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The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?

¹ Department of Orthopaedic Surgery, Carolinas Medical Center, Medical Education Building, Suite 503, P.O. Box 32861, Charlotte, NC 28232-2861. E-mail address for M.J. Bosse: mbosse{at}carolinas.org. E-mail address for S.H. Sims: ssims{at}carolinashealthcare.org
² Department of Emergency Medicine, Johns Hopkins University, Suite 6-100, 1830 East Monument Street, Baltimore, MD 21205. E-mail address: mmccarth{at}jhmi.edu
³ Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235. E-mail address: alan.jones{at}utsouthwestern.edu
⁴ Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address: lxwebb{at}wfubmc.edu
⁵ Florida Orthopaedic Institute, 4 Columbia Drive, #710, Tampa, FL 33606-3568. E-mail address: ots1{at}aol.com
⁶ Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205. E-mail address: emackenz{at}jhsph.edu

Investigation performed at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health, National Institute for Arthritis and Musculoskeletal and Skin Diseases (ROI-AR42659). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Methods: We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups.

Results: The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation.

Conclusions: Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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