Purpose: Open fractures of the tibia are common after high energy trauma. The question of whether to recommend amputation or limb salvage remains unanswered. Despite the abundance of literature on this topic, no formal systematic review comparing the two treatment options for open type IIIB and IIIC tibial fractures has been performed to critically compare outcomes. The purpose of this study is to conduct a systematic review to derive evidence-based recommendation concerning primary amputation versus limb salvage for IIIB and IIIC open fractures of the tibia.
Methods: We performed a formal systematic review of observational studies comparing outcomes of primary amputation and limb salvage in type IIIB and IIIC open tibial fractures. We searched MEDLINE, CINAHL and EMBASE, for articles that met our pre-determined inclusion and exclusion criteria. The outcomes of interest included: duration of hospital stay, clinical complications, total rehabilitation time, quality of life, limb function, pain, and time until return to work. Pooling of statistical data was performed when possible.
Results: We reviewed 1,947 articles, and twenty-six observational studies were included in our analysis. Length of hospital stay was similar for patients who underwent salvage (52 days: range 25-129) and those who underwent amputations (63 days: range 28-101). The most common complications after salvage attempts were nonunion (18%), osteomyelitis (16%), secondary amputation (9%) and flap failure (6%) based on our pooled analysis. These rates were regressed over year of publication to evaluate historical trends. The rate of secondary amputation decreased significantly over time (p=0.02). The rates of nonunion, osteomyelitis and flap failure all trended down over time but were not significant (p=0.09, p=0.21, p=0.87, respectively). Patients who underwent salvage took an average of 7.7 months to full-weight bearing (range 3.6-8.4 months) and an average of 11.0 months to union (range 7.9-12.3 months). Pain, quality of life and limb function outcomes differed between studies. Methods of assessment were varied across studies so outcomes could not be combined. Percent of patients who were able to return to work for patients who underwent salvage was 58% (range 19-100%) and for patients who underwent amputation was 73% (range 50-100%).
Conclusions: The current literature offers no evidence to support uniformly superior outcomes of either primary amputation or limb salvage for IIIB and IIIC tibial fractures. Given the current abundance of literature, it is unlikely that additional outcomes trials will support either of these two management options. The next phase of research should be an economic analysis that incorporates preference (utility) and cost in the analyses to determine the most optimal strategy based on these two factors.