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Commentary and Perspective   |    
The Dark Side of Amputation RehabilitationCommentary on an article by COL (Ret) William C. Doukas, MD, et al.: “The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study. Outcomes of Amputation Versus Limb Salvage Following Major Lower-Extremity Trauma”
Michael S. Pinzur, MD1
1 Loyola University Health System, Maywood, Illinois
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The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.


Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jan 16;95(2):e12 1-2. doi: 10.2106/JBJS.L.01322
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Whether one attends a scientific meeting devoted to high-energy extremity trauma, the diabetic foot, or musculoskeletal oncology, somewhere near the conclusion of the meeting will be either a presentation or a panel discussion directed toward the issue of limb salvage versus amputation. The participants will present their approach to this difficult clinical challenge, supported by little objective clinical data1.
Several attempts have been made to develop severity-of-injury scoring systems to guide trauma surgeons regarding whether they should direct their efforts toward meaningful limb salvage as opposed to performing primary limb amputation. To date, these efforts have not been able to provide a scoring system that avoids the subjective biases that impact our objective decision-making skills2.
The National Institutes of Health sponsored the Lower Extremity Assessment Project (LEAP) in order to provide surgeons with objective data on outcome expectations associated with mutilating limb injuries in civilian practice3. In this eight-clinical-center fourteen-million-dollar observational investigation, validated outcomes tools were used to follow the progress of 569 patients with high-energy lower-extremity injuries. Several subsequent publications from this ongoing observational database have addressed important clinical questions that previously had been treated on the basis of expert opinion or small non-case-controlled retrospective case series.
“The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study. Outcomes of Amputation Versus Limb Salvage Following Major Lower-Extremity Trauma” by Doukas and co-authors provides us with very disturbing objective outcome information that may translate well to civilian practice. The design of this investigation was carefully crafted on the basis of the benchmark established by the LEAP investigation. It is clear from this carefully crafted database that clinical outcomes following high-energy trauma may impart more of a negative impact on health-related quality of life than we previously thought. The valuable link between this investigation and the LEAP study is the continuity provided by Ellen J. MacKenzie, PhD, who was intimately involved with the design of both investigations.
One should not be surprised that these highly motivated physically fit patients reported less than optimal functional scores and high degrees of depression, despite the use of almost unlimited resources by highly experienced surgeons providing care in a health system focused on their recovery. The disturbing insight gained from this investigation is the high rate of posttraumatic stress disorder (PTSD) associated with mutilating limb injury. When one appreciates that one of the strongest predictors of a favorable outcome in the LEAP investigation was family support, the continuity role of Dr. MacKenzie may have been very important in leading the investigators to specifically test for PTSD.
For the foreseeable future, our highly experienced military trauma surgeons may have reached their limits with regard to restoring patient function following high-energy mutilating limb injury. The next frontier may well be in the nonsurgical rehabilitation that we provide for our wounded soldiers after their heroic sacrifice. One is hopeful that this landmark investigation will provide the impetus to tackle PTSD and the toll taken by the psychological impact of mutilating limb injury on highly motivated, highly functional productive young people.
Pinzur  MS;  Gottschalk  FAG;  Pinto  MA;  Smith  DG; American Academy of Orthopaedic Surgeons. Controversies in lower-extremity amputation. J Bone Joint Surg Am.  2007;89(  5):1118-27.[PubMed]
 
Bosse  MJ;  MacKenzie  EJ;  Kellam  JF;  Burgess  AR;  Webb  LX;  Swiontkowski  MF;  Sanders  RW;  Jones  AL;  McAndrew  MP;  Patterson  BM;  McCarthy  ML;  Cyril  JK. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am.  2001;83(  1):3-14.[CrossRef][PubMed]
 
Bosse  MJ;  MacKenzie  EJ;  Kellam  JF;  Burgess  AR;  Webb  LX;  Swiontkowski  MF;  Sanders  RW;  Jones  AL;  McAndrew  MP;  Patterson  BM;  McCarthy  ML;  Travison  TG;  Castillo  RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med.  2002;347(  24):1924-31.[CrossRef][PubMed]
 

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References

Pinzur  MS;  Gottschalk  FAG;  Pinto  MA;  Smith  DG; American Academy of Orthopaedic Surgeons. Controversies in lower-extremity amputation. J Bone Joint Surg Am.  2007;89(  5):1118-27.[PubMed]
 
Bosse  MJ;  MacKenzie  EJ;  Kellam  JF;  Burgess  AR;  Webb  LX;  Swiontkowski  MF;  Sanders  RW;  Jones  AL;  McAndrew  MP;  Patterson  BM;  McCarthy  ML;  Cyril  JK. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am.  2001;83(  1):3-14.[CrossRef][PubMed]
 
Bosse  MJ;  MacKenzie  EJ;  Kellam  JF;  Burgess  AR;  Webb  LX;  Swiontkowski  MF;  Sanders  RW;  Jones  AL;  McAndrew  MP;  Patterson  BM;  McCarthy  ML;  Travison  TG;  Castillo  RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med.  2002;347(  24):1924-31.[CrossRef][PubMed]
 
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