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Letters to the Editor to:

Scientific Articles:
Michael J. Bosse, Melissa L. McCarthy, Alan L. Jones, Lawrence X. Webb, Stephen H. Sims, Roy W. Sanders, Ellen J. MacKenzie, and the Lower Extremity Assessment Project (Leap) Study Group
The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?
J Bone Joint Surg Am 2005; 87: 2601-2608 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Insensate Foot As An Indication For Amputation In Severe Lower Extremity Trauma
S. Naidu Maripuri, Debnath UK , SpR, Trauma & Orthopaedics, Subramanian K, SpR ,Trauma & Orthopaedics   (7 June 2006)

Insensate Foot As An Indication For Amputation In Severe Lower Extremity Trauma 7 June 2006
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S. Naidu Maripuri,
Clinical Research Fellow
University Hospital of Wales, Cardiff, UK,
Debnath UK , SpR, Trauma & Orthopaedics, Subramanian K, SpR ,Trauma & Orthopaedics

Send letter to journal:
Re: Insensate Foot As An Indication For Amputation In Severe Lower Extremity Trauma

naidumsuk{at}yahoo.co.in S. Naidu Maripuri, et al.

EDITOR'S NOTE: The corresponding author has been invited to respond to this letter and to date, has not done so.

To the Editor:

We read with great interest the article by Bosse, et al,(1) and applaud their effort to establish that the insensate foot is not an indication for amputation in severe lower extremity injuries. We would like to add some additional comments and questions to the topic.

Why did the authors use the criteria of MESS(2) where the cold, paralysed, insensate and numb limb represents the highest degree of limb ischemia as opposed to the criteria for an insensate limb used in the NISSA rating system(3) which represents nerve injury?

It would be interesting to know the cause (nerve injury, vascular injury or both) of insensate foot in the salvage group who recovered sensation. How did the authors arrive at the conclusion that ‘sensory impairment at twenty four months appeared to be independent of treatment with either amputation or limb salvage’ when the table 1 represents the results of sensory loss in the amputated group as N/A?

We wonder how the decision was made to proceed with amputation in the insensate amputation group. Surely, the patient’s personal and social beliefs must be considered in the decision making for amputation along with the scoring systems(4).

References:

1. Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW. The Insensate Foot Following Severe Lower Extremity Trauma: An indication for amputation? J Bone Joint Surg [Am] 2005: 87(12); 2601-8.

2. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A evaluation of the mangled extremity severity score (MESS). J Orthop Trauma 1994: 8(2); 81-87.

3. Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990: 30(5); 568-72.

4. John V Z, Alagappan M, Devadoss S, Devadoss A. A completely shattered tibia. J Bone Joint Surg 2005: 87 (11); 1556-59.