Reoperation after combat-related major lower extremity amputations

Scott M Tintle, Scott B Shawen, Jonathan A Forsberg, Donald A Gajewski, John J Keeling, Romney C Andersen, Benjamin K Potter
Journal of Orthopaedic Trauma 2014, 28 (4): 232-7

OBJECTIVE: Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients.

DESIGN: Retrospective review of a consecutive series of patients.

SETTING: Tertiary Military Medical Center.

PATIENTS/PARTICIPANTS: Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009.

INTERVENTION: We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients.

MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status.

RESULTS: At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4).

CONCLUSIONS: In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

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