J Bone Joint Surg Am. 2021 Sep 1;103(17):1588-1597. doi: 10.2106/JBJS.20.01320.
Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation.
This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work.
The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval [CI] = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns.
Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
为患有严重下肢终末期损伤的患者选择最佳治疗方法仍然是一个挑战。对于某些损伤，截肢可能比保肢效果更好。本研究比较了保肢治疗和截肢治疗的患者的结局。
这是一项多中心前瞻性观察性研究，纳入了年龄在 18 至 60 岁之间的患者，这些患者接受了保肢治疗（n=488）或截肢治疗（n=151），治疗的损伤类型为 III 型 Pilon 或 IIIB 或 C 型踝关节骨折、III 型距骨或跟骨骨折、开放性或闭合性爆炸/压碎性足部损伤，随访时间为 18 个月。主要结局指标是短肌肉骨骼功能评估（SMFA）。如果进行截肢而不是保肢，对 SMFA 评分、身体机能、疼痛、剧烈活动参与度和重返工作的改善程度进行了截肢的因果效应估计。
接受保肢治疗的患者如果进行截肢，在大多数结局上的差异较小。最显著的差异是 SMFA 活动能力评分提高了 7 分（95%置信区间 [CI] = 2.0 至 10.7）。对于 Pilon/踝关节骨折和复杂损伤模式，改善最为明显。
对于最复杂的下肢终末期损伤，截肢应被视为一种治疗选择，而不是最后的手段。
治疗性 II 级。有关证据等级的完整描述，请参见作者说明。
