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Comparative Study
. 2024 May 1;106(9):776-781.
doi: 10.2106/JBJS.23.00878. Epub 2024 Mar 21.

Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study

Brianna R Fram  1 , Michael J Bosse  1 , Susan M Odum  1 , Lisa Reider  2 , Joshua L Gary  3 , Wade T Gordon  4 , David Teague  5 , Dana Alkhoury  2 , Ellen J MacKenzie  2 , Rachel B Seymour  1 , Madhav A Karunakar  1 ; The Major Extremity Trauma Research Consortium
Collaborators, Affiliations
Comparative Study

Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study

Brianna R Fram et al. J Bone Joint Surg Am. .

Abstract

Background: The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications.

Methods: The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing.

Results: There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury.

Conclusions: Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: No external funding was received for this secondary analysis. The original OUTLET study was funded by the United States Department of Defense Congressionally Directed Medical Research Program (award # W81XWH-10-2-0090). The original sponsor had no role in the design or conduct of the trial; the collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript for submission. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H951 ).

References

    1. Major Extremity Trauma Research Consortium (METRC). Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am. 2021 Sep 1;103(17):1588-97.
    1. Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, Keeling JJ, Pasquina PF, Wain HJ, Carlini AR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013 Jan 16;95(2):138-45.
    1. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002 Dec 12;347(24):1924-31.
    1. MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR, Castillo RC. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005 Aug;87(8):1801-9.
    1. Ellington JK, Bosse MJ, Castillo RC, MacKenzie EJ; LEAP Study Group. The mangled foot and ankle: results from a 2-year prospective study. J Orthop Trauma. 2013 Jan;27(1):43-8.

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