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The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?
Michael J. Bosse, MD1; Melissa L. McCarthy, ScD2; Alan L. Jones, MD3; Lawrence X. Webb, MD4; Stephen H. Sims, MD1; Roy W. Sanders, MD5; Ellen J. MacKenzie, PhD6
1 Department of Orthopaedic Surgery, Carolinas Medical Center, Medical Education Building, Suite 503, P.O. Box 32861, Charlotte, NC 28232-2861. E-mail address for M.J. Bosse: mbosse@carolinas.org. E-mail address for S.H. Sims: ssims@carolinashealthcare.org
2 Department of Emergency Medicine, Johns Hopkins University, Suite 6-100, 1830 East Monument Street, Baltimore, MD 21205. E-mail address: mmccarth@jhmi.edu
3 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235. E-mail address: alan.jones@utsouthwestern.edu
4 Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address: lxwebb@wfubmc.edu
5 Florida Orthopaedic Institute, 4 Columbia Drive, #710, Tampa, FL 33606-3568. E-mail address: ots1@aol.com
6 Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205. E-mail address: emackenz@jhsph.edu
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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health, National Institute for Arthritis and Musculoskeletal and Skin Diseases (ROI-AR42659). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Dec 01;87(12):2601-2608. doi: 10.2106/JBJS.C.00671
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Abstract

Background: Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation.

Methods: We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups.

Results: The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation.

Conclusions: Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    S. Naidu Maripuri
    Posted on April 21, 2006
    Insensate Foot As An Indication For Amputation In Severe Lower Extremity Trauma
    University Hospital of Wales, Cardiff, UK

    EDITOR'S NOTE: The corresponding author has been invited to respond to this letter and to date, has not done so.

    To the Editor:

    We read with great interest the article by Bosse, et al,(1) and applaud their effort to establish that the insensate foot is not an indication for amputation in severe lower extremity injuries. We would like to add some additional comments and questions to the topic.

    Why did the authors use the criteria of MESS(2) where the cold, paralysed, insensate and numb limb represents the highest degree of limb ischemia as opposed to the criteria for an insensate limb used in the NISSA rating system(3) which represents nerve injury?

    It would be interesting to know the cause (nerve injury, vascular injury or both) of insensate foot in the salvage group who recovered sensation. How did the authors arrive at the conclusion that ‘sensory impairment at twenty four months appeared to be independent of treatment with either amputation or limb salvage’ when the table 1 represents the results of sensory loss in the amputated group as N/A?

    We wonder how the decision was made to proceed with amputation in the insensate amputation group. Surely, the patient’s personal and social beliefs must be considered in the decision making for amputation along with the scoring systems(4).

    References:

    1. Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW. The Insensate Foot Following Severe Lower Extremity Trauma: An indication for amputation? J Bone Joint Surg [Am] 2005: 87(12); 2601-8.

    2. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A evaluation of the mangled extremity severity score (MESS). J Orthop Trauma 1994: 8(2); 81-87.

    3. Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990: 30(5); 568-72.

    4. John V Z, Alagappan M, Devadoss S, Devadoss A. A completely shattered tibia. J Bone Joint Surg 2005: 87 (11); 1556-59.

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