Department of Orthopaedic Surgery, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, TN, India.
Department of Plastic Surgery, Ganga Hospital, Coimbatore, TN, India.
Injury. 2021 Apr;52(4):996-1001. doi: 10.1016/j.injury.2020.12.027. Epub 2021 Jan 2.
Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world.
We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs.
Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010).
Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country.
Therapeutic Level II Prospective Cohort Study.
开放性胫骨骨折是一种罕见且难以治疗的损伤，因为涉及到骨骼、皮肤和神经肌肉损伤以及合并症。在治疗非常严重的病例时，经常会出现这样的问题：我们应该截肢还是保留肢体？这个问题在美国和英国的平民和军事环境中已经进行了探讨，但在发展中国家的替代社会文化和经济环境中尚未得到研究。
我们研究了 2018 年 2 月至 2019 年 6 月期间我院收治的 78 例严重开放性胫骨骨折成年患者。20 例患者接受了膝上截肢（AKA），16 例接受了膝下截肢（BKA），42 例接受了保肢治疗。我们使用我院的开放性损伤严重程度评分（GHOISS）评估损伤严重程度，该评分有单独的骨骼损伤、皮肤损伤、神经肌肉损伤和合并症子评分，只有 GHOISS＞13 的患者才被纳入研究。我们评估了功能结局测量值以及我院和其他次要成本产生的经济成本。
保肢治疗（LEFS：平均=51，SF-12 PCS：平均=48，SF-12 MCS：平均=49）与 BKA（LEFS：平均=39，p=0.005，SF-12 PCS：平均=40，p=0.003，SF-12 MCS：平均=43，p=0.052）和 AKA（LEFS：平均=31，p＜0.001，SF-12 PCS：平均=34，p＜0.001，SF-12 MCS：平均=43，p=0.043）相比，提供了更好的结局。保肢治疗的主要成本（指数：平均=3100 美元，总费用：平均=4400 美元）高于 BKA（指数：平均=2500 美元，p=0.012，总费用：平均=2600 美元，p＜0.001）和 AKA（指数：平均=2800 美元，p=0.020，总费用：平均=3200 美元，p＜0.001）。保肢治疗的次要成本高于 BKA 和 AKA（p＜0.001）。与膝下截肢患者相比，保肢治疗的患者在受伤后 36 个月更有可能重返工作岗位（调整后的比值比=0.11，p=0.010）。
保肢治疗与截肢相比，在初始成本较高的情况下，可获得更好的功能结局，但终生成本可能较低。与其他相关文献不同，截肢在印度给患者带来了沉重的身心负担，这可能是由于社会文化差异和耻辱感所致。截肢是患者难以接受的结果，会导致较差的结局；因此，我们认为在我们的发展中国家，应积极保留肢体。
治疗性 II 级前瞻性队列研究。
