Similar Outcomes for Limb Reconstruction and Amputation After Trauma

Individuals who undergo limb reconstruction or amputation following severe trauma to the lower leg fare about the same functionally. This outcome was reported in the New England Journal of Medicine after two years of a five-year observational study funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a component of the National Institutes of Health in the U.S. Department of Health and Human Services. The study, Lower Extremity Assessment Project (LEAP), is a multicenter initiative that followed 549 patients 16 to 69 years of age.

The objectives of the study were to 1) compare clinical and functional outcomes for those undergoing amputation versus reconstruction, 2) identify early clinical predictors of successful limb salvage and good functional outcomes, and 3) identify characteristics of the patient and environment that affect functional outcomes and well-being.

According to Stephen Katz, M.D., Ph.D., director of NIAMS, the current and possible future findings of this study should help surgeons and patients make better-informed decisions when choosing between reconstruction or amputation of a limb that has been severely damaged.

Despite medical and surgical advances in reconstruction of severely injured legs, patients undergoing this procedure were more likely than those who had amputations followed by a well-fit prosthesis to experience serious complications requiring rehospitalization for additional surgery. When overall functional outcome was determined by the Sickness Impact Profile, a measure of self-reported health status, there was very little difference between patients in the reconstruction and amputation groups. Fifty-three percent of patients in the amputation group and 49.4 percent of those in the reconstruction group returned to work within two years of their procedure. Neither the severity of fracture and soft-tissue injury nor the presence of other injuries in the same or opposite leg significantly affected functional outcome.

Predictors of a low score on the Sickness Impact Scale in either group were: rehospitalization for a major complication, less than a high-school education, nonwhite race, poverty, lack of private health insurance, poor social support, low self-efficacy (control of daily circumstances and adoption of healthy practices), smoking, and involvement in disability compensation litigation. The researchers acknowledge that these results suggest major improvement in outcomes might occur if more attention is paid to psychosocial counseling and vocational rehabilitation. Assessment will continue comparing the outcomes of the two procedures, the correlates of good outcomes, and cost.

Authors reporting the results of the study were from the following institutions: Carolinas Medical Center, Charlotte, N.C.; Johns Hopkins University, Baltimore, Md.; University of Maryland at Baltimore; Wake Forest University Baptist Medical Center, Winston-Salem, N.C.; Harborview Medical Center, Seattle, Wash.; Tampa General Hospital, Fla.; University of Texas Southwestern Medical Center, Dallas; Vanderbilt University School of Medicine, Nashville, Tenn.; and Cleveland MetroHealth Medical Center, Ohio.

To contact Dr. Bosse at the Carolinas Medical Center, e-mail inquiries to mbosse@carolinas.org or call (704) 355-6046.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a component of the U.S. Department of Health and Human Services National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases.

Reference: Bosse J, MacKenzie E, Kellam J, Burgess A, Webb L, Swiontkowski M, Sanders R, Jones A, McAndrew M, Patterson B, McCarthy M, Travison T, Castillo R. An analysis of two-year outcomes of reconstruction or amputation of leg-threatening injuries in level 1 trauma centers. NEJM, 2002; 347(24):1924-31.