Unsatisfactory outcome after lower limb salvage: decision-making pitfalls

We examined unsatisfactory outcome after microvascular reconstruction of 34 injured lower extremities at the Toronto Hospital between 1987 and 1992. Our purpose was to examine those factors that contributed to poor outcome in order to improve decislon making when treating the traumatized lower extremity. For the purpose of this review, poor outcome was defined by either secondary elective amputation or patient dissatisfaction. Patients were divided according to preoperative problem into one of three groups: osteo/cutaneous deficit (group 1), septic nonunion (group 2), and osteomyelitis (group 3). Despite successful microvascular reconstruction in each case, unsatisfactory outcome occurred in six (18%) patients. Four had undergone secondary elective amputation, and two were dissatisfied because of residual pain from another musculoskeletal source. Close examination of the factors that contributed to poor outcome in each of these cases has allowed identification of potential pitfalls that may compromise final outcome after limb salvage. On the basis of our observations and an up-to-date review of the relevant literature, we provide basic guidelines as to when and when not to attempt limb salvage.