THE MANGLED LOWER-EXTREMITY - CAN SALVAGE BE PREDICTED

The ability to predict amputation following combined orthopedic, vascu lar and soft tissue trauma to an extremity could eliminate prolonged a ttempts at salvage of a doomed Limb. We reviewed our experience with 4 8 mangled lower extremities in 46 patients. Twenty-one penetrating wou nds and 25 blunt injuries occurred in 37 men and nine women ranging in age from 3 to 59 years. Severity of injuries to muscle, skin, and maj or nerves were strongly interrelated (r = 0.49 to 0.74, P < 0.001), bu t there were no correlations between injuries to these tissues and sev erity of bone injury (r < 0.19, P > 0.20). Twenty-four limbs were salv aged, and 24 were amputated. Increased severity of soft tissue injury was associated with a greater probability of limb loss (P < 0.001), bu t limb salvage or amputation could not be predicted accurately by any variable or group of variables such as age, mechanism of injury, Injur y Severity Score, presence of shock, level of injury, venous injury or repair, sequence of repair (vascular vs skeletal), time of fasciotomy , arteriography, blood requirement, or duration of ischemia. Amputatio n was best predicted by severity of injury to the sciatic or tibial ne rves (P < 0.001), and by failure of arterial repair (P < 0.01). Severe extremity injuries require a coordinated approach and decisions regar ding amputation require careful judgement. These decisions cannot alwa ys be made at the time of presentation or during the initial operation . If after revascularization and skeletal stabilization the extremity is clearly nonviable or remains insensate, then delayed amputation can be performed under more controlled circumstances.