The most important thing to grasp about the prognosis of amputation is that the indication for the amputation and the character of the individual is more important than the level (although that is also important).
The key issue when giving a prognosis for a post-traumatic amputation is not to mix up the prognosis of post-traumatic amputees with vascular amputees.
The functional outcome and life expectancy of a 30 year old traumatic above knee amputee is very different from a 65 year old vascular AK amputee.
Many amputation papers have a large preponderance of vasculopathic & diabetic patients whose prognosis is poor compared to the post-traumatic group both in function & life expectancy. Many amputation series present the results by level of amputation, not by indication or age; look out for this.
Many will be familiar with the story of a Scottish military double-amputee who trekked to the South Pole in 2013. My father had a trans-tibial amputation in 1944 at age 23, but lived a mobile, independent & fulfilling life until his death at the age of 85. I do not think such accounts are uncommon.
Such accounts are of course anecdotal, and it would do these men & women no service if we gloss over the very real physical, mental, & relationship problems that they may experience and sometimes struggle to overcome.
In addition, there is evidence that post-traumatic amputation does have cardiovascular effects in the long term, that may result in reduced life expectancy.
Other factors that affect function markedly are deformity within the residuum or pain. The cause of pain should not be assumed, it should be sought; some causes are eminently curable. Pain can be due to chafe, infection, neuroma, complex regional pain syndrome (CRPS), or even arthritis. Deformity, commonly fixed flexion, increases pressure on vulnerable points, reduces stride length, and reduces functional limb length.
All these things and the length of the residuum should be brought out in your report. How likely is revision surgery? Are there pharmaceutical options? Can a Pain Clinic help? Could there be recurrence of osteomyelitis in the stump?
Your report on surgical aspects of the amputation is complementary to the prosthetist’s report. There is overlap between the two lanes; try to make that an area of harmony and inter-professional respect. Nothing looks worse in Court than a boundary dispute between adjacent experts.
Let’s dive in to some of the relevant surgical literature, sorted chronologically.
1988, Millstein, McCowan, & Hunter.’ Traumatic Partial Foot Amputations in Adults’. J Bone Joint Surg [Br] l988;70-B:251-4.
n=113; Follow-up = 1-68 years, mean 16. Of those who retained their original foot amputation, function was good (43%), fair (38%), & poor (19%).
Of 260 initial amputations, 49 (19%) were revised to a Syme’s or a below-knee amputation.
1999, Dougherty, ‘Long-Term Follow-up Study of Bilateral Above-the-Knee Amputees from the Vietnam War’. JBJS: October 1999 – Volume 81 – Issue 10 – p 1384-90
n=30. 26 had been injured by landmine or boobytrap. 23/27 surviving patients responded to an SF-36 questionnaire. 22% walked with prostheses, prostheses were used for average 7.7 hours/day. 70% had been employed outside the home since discharge. The SF-36 physical functioning score was significantly lower for these persons than than for matched controls -scarcely a surprising result. The author concluded: The patients in the present study have led relatively normal, productive lives within the context of their physical limitations.
2001, Dougherty. ‘Transtibial Amputees from the Vietnam War
TWENTY-EIGHT-YEAR FOLLOW-UP’. JBJS,VOLUME 83-A · NUMBER 3 · MARCH 2001, 383-389.
Group 1 had transtibial amputation only (n=28). Group 2 (n=44) had TTA plus at least one other major injury. Assessment = SF-36. Landmine or boobytrap caused 65% of injuries. The average scaled scores for Group 1 were similar to those for the age and gender-matched controls, but
the scores for Group 2 were significantly lower (p £ 0.001) than those for the age and gender-matched controls in
all categories. The author concluded: ‘Group-1 patients led relatively normal lives after sustaining a transtibial amputation in battle. The addition of another major injury (Group 2) appears to have significant long-term consequences with regard to SF-36 scores and the need for psychological care’.
2002, Bosse et al, ‘An Analysis of Outcomes of Reconstruction or Amputation after Leg-Threatening Injuries’. N Engl J Med 2002; 347:1924-1931 December 12, 2002 DOI: 10.1056/NEJMoa012604
n=569, severe limb injuries resulting in reconstruction or amputation. Multicentre, prospective study to determine functional outcomes. The Sickness Impact Profile was outcome measure, a multidimensional measure of self-reported health status. Scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability. At 2 years, no significant difference in scores between amputation and reconstruction group. 53% of amputees & 49.4% of reconstructees had returned to work.
Predictors of poorer outcome were:
- major complication
- low educational level (or is that a marker for a physically demanding job?)
- non-white race
- poverty
- lack of private health insurance
- poor social-support network
- low self-efficacy (the patient’s confidence in being able to resume life
activities) - smoking
- involvement in disability-compensation litigation
2003, Dougherty, ‘Long-Term Follow-Up of Unilateral Transfemoral Amputees from the Vietnam War’. The Journal of Trauma: Injury, Infection, and Critical Care: April 2003 – Volume 54 – Issue 4 – p 718-723
n=46, 28 years post-injury. The author found: Compared with the controls, patient responses to the SF-36 were significantly (p < 0.01) less in all categories except Mental Health and Vitality. Forty-three (93.5%) are or have been married. Forty-one (89.1%) are or have been employed an average of 20.1 years. Forty patients (87%) wore a prosthesis an average of 13.5 h/day...Although the patients do relatively well with employment and marriage stability, the low SF-36 scores suggest a significant disability.
2005, Mackenzie et al, ‘Long-Term Persistence of Disability Following Severe Lower-Limb Trauma: Results of a Seven-Year Follow-up’. JBJS: August 2005 – Volume 87 – Issue 8 – p 1801-1809
doi: 10.2106/JBJS.E.00032
The LEAP study results of Bosse et al 2002 (above) are confirmed at 7 years follow-up. 50% had substantial disability. Only 34.5% had a score typical of the general population of similar age/gender. The authors commented: Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, non-white race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury.
2006, MacKenzie & Bosse, ‘Factors Influencing Outcome Following Limb-Threatening Lower Limb Trauma: Lessons Learned From the Lower Extremity Assessment Project (LEAP)’. J Am Acad Orthop Surg 2006;14: S205-S210
This is a thoughtful contribution on the subject. The ‘conceptual framework’ illustrated in tabular form illustrates well the factors at play in the determination of outcome. I recommend getting a copy of this.
The authors comment: ‘This study and others provide
evidence of wide-ranging variations in outcome following major
limb trauma, with a substantial proportion of patients experiencing
long-term disability. In addition, outcomes often are more affected
by the patient’s economic, social, and personal resources than by
the initial treatment of the injury—specifically, amputation or
reconstruction and level of amputation. A conceptual framework
for examining outcomes after injury may be used to identify
opportunities for interventions that would improve outcomes.’
2007, Clasper JC, ‘Amputations of the Lower Limb: A Multidisciplinary Consensus’. Journal of the Royal Army Medical Corps, DOI: 10.1136/jramc-153-03-08 · Source: PubMed. An admirably clear and practical summary of contemporary military advice.
Recommendations
1 – The examination findings, together with the indications
to amputate the limb should be documented.
2 – Existing limb salvage scores should NOT be used to
determine the need for amputation.
3 – Whenever possible the decision to amputate a limb
should be confirmed by a second surgeon.
4 – All wounds should be photographed.
5 – Radiographs should be obtained prior to amputation.
6 – Neurological dysfunction (particularly numbness of the
sole of the foot) should NOT be part of the criteria
used to decide amputation.
7 – The site of amputation should be at the lowest level
possible.
8 – Guillotine amputations should not be performed.
9 – No fashioning of flaps at initial debridement.
10 – Bone should be cut at the most distal soft tissue
levels.11 – Amputation should not to be carried out at the level
of any fracture unless this is the appropriate skin/soft
tissue level.
12 – No part of the wound to be closed at initial surgery.
13 – No attempt to be made to prevent skin retraction.
14 – Through-knee amputation is
acceptable if appropriate.
The multidisciplinary group concluded that limb salvage scores should not be used in decision-making because of lack of specificity & sensitivity. Existing scores may be designed for the ischaemic limb rather than the heavily contaminated wounds of battle. In particular, loss of sensation of the sole of the foot often returns later (>50%) and should NOT be used as an indicator. Neurological and vascular status should be recorded, as well as the indications for amputation. They note that some differences exist between these recommendations and the recommendations of the ICRC & other humanitarian organisations. I suspect that this results from differences in resources & numbers, as well as philosophy.
2008, Ly et al, LEAP study, ‘Ability of Lower-Extremity Injury Severity Scores to Predict Functional Outcome After Limb Salvage’.
The following scales were studied: Mangled Extremity Severity Score; the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98.
n=601. Assessment = physical and psychosocial domains of the Sickness Impact Profile at both six months and two years following hospital discharge.
‘Currently available injury severity scores are not predictive of the functional recovery of patients who undergo successful limb reconstruction’.
2008, Naschitz & Lenger, ‘Why traumatic leg amputees are at increased risk for cardiovascular diseases‘. Q J Med 2008; 101:251–259
doi:10.1093/qjmed/hcm131
There is an increased risk of cardiovascular disease in post-traumatic lower limb amputees. This is due to increased insulin resistance & higher insulin levels, hypertension & obesity; hyper-coagulability; PTSD & depression; smoking, substance abuse & alcohol. There may be haemodynamic factors due to perturbed arterial flow proximal to the amputation site. Shear stress, circumferential strain, & reflected waves are thought to be responsible. The higher the amputation, the greater the effect. Abdominal aortic aneurysms are 5x more common in post-traumatic AKA patients 40 years after injury than in controls (Vollmar JF, Paes E, Pauschinger P, Henze E, Friesch A. Aortic aneurysms as late sequelae of above-knee amputation.
Lancet 1989; 2:834–5.)
In WW2 amputees, outcomes were studied by Hrubec Z, & Ryder RA. (‘Traumatic limb amputations and subsequent mortality from cardiovascular disease and other causes’. J Chron Dis 1980; 233:239–50.). 3887 were proximal limb amputees (above knee or elbow), 3890 were injured with disfigurement but without amputation, and 2917 were distal limb amputees (loss of only part of the hand or foot). These individuals were followed to 1977. The relative risk for death by cardiac causes was 1.58 times as great in unilateral above-knee amputees and 3.5 times as great in bilateral above-knee amputees in comparison with disfigured veterans.
2009, Chung et al, ‘A Cost-Utility Analysis of Amputation versus Salvage for Gustilo IIIB and IIIC Open Tibial Fractures’. Plast Reconstr Surg. 2009 December ; 124(6): 1965–1973. doi:10.1097/PRS.0b013e3181bcf156.
These authors found amputation to be more expensive, due to recurrent costs; limb salvage was deemed the dominant, cost-saving strategy. Amputation yielded fewer QALYs than salvage. The authors commented: ‘Unless the injury is so severe that salvage is not a possibility, based on this economic model, surgeons should consider limb salvage, which will yield lower costs and higher utility when compared to amputation’.
2009, Robbins et al, ‘A Review of the Long-Term Health Outcomes
Associated With War-Related Amputation’, MILITARY MEDICINE, 174, 6:588, 2009.
The authors reviewed the literature for health outcomes following war-related amputations and 17 studies were retrieved with evidence that (a) amputees are at a significant risk for developing cardiovascular disease;
(b) insulin may play an important role in regulating blood pressure in maturity-onset obesity; (c) lower-extremity amputees are at risk for joint pain and osteoarthritis; (d) transfemoral amputees report a higher incidence of low back pain than transtibial amputees; and (e) 50 to 80% report phantom limb pain, with many amputees stating they were either
told that their pain was imagined or their mental state was questioned.
2009, Struyf et al, ‘The Prevalence of Osteoarthritis of the Intact Hip and Knee Among Traumatic Leg Amputees’. Archives of Physical Medicine and Rehabilitation, Volume 90, Issue 3, March 2009, Pages 440-446
n=78. The prevalence of knee OA was 27% (men 28.3%, women 22.2%). Hip OA prevalence was 14% (men 15.3%, women 11.1%). This was higher compared with the general population (knee OA men 1.58%, women 1.33%, hip OA men 1.13%, women 0.98%, age adjusted). No significant relationships were found between the prevalence of OA and level of amputation, time since amputation, mobility, or age.
The prevalence of hip & knee OA is significantly higher than in the general population.
2009, Sansam et al. ‘PREDICTING WALKING ABILITY FOLLOWING LOWER LIMB AMPUTATION: A SYSTEMATIC REVIEW OF THE LITERATURE’. J Rehabil Med 2009; 41: 593–603
Following lower limb amputation the following factors predict walking ability:
- cognition,
- fitness,
- ability to stand on one leg,
- independence in activities of daily living and pre-operative mobility.
- shorter time from surgery to rehabilitation
- absence of stump problems
- unilateral and distal amputation levels, and younger age
- Sex probably does not have a significant influence on walking ability
2010, Wade et al, ‘Outcomes Associated with the Internal Fixation of Long-Bone Fractures Proximal to Traumatic Amputations’. JBJS: October 6, 2010 – Volume 92 – Issue 13 – p 2312-2318
doi: 10.2106/JBJS.J.00138
In summary – worthwhile, don’t worry, preserve length. The authors commented: Thirty-three patients (89%) developed an infection requiring surgical debridement. However, all fractures were treated until union occurred, and amputation level salvage was successful in all instances. Heterotopic ossification developed in twenty-eight patients (76%), with operative excision required in eleven patients (39%).
Authors’ conclusions: High complication rates, but acceptable final results, can be achieved with internal fixation of a fracture proximal to a traumatic amputation to preserve functional joint levels or salvage residual limb length.
2011, Perkins et al, ‘Factors affecting outcome after traumatic limb amputation’.British Journal of Surgery 2012; 99(Suppl 1): 75–86. Published online inWiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7766
A relatively recent & readable review. Quotes:
- phantom limb pain, 50-80% of amputees. Early, often some improvement with time
- residual limb pain, persists to some extent in 55-76%
- Back pain, 52-81% of traumatic amputees (higher prevalence than population norms), higher in AKA than BKA
- X2 higher risk of knee pain in uninjured knee than non-amputees; 50-63% in AKA, 36-41% in BKA. Prevalence in matched controls is ~20%.
- ischaemic heart disease relative risk (RR) x 3.3
- abdominal aortic aneurysm RR X 5.1
- cardiac death x1.58 in unilateral amputees; X 3.5 in bilateral above amputees
2011, Penn-Barwell JG, ‘Outcomes in lower limb amputation following trauma: A systematic review and meta-analysis’.Injury, Int. J. Care Injured 42 (2011) 1474–1479
n=3105. 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. Primary outcome score = Physical Component Score of the Short Form-36 measure of quality of life; secondary outcomes were pain, employment, ability to walk 500 m & proportion of time that prosthesis is worn. He commented:
‘There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500 m than those with an AKA or bilateral amputation (p = 0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA’.
2012, Yang et al, ‘High Prevalence of Stump Dermatoses 38 Years
or More After Amputation’. Arch Dermatol. 2012;148(11):1283-1286
n=416 veterans mostly of the Vietnam war; 247 completed study. 48% reported a skin problem in in the previous year. Skin breakdown (25%), rash (21%), abrasion (21%). 25% reported skin problems more than 50% of the time. 37% had to alter or replace their prosthesis. Stump dermatoses limited or prevented prosthesis use in in the preceding year for 55% or caused pain or discomfort at the stump in 61%. The authors concluded that prevention, early management, & advanced treatment were important.
2013, Doukas et al, ‘The Military Extremity Trauma Amputation/Limb
Salvage (METALS) Study’. J Bone Joint Surg Am. 2013;95:138-45 d http://dx.doi.org/10.2106/JBJS.K.00734
n=324. Retrospective cohort of military individuals who had deployed to Iraq or Afghanistan, and had sustained lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. SMFA used to assess function; also the Center for Epidemiologic Studies Depression Scale); PTSD Checklist-military version; the Chronic Pain Grade Scale, and the Paffenbarger Physical Activity Questionnaire.
Except for arm/hand function, the patients scored significantly worse than population norms in all SMFA domains. 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, amputees had better scores in all SMFA domains compared with reconstructees (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. NB potential for selection bias.
Summary. Traumatic amputees face a significant burden of physical disability, and sometimes psychological disability. Despite this, they may cope surprisingly well in employment, sport and daily life. Pain is frequent, & sometimes constant. Skin problems of the stump are also a repeated trial.
Nevertheless, there are potential long-term cardiovascular & joint complications lurking insidiously in the wings. Doctors should bear this in mind, and encourage healthy lifestyles and keep them under cardiovascular and metabolic surveillance.