Infectious Complications and Soft Tissue Injury Contribute to Late Amputation After Severe Lower Extremity Trauma

Background: Although most combat-related amputations occur early for unsalvageable injuries, > 15% occur late after reconstructive attempts. Predicting which patients will abandon limb salvage in favor of definitive amputation has not been explored. The purpose of this study was to identify factors contributing to late amputation for type III open tibia fractures sustained in combat. Methods: Operative databases were reviewed to identify all combat-related type III open diaphyseal tibia fractures from March 2003 to September 2007. Patients were categorized based on their definitive treatment: group I, limb salvage; group II, early amputation (< 12 weeks postinjury); group III, late amputation (> 12 weeks postinjury). Injury, treatment, and complication data were extracted from medical records and compared across groups. Results: We identified 213 consecutive fractures, including 166 (77.9%) treated definitively with limb salvage, 36 (16.9%) with early amputation, and 11 (5.2%) with late amputation. There was no difference in fracture severity among the three groups. Before amputation, group III was more likely to use autograft and bone morphogenic protein (27.3%), compared with group I (4.8%) and group II (0%), and was more likely to undergo rotational flap coverage (45.5%), compared with group II (0%). Group III patients had the highest average number of revision surgeries and rate of deep soft tissue infection and were more likely to have osteomyelitis (54.5%) before amputation compared with group I (13.9%) and group II (16.7%). Conclusion: Patients definitively managed with late amputation were more likely to have soft tissue injury requiring flap coverage and have their limb salvage course complicated by infection.