American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary for Limb Salvage or Early Amputation

Colonel B. K. Potter, MD; Michael J. Bosse, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(13):e628-e634. 

In This Article

Abstract and Introduction

Abstract

Clinical Practice Guideline for Limb Salvage or Early Amputation is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to address treatment for severe lower limb trauma below the distal femur by either amputation or limb salvage by providing evidence-based recommendations for key decisions that affect the management of patients with lower extremity trauma. This guideline contains 11 recommendations to evaluate the decision factors important for limb salvage versus early amputation. In addition, the work group highlighted the need for better research in the treatment and the shared decision making process of high-energy lower extremity trauma.

Introduction

The American Academy of Orthopaedic Surgeons (AAOS) and the Major Extremity Trauma and Rehabilitation Consortium, with input from representatives from the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, the American Orthopaedic Foot & Ankle Society, the Musculoskeletal Tumor Society, the American Society for Plastic Surgeons, the Society of Critical Care Medicine, and the Society for Vascular Surgery, recently published their clinical practice guideline (CPG), Limb Salvage or Early Amputation.[1] This CPG was approved by the AAOS Board of Directors in December 2019. The purpose of this CPG is to treat patients with limb-threatening lower extremity injuries based on current best evidence.

The true frequency of limb-threatening, high-energy lower extremity trauma (HELET), in general, or as defined for purposes of this CPG, specifically, remains difficult to accurately quantify, but thousands of patients per year are subject to this life-changing event. Providing affected patients and their families with the best counseling, to facilitate shared decision making and set realistic expectations, and the best treatment, based on the best available evidence, is critical toward achieving optimal outcomes.

The LEAP study demonstrated poor, but similar, functional outcomes in a civilian population of HELET patients at both 2 and 7 years after injury and treated by either limb salvage or amputation.[2,3] Based on this and the higher lifetime costs of amputation, the LEAP authors recommended that limb salvage be pursued whenever reasonably possible.[4] However, the more recent METALS (Military Extremity Trauma Amputation/Limb Salvage) study of a cohort of combat-injured military patients demonstrated better outcomes after amputation.[5] Similarly, LEAP patients requiring ankle arthrodesis or flap coverage had worse outcomes than those treated with transtibial amputation,[6] and a series of combat-related open calcaneal fractures reported an amputation rate of 43% and better outcomes in those patients treated with amputation.[7] These discrepancies highlight the difficult decisions facing both survivors of HELET and the multidisciplinary teams treating them.

Other areas of related uncertainty abound. Scoring systems to guide treatment decisions after HELET are lacking,[8,9] and the specific patient and injury factors which should encourage one treatment strategy versus the other remain poorly defined. Awareness of and emphasis on patient resilience assessment and facilitation after HELET have increased, but whether this should also affect treatment decisions remains unclear. Furthermore, although the costs of amputation exceed those of limb salvage, the costs of late amputation are greater than either, and in a worst-case scenario, this outcome suggests that patients may have been subjected to potentially unnecessary or futile procedures. These issues say nothing of the medicolegal implications of making the "wrong" decision for a given patient.

Therefore, the Department of Defense partnered with the AAOS to develop an evidence-based CPG to aid practitioners in the treatment of severe HELET.[1] Furthermore, the CPG represents a call for continued research directions to improve the initial and subsequent evaluation and decision-making elements for limb salvage or amputation after severe lower extremity trauma. An exhaustive literature search was conducted resulting initially in over 830 manuscripts for full review. The articles were then graded for quality and aligned with the work group's patients, interventions, and outcomes of concern. For CPG PICO (ie, population, intervention, comparison, and outcome) questions that returned no evidence from the systematic literature review, the work group used the established AAOS CPG methodology to generate three companion consensus statements regarding the evaluation and treatment of severe lower extremity trauma.

In summary, the limb salvage or early amputation guideline involved reviewing over 3,800 abstracts and more than 830 full-text articles to develop 11 recommendations supported by 36 research articles meeting stringent inclusion criteria. Each recommendation is based on a systematic review of the research-related topic, which resulted in one recommendation classified as high, six recommendations classified as moderate, and four recommendations classified as limited. The strength of recommendation is assigned based on the quality of the supporting evidence. The strength of recommendation also takes into account the quality, quantity, and trade-offs between the benefits and harms of a treatment; the magnitude of a treatment's effect; and whether data on critical outcomes are available.

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