A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated with Flap-Based Limb Salvage

Objectives:To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma.Design:Retrospective review.Setting:Level II trauma center.Patients:307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014.Intervention:We reviewed patient medical records, radiographs, and clinical photographs.Main Outcome Measurements:Early and late amputation rates, time to amputation, reason for amputation.Results:307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion.Conclusions:This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.