Stewart Christopher C, Reider Lisa, Soifer Rachel, Namiri Nikan K, O'Toole Robert V, Karunakar Madhav A, Potter Benjamin K, Bosse Michael, Morshed Saam
Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
J Orthop Trauma. 2025 May 1;39(5):237-244. doi: 10.1097/BOT.0000000000002959.
To describe and enumerate surgeries for patients who underwent reconstruction or amputation after severe distal tibial, ankle, and mid- to hindfoot injuries.
Secondary analysis of a multicenter prospective observational study.
Thirty-one US level I trauma centers and 3 military treatment facilities.
Participants aged 18 to 60 years with Gustilo type-III pilon fracture (Orthopaedic Trauma Association [OTA] 43B or 43C), IIIB or C ankle fracture (OTA 44A, 44B, or 44C), type-III talar or calcaneal fracture (OTA 81B, 82B, or 82C), or open or closed crush or blast injuries to the hindfoot or midfoot who underwent limb reconstruction or amputation from 2012 to 2017.
The number of temporizing, definitive, and complication surgeries was compared by treatment and injury.
Five hundred seventy-four participants with 221 ankle and pilon injuries, 140 talus and calcaneal injuries, and 213 other foot injuries were followed for 18 months. The mean age was 38 (range 8-64) years, and 33% were female. Participants underwent reconstruction (n = 472), primary amputation (n = 76), and failed reconstruction followed by amputation (n = 26). Eight hundred forty-one temporizing, 958 definitive, and 501 complication surgeries were performed. The number of surgeries was highest for those who underwent failed reconstruction [mean 5.8, 95% confidence interval (CI), 4.9-6.8, range 3-13] compared with reconstruction (mean 3.8, 95% CI, 3.5-4.0, range 1-21) and primary amputation (mean 4.9, 95% CI, 4.3-5.5, range 2-14) ( P < 0.01). Those with ankle and pilon injuries required more surgeries (4.7, 95% CI, 4.3-5.1, range 1-21) than those with hindfoot (3.4, 95% CI, 3.0-3.7, range 1-10) and other foot (3.7, 95% CI, 3.4-4.0, range 1-14) injuries ( P < 0.01). The average participant would complete definitive treatment 23 days after their injury, and those who required surgery for a complication spent 41 days in the complication phase of treatment.
Patients with high-energy lower extremity trauma underwent nearly 4 surgeries over 3 weeks until completion of definitive treatment, regardless of whether they underwent limb reconstruction or amputation. Those with ankle or pilon injuries and failed reconstruction attempts experienced the most operations, and those with complications required over an additional month of surgical care. These data may inform a shared decision-making process around limb optimization.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
描述并列举严重胫骨干远端、踝关节及中后足损伤后接受重建或截肢手术的患者的手术情况。
多中心前瞻性观察性研究的二次分析。
31家美国一级创伤中心和3家军事治疗机构。
年龄在18至60岁之间，患有Gustilo III型pilon骨折（骨科创伤协会[OTA]43B或43C）、IIIB或C型踝关节骨折（OTA 44A、44B或44C）、III型距骨或跟骨骨折（OTA 81B、82B或82C），或2012年至2017年期间因后足或中足开放性或闭合性挤压伤或爆炸伤而接受肢体重建或截肢的患者。
按治疗方式和损伤类型比较临时手术、确定性手术及并发症手术的数量。
574例参与者，其中221例踝关节和pilon损伤、140例距骨和跟骨损伤、213例其他足部损伤，随访18个月。平均年龄为38岁（范围8 - 64岁），3３%为女性。参与者接受了重建手术（n = 472）、一期截肢手术（n = 76）以及重建失败后行截肢手术（n = 26）。共进行了841例临时手术、958例确定性手术和501例并发症手术。与接受重建手术（平均3.8次，95%置信区间[CI]，3.5 - 4.0，范围1 - 21）和一期截肢手术（平均4.9次，95%CI，4.3 - 5.５，范围2 - 14）相比，重建失败的患者手术次数最多（平均5.8次，95%CI，4.9-6.8，范围3 - 13）（P < 0.01）。踝关节和pilon损伤的患者比后足损伤（平均3.4次，95%CI，3.0 - 3.7，范围1 - 10）和其他足部损伤（平均3.7次，95%CI，3.4 - 4.0，范围1 - 14）的患者需要更多手术（平均4.7次，95%CI，4.3 - 5.1，范围1 - 21）（P < 0.01）。平均而言，参与者在受伤后23天完成确定性治疗，而因并发症需要手术的患者在治疗并发症阶段花费41天。
无论接受肢体重建还是截肢，高能下肢创伤患者在完成确定性治疗前的3周内平均接受近4次手术。踝关节或pilon损伤且重建尝试失败的患者手术次数最多，而有并发症的患者需要额外一个多月的手术治疗。这些数据可为围绕肢体优化的共同决策过程提供参考。
治疗性二级证据。有关证据级别的完整描述，请参阅作者须知。
