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A contemporary analysis of the management of the mangled lower extremity

de Mestral, Charles MD; Sharma, Sunjay MD; Haas, Barbara MD, PhD; Gomez, David MD, PhD; Nathens, Avery B. MD, PhD, MPH

Journal of Trauma and Acute Care Surgery: February 2013 - Volume 74 - Issue 2 - p 597–603
doi: 10.1097/TA.0b013e31827a05e3

BACKGROUND The management of a mangled lower extremity is complex and requires consideration of a patient’s injury pattern, medical history, social context, and preference. The Lower Extremity Assessment Project provides the highest level of evidence guiding management; however, the Lower Extremity Assessment Project cohort was recruited 15 years ago and was restricted to Level I trauma centers. Furthermore, as our ability to salvage limbs has improved, the decision to amputate in the early period following injury remains particularly challenging. Given these considerations, our primary objective was to characterize the contemporary management of the mangled lower extremity across a range of trauma centers and identify which patient and injury characteristics are associated with early amputation.

METHODS We used a retrospective cohort design and included adults in the National Trauma Databank (2007–2009) with a mangled lower extremity treated at Level I or II trauma centers. A mangle injury was defined as (1) a severe crush injury or (2) the combination of a severe fracture with selected severe injuries from at least two of three categories as follows: soft tissue, artery, or nerve. Logistic regression was used to evaluate the association of patient and injury characteristics with our primary outcome: amputation performed before the end of the first full calendar day following emergency department arrival (early amputation).

RESULTS A total of 1,354 patients were identified from 222 centers; 278 (21%) underwent amputation during their hospital course, with 124 (9%) undergoing early amputation. On multivariable analysis, only injury characteristic was associated with early amputation. The presence of severe head injury (Abbreviated Injury Scale [AIS] score ≥ 3), shock in the emergency department (systolic blood pressure < 90 mm Hg), limb injury type, and higher-energy mechanism were independently associated with early amputation.

CONCLUSION Nearly half of all in-hospital amputations for mangled lower extremities are performed early. The decision to amputate early may not be guided by age, comorbidity level, or insurance status but rather by systemic and local injury characteristics.

LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic/epidemiologic study, level IV.

From the Li Ka Shing Knowledge Institute (C.D.M., S.S., B.H., D.G., A.B.N.), St. Michael’s Hospital; and Department of Surgery (C.D.M., S.S., B.H., D.G., A.B.N.), University of Toronto, Toronto, Ontario, Canada.

Submitted: April 11, 2012, Revised: August 3, 2012, Accepted: August 3, 2012.

Dr. Nathens is supported by a Canada Research Chair in systems of Trauma Care.

This article was presented at the surgical forum of the 97th Annual Clinical Congress of the American College of Surgeons, San Francisco, California, October 23–27, 2011.

Address for reprints: Dr. Charles de Mestral, MD, 30 Bond St Queen Wing 3-076, Toronto, ON, Canada, M5B 1W8; email:

© 2013 Lippincott Williams & Wilkins, Inc.