Study Compares Outcomes of Amputation and Limb Salvage SurgeryFollowing Lower Extremity Trauma

According to a congressional research service report issued on Sept. 28,
2010, the total number of amputations performed due to Operation Iraqi Freedom,
Operation Enduring Freedom and unaffiliated conflicts was 1,621. The
Department of Defense, in an attempt to examine the functional
outcomes and disability of U.S. service members following severe lower
extremity trauma due to high-energy blasts, funded the Military Extremity
Limb Salvage Study (METALS). The goal of the study was to
examine and compare the experiences of service members who underwent amputation
versus those who opted for limb salvage surgery. The METALS study group
hypothesized that outcomes between those undergoing amputation and those
undergoing limb salvage would be similar.

For the study, major limb trauma was defined as having a traumatic
amputation or one or more of the following: revascularization, bone graft or
bone transport, local or free flap coverage, complete deficit of a major nerve,
or a complete compartment injury or syndrome. According to Col. (Ret.) William
Doukas, Walter Reed Army Medical Center, who spoke at the 2010 Orthopaedic
Trauma Association Annual Meeting in Baltimore, 37% of reported amputations
were transfemoral and 52% were transtibial.

The retrospective cohort study of 298 U.S. service members who sustained
a major lower limb injury while serving in Iraq or Afghanistan revealed that
major lower limb trauma sustained in the military results in significant
long-term disability.

In fact, one-fifth reported pain that interfered with their daily
activities and 35% were not working, on active duty or currently enrolled in
school, according to the study.

The short musculoskeletal functional assessment (SMFA) was used to
measure overall function. Symptoms of depression, post-traumatic stress and
chronic pain were also studied. Although there were no significant differences
when comparing depressive symptoms, post-traumatic stress or pain interference,
those who underwent at least one major amputation had better SMFA scores than
those who opted for limb salvage.

“In comparing SMFA function scores, unilateral amputees did
significantly better than unilateral limb salvage patients,” Doukas said
in his presentation. “Patients with at least one amputation did better
than patients with both legs salvaged.”

After adjusting for covariates, patients with at least one major
amputation had better SMFA scores compared to limb salvage patients in all the
areas tested, which included mobility, hand/arm function, activities and
emotional status, according to Doukas.

“When the patients were asked if they were involved in sports and
activities such as basketball and hiking, those who had undergone amputation
were much more likely to be involved in sports and activities than those who
had undergone limb salvage,” Doukas said.

The researchers concluded that as a group, service members undergoing
amputation appear to have better functional outcomes than those treated with
limb salvage. Further study is needed to determine if the differences are
related to rehabilitation, ancillary services or other external factors. —
by Anthony Calabro

For more information:

  • Congressional Research Service. U.S. Military Casualty Statistics:
    Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom.
    Available at: Accessed: Dec.
    6, 2010.
  • Doukas W, Hayda R, Frisch HM, et al. The Military extremity trauma
    association limb salvage (METALS) study: Comparing outcomes for amputation
    versus limb salvage following major lower extremity trauma. Paper #72.
    Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association.
    Oct. 13-16, 2010. Baltimore.


I think the big surprise of the study is that when we looked at
functional outcomes, the amputees seemed to perform better than the limb
salvage patients. One would think the results would be similar or even the
other way around. We have done work in the past with the civilian sector that
showed the outcomes between amputation and limb salvage were similar.
Unfortunately, this study was limited and we really were not able to answer
that important question — why? We have to do to more work to find out the
reasons for these differences.

It is important not to take away the message that
amputation is better than limb salvage. There are a lot of factors going on
here and we really have to find out why we are seeing this difference. I think
that is an important message.

— Ellen MacKenzie, PhD
Chair, Fred and
Julie Soper professor in health policy and management, Johns Hopkins Bloomberg
School of Public Health

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