Limb Salvage vs. Amputation: Factors Influencing the Decision-Making Process and Outcomes for Mangled Extremity Injuries

In the setting of acute severe limb injury, the clinical decision to either attempt limb salvage or to perform a primary amputation presents a significant challenge to the trauma team. The initial step in the management of a mangled limb is invariably resuscitation and stabilisation of the patient and an evaluation of the limb. However, the decision-making process on whether to amputate vs attempt limb salvage is dependent on a range of complex factors. This includes assessing the degree of injury to the components of the limb architecture, essential skeletal stability, soft tissues, vasculature, and neurological structures. Whether or not the patient would survive an attempt to limb salvage is of course not the only variable to be taken into account. The likely and expected outcomes of attempted salvage in each individual case must be considered and furthermore, what the acceptable side-effect profile including the risk of failure would be for each individual patient should be assessed against the importance, real or perceived, that limb function is maintained. Finally, the patient's choice should also be taken into account alongside their occupation and pre-morbid functional status. How the surgeon makes this life-changing, or life-threatening decision, is of great clinical significance, and there are myriad scoring systems published that purport to assist in this matter. However, the changing structures of the trauma system, expansion and advancement of skillsets and technology means an updated review is required to help weigh up the challenging decision of limb amputation vs salvage, which usually takes place in a time-pressured and highly emotional emergency setting. An evidence-based, standardised structure to assist in these calculations could support surgeons and improve outcomes for these patients.