CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 301, pp. 227-232
0 1994 J. B. Lippincott Company
The Function of Below-Knee Amputee Versus the
Patient With Salvaged Grade I11 Tibia1 Fracture
MARGARET
J. FAIRHURST,
F.R.C.S.(GLAS.),F.R.A.C.S.(ORTH.)
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This retrospective study compares the end-stage
function of the traumatic below-knee amputee with
that of the patient with salvaged Grade 111 tibial
fracture. Twenty-four patients, 12 below-knee am-
putees and 12 with salvaged tibiae, were inter-
viewed and examined one year or more after the
completion of treatment. Emphasis was on func-
tion of the limb, the patient, and the quality of life.
The early amputees had higher scores, fewer oper-
ations, and six-week hospitalization on average,
and returned to work and sport within six months.
Neither the amputees, nor the salvaged group,
functioned entirely normally. Most patients made
significant alterations to work and sporting activi-
ties, and approximately one third believed there
was deterioration in the quality of life. These re-
sults suggest that amputation should be strongly
considered when confronted with a borderline sal-
vageable tibial injury or prolonged salvage at-
tempts.
The management of severe compound
fractured tibiae continues to excite debate in
the orthopaedic literature. To date, emphasis
has been on increasingly sophisticated tech-
niques of salvage, with amputation regarded
as failure.2A5-8,I5-17,23,25,27
Recently the question of primary amputa-
tion or salvage has been examined in the or-
thopaedic literature and at the New Zealand
From Waikato Hospital, Hamilton, New Zealand.
Reprint requests to Margaret J. Fairhurst, 82 Fifth
Ave., Hamilton, New Zealand.
Received: February 3, 1993.
Revised: August 10, 1993.
Accepted August 10, 1993.
227
Orthopaedic Association and at the Ameri-
can Academy of Orthopaedic Surgeons meet-
ings.1,4,9,10,13,14,18,21,28 Scoring systems have
been developed in an attempt to predict
which tibiae are technically salvageable as
opposed to those best managed by amputa-
t i ~ n . ~These
. ’ ~ systems score tibial injuries on
the basis of local factors (skin, nerve, vascu-
lar, and bone injury) and overall patient fac-
tors (injury severity score, shock, age, preex-
isting disease, and lag time from injury to
treatment). Scores greater than 20 points
from the Mangled Extremity Score of Greg-
ory et aL8, or 7 points from the Mangled Ex-
tremity Severity Score of Helfet et al.,” result
in amputation. Treatment protocols for these
injuries are well established, emphasizingade-
quate debridement and lavage, appropriate
antibiotic therapy, rigid stabilization of frac-
tures, and early aggressivesoft-tissue manage-
ment, often employing plastic surgical tech-
niques.6, I6,19,23.24,26,27
The demands that salvage of severe tibial
fractures place on surgeons and patients are
well recognized. Prolonged periods during
which the patient is removed from work and
home are required. These socioeconomiccon-
siderations are often given less importance
than warranted, as it is these parameters that
will ultimately determine success or failure.
This study compares end-stage function of
the two groups. The return of function to the
limb and overall patient function is regarded

228 Fairhurst
as success. To date in the literature, there is
no information comparing end-stage func-
tion of either group. There is, however, a
strong feeling among many orthopaedic sur-
geons that the function of a patient with a
below-knee amputation and a well-fitting
modern prosthesis is far superior to that of
the salvaged Grade I11 tibial fracture with an
often wasted, painful leg and associated stiff
knee and ankle.
MATERIALS AND METHODS
The subjects were patients admitted to Waikato
Hospital, Hamilton, New Zealand, since January
1983 with Grade 111 compound tibial fractures.
They were mostly male road-trauma cases. The
mean age at injury was 25 years (range, 14-45
years).
The year 1983 was chosen as the starting point
for this study because the plastic surgeons began
doing free flaps on selected patients with these inju-
ries at this time. The patients were traced initially
from the theater operating register. Subsequently
hospital notes were searched, and patients then
contacted.
Of this group of 28 consecutive patients, 12 am-
putees and 12 patients with salvaged limbs were
interviewed and examined. Two patients did not
attend for review, one patient was overseas, and
one patient had committed suicide, accounting for
the four patients lost to follow-up examination
(Table 1).
The patients were interviewed using the ampu-
tee, salvage, and quality of life protocols. An over-
all score was determined of a maximum 66 points.
This score was a sum of scores calculated from a
limb score, a limb function score, and a quality of
life score.
The scoring system was developed with refer-
ence to established hip and quality of life scoring
systems in the literature.”~12~20 This system is
weighted toward function of the limb overall, as
TABLE 1.
Amputee Group Salvaged Group
I4 patients- 14 patients-
12 interviewed 12 interviewed
1 nonattender 1 nonattender
1 decreased I overseas
M:F = 13:l M:F = 12:2
Clinical Onhopaedics
and Related Research
perceived by the patients rather than objectively
by the surgeon. Mobility is measured indirectly
with reference to prosthetic use in the amputee
group and with reference to limb pain and per-
ceived deformity in the salvaged group. Addi-
tional scores for type ofgait, walking distance, and
sport participation add extra weight to overall
function of the limb.
RESULTS
The results are presented in Tables 1, 2,
and 3.The amputees have been grouped by
time to amputation into an early (less than
one month from injury) and a late (greater
than eleven months from injury) group. The
grading system of Gustilo et aL9 was used for
compound fractures. There was one Grade
IIIA fracture in each of the amputee and sal-
vaged groups, and there was one Grade IIIC
fracture in the amputee group. The re-
mainder were Grade IIIB fractures.
The time to amputation ranged from one
day to 16 years. Four amputees had their am-
putation less than a month after injury. This
was an informed decision made by the pa-
tient after discussion. Eight patients had late
amputations ranging from 1 1 months to 16
years after injury. All of these patients had
acquired stiff equinus ankles, which were
painful. In addition, five had recurrent osteo-
myelitis, and two of these were infected non-
unions. Two had dysesthetic soles that pro-
hibited weight bearing.
In eight of the patients ultimately requiring
amputation, salvage had been attempted. All
these patients had microvascular free flaps or
local flaps in an attempt to cover exposed
bone, bridge osseous defects, or both. Six of
these eight patients when questioned wished
they had had earlier amputations, and would
opt for earlier amputations if reinjured simi-
larly.
In the salvaged group, fracture union was
achieved at a median of ten months, with
seven patients having had free flaps. Hap do-
nor-site morbidity was minimal.
Return to work was accomplished by six
months in the early amputee group. Late am-
Number 301
April, 1994
TABLE 2. Scores
Early Amputea
(1 bilateral)
Score (points) (4 patients)
Total 6 1.5 (median)
(maximum, 66) (range, 48-66)
Limb 24 (median)
(maximum, 24) (range, 22-24)
Function 20.5 (median)
(maximum, 24) (range, 10-24)
Quality of Life 18 (median)
(maximum, 18) (range, 14- 18)
putees required 36 months to return to work
and salvaged tibiae patients 18 months.
Three patients had not returned to work, two
in the amputee group and one in the sal-
vaged tibiae group. Of the 2 I patients work-
ing, six returned to their original job and
the remainder modified their jobs or had re-
training.
Many of the patients returned to sporting
activities. Three amputees and four salvaged
tibiae patients competed at the same level of
sporting activity. One salvaged tibial patient
became a triathlete three years after injury.
Only one amputee could run, and he played
indoor basketball. The remaining patients in
both groups had modified their sporting activ-
ities, mostly to water sports.
Concomitant injuries to the ipsilateral
limb were similar in both groups. There were
three ipsilateral femoral fractures in each
group. There was one 0s calcis fracture in the
amputee group and one each of subtalar dis-
location, peroneal nerve palsy, and soft-tis-
sue thigh injury in the salvaged group. One
patient had a Grade IIIB tibial fracture that,
after one failed and one successful attempt at
free-flap coverage, went on to delayed ampu-
tation nine months after injury for an unun-
ited tibial fracture with a painful equinus
foot. He continually had problems with os-
teomyelitis in his stump and limb fitting. He
had spent eight months as an inpatient dur-
ing the three years from injury to death. He
Amputee vs. Tibia1 Fracture Function 229
Late Amputees Salvaged Tibiae
(8 patients) (12 patients)
53 (median) 47 (median)
(range, 39-59) (range, 3 1-64)
22.5 (median) 17.5 (median)
(range 18-24) (range, 1 1-23)
16.5 (median) 16.5 (median)
(range, 3-20) (range, 3-24)
13.5 (median) 12 (median)
(range, 6- 15) (range, 0- 18)
died three years after injury in a head-on mo-
torcycle accident.
TOTALSCORE
The raw total scores were higher in the
early and late amputee groups. However,
when examined statistically using x2 and me-
dian tests, these differences were not signifi-
cant (p < 0.05).
LIMBSCORE
Limb score was determined from an as-
sessment of pain, skin stability, prosthetic
use, or deformity. Statistical examination us-
ing the median test showed a significant dif-
ference between the amputees and salvaged
groups (p = 0.001). None of the amputees
had painful stumps, although most were
aware of their amputated limb at times. Skin
problems were minimal with the occasional
sebacious cyst that required attention, partic-
ularly over the hamstring tendons. All ampu-
tees had comfortably fitting prostheses.
Seven of the 12 salvaged tibiae patients had
mild to moderate pain at times. Four patients
had intermittent skin instability with break-
down, and five patients had a degree of dys-
esthesia in the sole of the foot, which was un-
bearable in two patients. Three patients were
more than 3 cm short in the injured limb,
and one had greater than 10" valgus mal-
union at the tibial fracture site. Four patients
 Clinical Orthopaedics
230 Fairhurst and Related Research

a,
a had clawed toes; six had stiffness of the ankle
in and subtalar joints precluding squatting.
5
2 SCORE
LIMBFUNCTION
d
N

d
This score was determined from an assess-
ment of gait, walking distance, and sport par-
ticipation. Amputees and salvaged tibia1
scores were similar and differences were not
statistically significant. The majority of the
patients in both groups had a minimally de-
in

5 tectable limp and had significantly modified

g or ceased their sporting activities.
0 2
QUALITY
OF LIFE SCORE

This was determined from the patient's

perception of his or her ability to work, abil-
ity to relate to people, and self-image before
and after injury.
Of the amputee patients, seven had modi-
fied their work, four deliberately retraining
themselves. Most of the patients believed that
their interpersonal relationships had not suf-
fered as a result of their injury, and eight of
the 12 patients had no problems with self-
image. If reinjured similarly, all the early am-
putees again would want an early amputation
and six of the delayed amputees would want
x- an early amputation.
Of the salvaged group only three could per-
form their jobs as before, one had not re-
turned to work, and the remainder had modi-
fied their work. Four of the 12 patients be-
lieved their interpersonal relationships had
been moderately to severely affected by their
injury. Six of the 12 patients believed that
-
n
L they suffered from a degree of poor self-
"J
image, as a result of their cosmetic appear-
ance, after injury.
Despite this, scores from the amputee and
salvaged groups were similar and not signifi-
cantly different. In retrospect, seven of the 12
patients, if reinjured similarly, would want
the same scenario and limb salvage. Two pa-
tients would want early amputation, the re-
maining three were indecisive. The patients'
decisions depended on whether they were
having trouble with the affected leg at the
Number 301
April, 1994
time of the evaluation. One patient had recur-
rent osteomyelitis flares, which occasionally
necessitated inpatient treatment. At times, he
considered amputation.
DISCUSSION
This retrospective study compares the end-
stage function of the traumatic below-knee
amputee (early amputees and late amputees),
with that of patients with salvaged Grade I11
compound tibial fractures.
Tables 2 and 3 demonstrate the differences
between the groups. As a group, the late am-
putees had a higher number of operations (six
more than the salvaged group on average)
and spent more time as an inpatient (five
months more than salvaged group). The re-
turn to work was on average 18 months later
than that of the salvaged group. The return to
sports activity was similar at two years. The
early amputee group, albeit small, demon-
strated a smaller number of total operations,
with six-weeks’ average hospitalization, and
return to work and sport within six months.
The early amputee group had higher scores
for limb, limb function, and quality of life, in
addition to the total score. The late ampu-
tees, compared with the salvaged tibiae
group, had a higher total score and limb
score. Function and quality of life scores were
similar.
These figures, despite being derived from a
small study group, would concur with the be-
liefs among many orthopaedic surgeons that
the function of a patient with a below-knee
amputation and a well-fitting modern pros-
thesis is superior to that of the salvaged Grade
111tibial fracture.
The decision to amputate is an emotional
one, both for the patient and for the surgeon
who has invested much in the preservation of
the limb. The aspirations of both are a nor-
mal limb, which is rarely achieved. Accurate,
objective criteria for the prediction of ampu-
tation in severe lower-limb trauma have been
developed in the Mangled Extremity Severity
Score of Helfet et a1.,15which should be used
prospectively.
Amputee vs. Tibia1 Fracture Function 231
If salvage attempts are making slow pro-
gress after severe lower-limbtrauma, the find-
ings of this study in combination with the lit-
erature examining the question of primary
amputation versus salvage, add significance
to primary amputation as a treatment option
in these circumstance^.',^^^,^^,^^,^^,^^^^^
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