What is the Surgical Burden of Treatment for High-Energy Lower Extremity Trauma? A Secondary Analysis of the OUTLET Study.

Abstract

Objectives: To describe and enumerate surgeries for patients who underwent reconstruction or amputation after severe distal tibial, ankle, and mid- to hindfoot injuries.

Methods:

Design: Secondary analysis of a multicenter prospective observational study.

Setting: Thirty-one US level I trauma centers and 3 military treatment facilities.

Patient selection criteria: 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.

Outcome measurements and comparisons: The number of temporizing, definitive, and complication surgeries was compared by treatment and injury.

Results: 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.

Conclusions: 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.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.