When a severely injured or devascularized lower limb to be amputated and when should salvage be attempted ? Also, if the initial attempt in salvaging the limb is successful, what is the appropriate strategy for reconstruction? These are the most difficult questions faced by the orthopaedic traumatologists. With few exceptions, the decision is never clear-cut and it is extremely difficult in the immediate postinjury period to select who would be better off with an amputation.1,2
High energy injuries from motor vehicle crashes and industrial accidents may cause severe comminution of bone, a crushing insult on soft tissue and complete devascularization of either the distal part of the leg or of an extended segment of bone and soft tissues. In all high grade open fractures including blunt type IIIC injuries (requiring vascular repair) and some type IIIB injuries with very extensive crushing zone and involvement of all muscular compartments and nerve damage, primary amputation should be considered. Although the osseous damage is obvious on x-rays, the degree of soft tissue involvement may be assessed only indirectly.
Recent advances in trauma management and support, vascular reconstruction, nerve grafting and vascularized tissue transfer have dramatically extended the surgeon's ability to salvage a severely injured limb.3,4 However, not all injured extremities can benefit from these modern reconstructive techniques and there is still an ongoing debate regarding the criteria that predict successful salvage of severely injured extremities. The number of cases selected for limb salvaging varies from 25 up to 40% in some more recent series. In contrary several orthopedic surgeons, considering amputation as failure of their therapeutic intervention, not infrequently have attempted to preserve a functionless limb in a costly, highly morbid and sometimes lethal reconstructive process.
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