We initially believed that amputation contributed to early recovery of social life of patients with severe lower limb injuries. However, the obtained data on patient-reported outcomes at 1 year after injury, as investigated in this study, suggested that limb salvage provided better outcomes in terms of limb function and mental health. Additionally, while limb salvage required a higher number of operations, it did not affect the prevalence of surgical site infections and patient employment status. Furthermore, as shown in the LEFS score distribution in Fig. 2, we found that the LEFS score in the amputation group did not exceed 62. This finding implied that some functional restriction remained in the amputation group even in cases showing good progress (Fig. 2).
In our study, we noted cases of co-manifestation of injuries in other body parts owing to the severity of the primary injury. There were also patients who had existing pre-injury functional impairment caused by aging, which affected the evaluation. Therefore, we conducted an additional analysis using the same method, but for a limited number of patients, after excluding patients with contralateral leg injuries, pelvic ring or acetabular fractures, and a pre-injury LEFS score of < 77 (Fig. 3). We established an LEFS score of < 77 as the standard for pre-injury functional impairment because the median LEFS score in a study of healthy subjects was 77 . Even after limiting the analysis to fewer patients and taking into account patient background, no differences were observed in the functional aspects of patient-reported outcomes at 1 year after injury, although the mental aspects of outcomes were better in the salvage group. However, considering the distribution of LEFS scores, while the amputation group did not perform well, some patients in the salvage group had poorer outcomes than all patients in the amputation group. In other words, not all patients in the salvage group had better outcomes than those in the amputation group (Fig. 4). In the case of unsuccessful limb salvage surgery, the salvage group had worse functional and mental outcomes than the amputation group . Variations in the outcomes of the salvage group cannot be overlooked.
Several reports [1–3, 7, 8] have suggested that amputation is a better approach for treating severe lower limb injuries than salvage. This claim is based on various perspectives of rebuttals against treatments that aim for limb salvage, such as advances in prosthetic limb technology, perioperative complications, duration of rehabilitation, number of operations, rate of operation site infections, and financial problems. Limb amputation is often the intervention of choice based on these reports. A study reported that limb salvage is accompanied by long rehabilitation, higher total cost, and an increased likelihood of a larger number of additional operations and re-admissions to the hospital . Another study claimed that infection, reoperation, and hospitalization rates were significantly lower in the amputation group and that amputation provided better outcomes in terms of functioning and quality of life in patients with severe leg injuries . New prosthetic limb technology allowed amputees to participate in activities and exercise and perform recreational activities that were previously impossible .
Some circumstances, such as those related to the patients’ general condition and social background, necessitate amputation. However, according to several reports, limb salvage is more desirable than amputation in terms of psychological and long-term functional prognoses. By contrast, other reports have suggested that the time required by patients to return to work and hospitalization period are similar between the two interventions [1–3, 9–11]. A meta-analysis showed that limb salvage and amputation are functionally equivalent, but limb salvage is the more psychologically acceptable approach ; this is consistent with another study that claimed amputation is more difficult to accept psychologically than salvage . Most patients with salvaged limbs face problems in their daily lives owing to a limited range of motion, but none want amputation as an intervention . A previous study showed no significant difference in the functional outcomes between the limb salvage and amputation groups for at least 7 years .
At present, it is becoming possible not only to preserve the injured limb but also to reconstruct it for better functional outcomes [2, 12–16]. A study showed the increased possibility of limb salvage, even in patients with popliteal artery injuries , whereas another study reported that limb salvage is valuable even in patients with posterior tibial nerve injury . Given these circumstances, the present study focused on early recovery based on the patients’ perspectives.
One limitation of this study is the lack of randomization. According to the OTA-OFC summative score, patients who underwent limb amputation had more severe injuries. As amputation is ultimately chosen for mangled injuries, it is unavoidable for prospective studies. We believe that randomized studies involving a larger number of patients are required, either by excluding patients with high OTA-OFC summative scores or by taking OTA-OFC summative scores into account. Furthermore, to improve the postoperative outcome of severe leg injuries, it is essential to properly implement a comprehensive rehabilitation program that includes not only the physical aspects but also the psychological and social aspects . At our facility, we believe that each patient was provided the opportunity to undergo rehabilitation with appropriate duration and quality, regardless of whether the intervention chosen was limb salvage or amputation.
With the advancement of reconstruction technology, it has become possible to salvage the affected limb. Therefore, it is crucial to understand the concept of “how the patient feels.” We believe that the results of this study, which is based on patient-reported outcomes, are meaningful. For severe lower leg injuries, it is desirable to acquire knowledge and skills in revascularization, microvascular surgery, and flap surgery and consider salvaging the affected limb. However, the results of our additional analysis on a limited number of patients revealed that some patients with limb salvage had lower functional ability than patients with amputation and that limb salvage conducted without ascertaining the condition completely may result in worse outcomes than amputation.