resource investment than amputation?


Rationale


Limb salvage and amputation impose different stressors on a patient’s financial and emotional well‐being. An understanding of the investment required in each intervention enables the clinician to better counsel patients.


Clinical comment


Salvage may require multiple, costly procedures, and may result in failure rates as high as 40%.1–5 More than half of patients develop mental health conditions after a failed limb salvage and many would not opt for it again.2–6 However, at time of injury, 92% prefer an attempt at salvage.3 Appreciating the financial and psychological costs of limb salvage compared with amputation may assist patients with decision‐making.


Available literature and quality of the evidence


The most current relevant literature consists of:



  • Level II: 2 cost‐analysis studies based on prospectively collected data.7,8
  • Level III: 3 retrospective chart reviews.3,9,10

Findings


Financial cost of limb salvage and amputation


Georgiadis reported a lower acute hospitalization charge (US$65,624) for amputation than for salvage ($109,044) (p <0.006)(level III).4 Hertel reported equal mean annual hospital cost, based on four years, for amputation (15 112 CHF and salvage (17 365 CHF) (level III).9 MacKenzie reported equal long‐term hospital costs for amputation ($78 221) and salvage ($81 091) (level II).8 Hertel reported higher total cost, including pension and loss of wage benefits for amputation (64 000 CHF) compared to salvage (33 000 CHF) (p <0.01).9 When considering lifetime prosthesis‐related costs, MacKenzie reported that amputation is three times more costly ($509 275) than salvage ($163,282).8 Chung calculated cost as amount of money paid for a single extra quality‐adjusted life years (QALYs). Assuming the patient has 40 years of life remaining, the average cost is $91 105 for amputation and $81 316 for salvage at two years after injury (level II).7 The remaining lifetime cost is again higher for amputation ($350 465) than for salvage ($133 704).7


Duration of hospitalization for limb salvage and amputation


Georgiadis reported a shorter acute hospitalization for amputation (48 days) than salvage (71 days) (p <0.05).4 Dagum reported equal stays for amputation (28 days) and salvage (25 days) (level III).3 Georgiadis reported shorter readmission for amputation (5 days) than for salvage (18 days).4 Hutchins reported equal total hospital stays, including readmission, for amputation (14 weeks) and for salvage (14.8 weeks) (level III).10 Additionally, it is important to account for the time spent in rehabilitation centers. Hutchins reported that total acute and rehabilitation admission times were equal for amputation (101 days) and for salvage (129 days).10 Shorter outpatient rehabilitation time was required for amputation (12 months) than for salvage (30 months), although this was self‐reported by patients (p <0.009).10


Resolution of clinical scenario


Level II and III evidence suggests that the cost of limb salvage is:



  • Less than amputation, when considering lost wages, pension, lifetime prosthesis‐related charges, and QALYs.
  • Equal to amputation in regard to in‐hospital charges, duration of hospitalization, and duration of inpatient rehabilitation in most studies.
  • More than amputation in regard to duration of outpatient rehabilitation.

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on The Mangled Extremity

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