TREATMENT OF HIGH ENERGY LIMB THREATENING LOWER EXTREMITY TRAUMA: AN ETHICAL ARGUMENT FOR AMPUTATION

High-energy lower extremity trauma is a limb and sometimes life-threatening injury. These injuries permanently and irrevocably change a patient’s body and life. They can be treated with immediate amputation, reconstruction or delayed amputation after failure of reconstruction. In this paper, I explore the evidence concerning the treatment of mangled extremities, and I identify gaps in the evidence. Based on what is currently known, I argue that physicians not only have an obligation to reframe amputation as a treatment choice rather than a procedure for when all else fails, but also that they have an obligation to promote amputation as the preferred treatment option for these injuries, due to the significant harms and limited benefit of limb reconstruction

Ethical challenges in vascularized composite allotransplantation of the lower extremity: lessons learned from hand transplantation and implications for the future

Vascularized composite allotransplantation (VCA) is a novel surgical practice that involves the transplantation of multiple tissue types as a functional unit without the primary purpose of extending life. While VCA of the upper extremity is becoming increasingly accepted and performed, VCA of the lower extremity remains largely unexplored despite its acknowledged potential value. There are inherent ethical concerns surrounding VCA that are dominated by a conflict between the principles of beneficence and maleficence. The primary question is whether the quality-of-life benefits to the patient outweigh the risks associated with long-term immunosuppression for a non-lifesaving procedure. In addition, the ethical conversation involves concerns regarding informed consent, donor autonomy, patient privacy and public disclosure, patient selection, and unique considerations in the pediatric patient. Lower extremity VCA has additional ethical issues compared to upper extremity VCA, as current lower limb prostheses provide excellent, near baseline function that upper limb constructs have not yet been able to achieve. In this review, we discuss the ethical challenges of lower extremity VCA using available evidence for the upper extremity. We also compare ethical considerations of VCA of the extremity with other surgical alternatives to limb loss - namely, limb salvage and replantation - and address how the conversation may be altered with further advancements in immunosuppression and prosthetic technology

Near-Complete Traumatic Amputation of the Forefoot After Motorboat Propeller Injury

We report a case of a near-complete amputation of the forefoot of a 20-year-old man as a result of a motorboat propeller injury sustained in a saltwater river. He was treated with open reduction, percutaneous pinning, extensor tendon repair, and an extended course of antibiotic prophylaxis. We review the literature regarding motorboat propeller injuries to the foot and ankle

Incidence, Risk Factors, and Treatment of Achilles Tendon Rupture in Patients with End-Stage Renal Disease

Category: Trauma Introduction/Purpose: Patients who are dialysis-dependent and those who have received kidney transplants may be at increased risk for Achilles tendon rupture (ATR) as a result of compromised kidney function. Our goal was to examine the incidence, risk factors, and type of ATR treatment in patients with end-stage renal disease (ESRD). Methods: We studied all Medicare patients with ESRD from 1999 through 2013, as captured by the Centers for Medicare & Medicaid Services and the United States Renal Data System. Patients were categorized as not waitlisted for a transplant, waitlisted but not yet transplanted, or received a transplant. Patients were migrated to the corresponding groups at the time when they were waitlisted or received a transplant. We performed multivariate negative binomial regression using age, race, sex, body mass index, cause of ESRD, comorbidities, and year of study entry as covariables to estimate the adjusted incidence rate ratios (aIRR) for all groups and to identify risk factors for ATR. We performed a subgroup analysis using the above methods for participants with Medicare Part D to characterize the association of fluoroquinolones and steroids with ATR. Results: We identified 1091 ATRs (incidence, 3.80 per 10,000 person-years; 95% confidence interval [CI], 3.58–4.03). Patients who sustained an ATR were significantly younger, had higher mean body mass index, and had fewer comorbidities than patients without ATR. Compared with the incidence of ATR among transplant recipients, the incidence of ATR was lower in the non-waitlisted group (aIRR, 0.44; 95% CI, 0.37–0.53) and similar in the waitlisted group (aIRR, 0.94; 95% CI, 0.78–1.12). Patients who used fluoroquinolones and steroids had a higher incidence of ATR (aIRR 1.65; 95% CI, 1.32 -1.84 and aIRR 1.72, 95% CI, 1.44-2.05 respectively). A small proportion of patients (n = 184; 17%) received surgical treatment within 14 days of diagnosis of ATR, and the 30-day cumulative incidence of surgical site infections was 6.5%. Conclusion: The incidence of ATR was higher in the transplanted and waitlisted groups compared with the non-waitlisted group. Younger age, higher body mass index, better health, fluoroquinolone use and steroid use were significant risk factors for ATR. Patients were more likely to receive nonoperative than surgical treatment for ATR. Those who underwent surgical treatment for ATR had a low incidence of surgical site infection