Amputation Versus Reconstruction in Severe Lower Extremity Injury: A Systematic Review and Meta-analysis



1 Addenbrookes Major Trauma Unit, Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, Cambridgeshire, UK

2 School of Clinical Medicine, University of Cambridge, Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, CB2 0SP, UK


Objectives: Cases of severe lower limb injuries that previously were amenable only to amputation can now, in certain circumstances, be managed with reconstruction. The present systematic review and meta-analysis was designed to compare the results of amputation and reconstruction in severe lower extremity injuries. Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were comprehensively searched for studies comparing amputation and reconstruction for severe lower extremity injuries. The search terms used were the following: “amputation”, “reconstruction”, “salvage”, “lower limb”, “lower extremity”, and “mangled limb”, “mangled extremity”, “mangled foot”. Two investigators screened eligible studies, assessed the risk of bias and extracted the data from each study. Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). The I2 index was used to assess heterogeneity. Results: Fifteen studies with 2,732 patients were included. Amputation is associated with lower rehospitalization rates, lower length of stay in the hospital, lower number of operations and additional surgery and fewer cases of infection and osteomyelitis. Limb reconstruction leads to faster return to work and lower rates of depression. The outcomes with respect to function and pain are variable among the studies. Statistically significance was achieved only with regards to rehospitalization and infection rates. Conclusion: This meta-analysis suggests that amputation yields better outcomes in variables during the early postoperative period, while reconstruction is associated with improved outcomes in certain long-term parameters. Severe lower limb injuries should be managed on their individual merit. The results of this study may be a useful tool to aid in the decision-making for the treating surgeon. High-quality Randomized Controlled Studies are still required to further our conclusions. Level of evidence: III


Main Subjects

1. Moher D, Liberati A, Tetzlaff J, Altman DG, P. Group. Preferred
reporting items for systematic reviews and meta-analyses:
the PRISMA statement. Int J Surg 2010;8:336-341.
2. Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: a tool for
assessing risk of bias in non-randomised studies of
interventions. BMJ. 2016; 355:i4919. doi:10.1136/bmj.i4919.
3. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL.
Open tibial fractures with severe soft-tissue loss. Limb
salvage compared with below-the-knee amputation. J Bone
Joint Surg Am 1993; 75:1431-1441. doi:10.2106/00004623-
4. Dahl B, Andersson AP, Andersen M, Ebskov LB, Reumert T.
Functional and social long-term results after free tissue
transfer to the lower extremity. Ann Plast Surg 1995; 34:372-
375. doi:10.1097/00000637-199504000-00005.
5. Hertel R, Strebel N, Ganz R. Amputation versus reconstruction
in traumatic defects of the leg: outcome and costs. J Orthop
Trauma .1996;10:223-229. doi:10.1097/00005131-
6. Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed
MN, Blight KR. Salvage after severe lower-extremity trauma:
are the outcomes worth the means? Plast Reconstr Surg,
103(4), 1212-1220. doi:10.1097/00006534-199904040-
7. Hoogendoorn JM, van der Werken C. Grade III open tibial
fractures: functional outcome and quality of life in amputees
versus patients with successful reconstruction. Injury. 2001;
32:329-334. doi:10.1016/s0020-1383(00)00250-3.
8. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of
outcomes of reconstruction or amputation after legthreatening injuries. N Engl J Med. 2002; 347:1924-1931.
9. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment
Project (LEAP)--the best available evidence on limbthreatening lower extremity trauma. Orthop Clin North Am
.2010; 41:233-239. doi:10.1016/j.ocl.2009.12.006.
10. Doukas WC, Hayda RA, Frisch HM, et al. The Military
Extremity Trauma Amputation/Limb Salvage (METALS)
study: outcomes of amputation versus limb salvage following
major lower-extremity trauma. J Bone Joint Surg Am. 2013;
95:138-145. doi:10.2106/JBJS.K.00734.
11. Ellington JK, Bosse MJ, Castillo RC, MacKenzie EJ, L.S. Group.
The mangled foot and ankle: results from a 2-year
prospective study. J Orthop Trauma. 2013; 27:43-48.
12. Melcer T, Sechriest VF, Walker J, Galarneau M. A comparison
of health outcomes for combat amputee and limb salvage
patients injured in Iraq and Afghanistan wars.J Trauma Acute
Care Surg, 2013;75(2):S247-54.
13. Demiralp B, Ege T, Kose O, Yurttas Y, Basbozkurt M.
Amputation versus functional reconstruction in the
management of complex hind foot injuries caused by landmine explosions: a long-term retrospective comparison. Eur J
Orthop Surg Traumatol. 2014; 24:621-626.
14. Edelstein DA, Florescu I. Crushing injuries of the foot and
ankle, with complex open fractures: result of a prospective
study with a 3 year follow-up. J Med Life .2016;9:255-258.
15. Ladlow P, Phillip R, Coppack R, et al. Influence of Immediate
and Delayed Lower-Limb Amputation Compared with LowerLimb Salvage on Functional and Mental Health Outcomes
Post-Rehabilitation in the U.K. Military. J Bone Joint Surg Am.
2016; 98:1996-2005. doi:10.2106/JBJS.15.01210.
16. Barla M, Gavanier B, Mangin M, Parot J, Bauer C, Mainard D. Is
amputation a viable treatment option in lower extremity
trauma? Orthop Traumatol Surg Res. 2017; 103:971-975.
17. Fioravanti M, Maman P, Curvale G, Rochwerger AA, Mattei JC.
Amputation versus conservative treatment in severe open
lower-limb fracture: A functional and quality-of-life study.
Orthop Traumatol Surg Res. 2018; 104:277-281.
18. Johansen K, Daines M, Howey T, Helfet D, Hansen Jr ST.
Objective criteria accurately predict amputation following
lower extremity trauma. J Trauma. 1990; 30:568-572.
19. Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective
evaluation of the clinical utility of the lower-extremity injuryseverity scores. J Bone Joint Surg Am. 2001; 83:3-14.
20. Schiro GR, Sessa S, Piccioli A, Maccauro G. Primary
amputation vs limb salvage in mangled extremity: a
systematic review of the current scoring system. BMC
Musculoskelet Disord. 2015; 16:372. doi:10.1186/s12891-
21. Loja MN, Sammann A, DuBose J, et al. The mangled extremity
score and amputation: Time for a revision. J Trauma Acute
Care Surg. 2017; 82:518-523.
22. Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A metaanalysis of amputation versus limb salvage in mangled lower
limb injuries--the patient perspective. Injury. 2011; 42:1194-
1197. doi:10.1016/j.injury.2010.05.003.
23. Busse JW, Jacobs CL, Swiontkowski MF, Bosse J, Bhandari M,
Evidence-Based Orthopaedic Trauma Working G. Complex
limb salvage or early amputation for severe lower-limb
injury: a meta-analysis of observational studies. J Orthop
Trauma. 2007; 21:70-76.