The mangled lower leg

Abstract

A surgeon faced with a patient presenting with an open tibial/fibular fracture in combination with severe damage of the surrounding soft tissues, has to make the difficult decision whether to attempt salvage or to perform an immediate amputation of the leg. Until late in the nineteenth century the mortality from open fractures was high - mainly due to sepsis after infection. Theodor Billroth, the famous surgeon, reported in 1881 that 46 of 93 patients with an open fracture of the lower leg whom he treated in Zurich, died. Gunshot wounds were particularly notorious and though generally treated with immediate amputation, most of these victims did not survive. It is recorded that in the American Civil War (1861-1865), the overall mortality rate after nearly 30.000 amputations was in the order of 30%, for above-knee amputations it reached 54%. In the Franco-Prussian War (1870-1871), the death rate from open fractures was 41%, while for open fractures of the knee this rate was even 77%. With the growing understanding of bacterial contamination and cross infection, the introduction of antisepsis and aseptic surgery, the advances in operative fracture stabilisation and, more recently, the various options for bone and soft-tissue reconstruction, the problems from open fractures have been greatly reduced. The emphasis came from life saving via limb salvage on restoration of limb function and preservation of quality of life. At the present time, the majority of open tibial fractures are caused by traffic accidents. In the Netherlands, approximately 5.000 patients annually are admitted to hospital with a lower leg fracture - both as an isolated injury and as part of polytrauma. It is estimated that open fractures account for 10% of this total. The improvements in treatment of mangled lower legs have opened the door to therapeutical options, previously unavailable to the surgeon. Nowadays, attempt at salvage is frequently chosen, because due to modern reconstructive techniques this is successful in the majority of cases. However, in some patients - for example due to persisting ischemia of the lower leg or to concomitant life-threatening injuries - it is obvious that immediate (primary) amputation is the option of choice. Unfortunately, in some of these cases nevertheless salvage is attempted - mainly due to a combination of wrong clinical judgement and optimistically thinking of the surgeon. Although these attempts seem successful eventually, after a long period of untreatable infections and other complications (secondary) amputation has to be performed as yet. These patients generally undergo more and more complex operations, and suffer more from complications than patients with a primary amputation. It is clear that it should be avoided that a patient will end up in such a situation. In this thesis, we tried to clarify several aspects of this difficult clinical problem by answering the following questions: 1. Is it possible to predict outcome in individual patients with a mangled lower leg? 2. What are the short-term consequences of the chosen treatment? 3. How is the long-term outcome of successful salvage and amputation? 4.What are the influences of smoking on the healing of open tibial fractures? 5. How are the results of treatment of infected segmental defect pseudarthrosis of the tibia