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Observational Study
. 2025 May 1;39(5):237-244.
doi: 10.1097/BOT.0000000000002959.

What is the Surgical Burden of Treatment for High-Energy Lower Extremity Trauma? A Secondary Analysis of the OUTLET Study

Christopher C Stewart  1 , Lisa Reider  2 , Rachel Soifer  2 , Nikan K Namiri  3 , Robert V O'Toole  4 , Madhav A Karunakar  5 , Benjamin K Potter  6 , Michael Bosse  5 , Saam Morshed  1 ; METRC
Collaborators, Affiliations
Observational Study

What is the Surgical Burden of Treatment for High-Energy Lower Extremity Trauma? A Secondary Analysis of the OUTLET Study

Christopher C Stewart et al. J Orthop Trauma. .

Abstract

Objectives: To describe and enumerate surgeries for patients who underwent reconstruction or amputation after severe distal tibial, ankle, and mid- to hindfoot injuries.

Design: Secondary analysis of a multicenter prospective observational study.

Setting: Thirty-one US level I trauma centers and 3 military treatment facilities.

Patient selection criteria: Participants aged 18 to 60 years with Gustilo type-III pilon fracture (Orthopaedic Trauma Association [OTA] 43B or 43C), IIIB or C ankle fracture (OTA 44A, 44B, or 44C), type-III talar or calcaneal fracture (OTA 81B, 82B, or 82C), or open or closed crush or blast injuries to the hindfoot or midfoot who underwent limb reconstruction or amputation from 2012 to 2017.

Outcome measurements and comparisons: The number of temporizing, definitive, and complication surgeries was compared by treatment and injury.

Results: Five hundred seventy-four participants with 221 ankle and pilon injuries, 140 talus and calcaneal injuries, and 213 other foot injuries were followed for 18 months. The mean age was 38 (range 8-64) years, and 33% were female. Participants underwent reconstruction (n = 472), primary amputation (n = 76), and failed reconstruction followed by amputation (n = 26). Eight hundred forty-one temporizing, 958 definitive, and 501 complication surgeries were performed. The number of surgeries was highest for those who underwent failed reconstruction [mean 5.8, 95% confidence interval (CI), 4.9-6.8, range 3-13] compared with reconstruction (mean 3.8, 95% CI, 3.5-4.0, range 1-21) and primary amputation (mean 4.9, 95% CI, 4.3-5.5, range 2-14) ( P < 0.01). Those with ankle and pilon injuries required more surgeries (4.7, 95% CI, 4.3-5.1, range 1-21) than those with hindfoot (3.4, 95% CI, 3.0-3.7, range 1-10) and other foot (3.7, 95% CI, 3.4-4.0, range 1-14) injuries ( P < 0.01). The average participant would complete definitive treatment 23 days after their injury, and those who required surgery for a complication spent 41 days in the complication phase of treatment.

Conclusions: Patients with high-energy lower extremity trauma underwent nearly 4 surgeries over 3 weeks until completion of definitive treatment, regardless of whether they underwent limb reconstruction or amputation. Those with ankle or pilon injuries and failed reconstruction attempts experienced the most operations, and those with complications required over an additional month of surgical care. These data may inform a shared decision-making process around limb optimization.

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

Keywords: amputation; limb reconstruction; limb salvage; operative burden; resource utilization.

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Conflict of interest statement

S. Morshed: Orthopaedic Trauma Association: Board or committee member; Philips: Paid consultant; SI-Bone, Inc: Paid consultant. R. V. O'Toole: Imagen: Paid consultant; Stock or stock Options, Lincotek (formerly Coorstek): IP royalties; Stryker: IP royalties; Paid consultant. M. A. Karunakar: Journal of Orthopaedic Trauma: Editorial or governing board; Orthopaedic Trauma Association: Board or committee member; Osteocentric: Stock or stock Options; Unpaid consultant; Synthes: Paid presenter or speaker. B. K. Potter: Biomet: Unpaid consultant; Clinical Orthopaedics and Related Research: Editorial or governing board; Journal of Orthopaedic Trauma: Editorial or governing board; Signature Orthopaedics: Paid consultant. The remaining authors report no conflict of interest.

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;103:1588–1597.
    1. American Academy of Orthopaedic Surgeons/Major Extremity Trauma and Rehabilitation Consortium. Evidence-Based Clinical Practice Guideline for Limb Salvage or Early Amputation ; 2019. Available at: https://www.aaos.org/lsacpg . Accessed March 2, 2022.
    1. Harrington CJ, Wade SM, Hoyt BW, et al. A longitudinal perspective on conversion to amputation for combat-related extremity injuries treated with flap-based limb salvage. J Orthop Trauma. 2023;37:361–365.
    1. Humbyrd CJ, Rieder TN. Ethics and limb salvage: presenting amputation as a treatment option in lower extremity trauma. J Bone Joint Surg Am. 2018;100:e128.
    1. Bosse MJ, Teague D, Reider L, et al. Outcomes after severe distal tibia, ankle, and/or foot trauma: comparison of limb salvage versus transtibial amputation (OUTLET). J Orthop Trauma. 2017;31(suppl 1):S48–s55.

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