Long-term outcomes after high-energy open tibial fractures: Is a salvaged limb superior to prosthesis in terms of physical function and quality of life?

  • C. Frisvoll
  • J. Clarke-Jenssen
  • J. E. Madsen
  • G. Flugsrud
  • F. Frihagen
  • G. S. Andreassen
  • T. BereEmail author
Original Article • LOWER LIMB - FRACTURES



The aim of this study was to describe complication rates and long-term functional outcomes among patients with amputated versus reconstructed limb after high-energy open tibial fractures.


Patients treated operatively for a high-energy open tibial fracture, classified as Gustilo–Anderson (GA) grade 3, at our hospital in the time period 2004–2013 were invited to a clinical and radiographic follow-up at minimum 2 years after injury. Eighty-two patients with 87 GA grade 3 fractures were included. There were 39 type GA 3A, 34 GA 3B, and 14 GA 3C.


The GA 3A reconstruction group had the lowest complication rate and the best long-term outcome scores at mean 5 years (range 2–8 years) after injury. Within the group of GA 3B and 3C fractures, we found no significant differences in long-term outcomes among patients with reconstructed versus amputated limbs. The mean physical component summary score of the SF-36 in the reconstruction versus amputation group was 54.2 (95% CI 46.3–62.1) versus 47.7 (95% CI 32.6–62.2), respectively (p = 0.524), while the mean mental component summary score was 63.7 (95% CI 50.6–71.8) versus 59.2 (95% CI 48.8–68.0), respectively (p = 0.603). On the 6-minute walk test, the reconstruction group walked on average 493 m (95% CI 447–535 m) versus 449 m (95% CI 384–518 m) in the amputation group. The return to work rate was 73% (16 of 22) in the reconstruction group versus 50% (7 of 14) in the amputation group (p = 0.166). The mean patient satisfaction score (VAS 0–100) was 67 (95% CI 67–77) in the reconstruction group versus 65 (95% CI 51–76) in the amputation group (p = 0.795). Regardless of the treatment strategy, the complication rate was high.


Amputation should be considered as a viable treatment option, equal to limb salvage, after high-energy open tibial fracture with severe vascular damage or soft tissue loss.


Lower leg trauma Bone fracture Soft tissue damage Surgery Functional outcome 



The authors would like to thank Anne Christin Brekke for assistance with coordinating and testing, and Olav Søvik Eken for constructive and valuable feedback on the final manuscript.

Author's contribution

CF, JCJ, JEM, GF, FF, GSA and TB contributed to study conception, design, and methodology. CF, JCJ and TB coordinated the study, performed the clinical assessments, and analyzed the data. CF and TB wrote the first draft of the paper, and all authors contributed to the final manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Gustilo BR, Mendoza MR, Williams ND (1984) Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma Inj Infect Crit Care 24(8):742–746CrossRefGoogle Scholar
  2. 2.
    Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM (2011) A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—the patient perspective. Injury 42(11):1194–1197CrossRefPubMedGoogle Scholar
  3. 3.
    Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M (2007) Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 21(1):70–76CrossRefPubMedGoogle Scholar
  4. 4.
    Higgins TF, Klatt JB, Beals TC (2010) Lower extremity assessment project (leap)—the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 41(2):233–239CrossRefPubMedGoogle Scholar
  5. 5.
    Saddawi-Konefka D, Kim HM, Chung KC (2008) A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 122(6):1796–1805CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF et al (2002) An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 347(24):1924–1931CrossRefPubMedGoogle Scholar
  7. 7.
    Bosse MJ, McCarthy ML, Jones AL, Webb LW, Sims SH, Sanders RW et al (2005) The insensate foot following severe lower extremity trauma: an indication for amputation? J Bone Jt Surg 87(12):2601–2608Google Scholar
  8. 8.
    Chung KC, Shauver MJ, Saddawi-Konefka D, Haase SC (2011) A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives. Ann Plast Surg 66(2):185–191CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR (1999) Salvage after severe lower-extremity trauma: are the outcomes worth the means? Plast Reconstr Surg 103(4):1212–1220CrossRefPubMedGoogle Scholar
  10. 10.
    Dahl B, Andersson AP, Andersen M, Andersen GR, Ebskov LB, Reumert T (1995) Functional and social long-term results after free tissue transfer to the lower extremity. Ann Plast Surg 34(4):372–375CrossRefPubMedGoogle Scholar
  11. 11.
    Doukas WC, Hayda RA, Frisch M, Andersen RC, Mazurek MT, Ficke JR et al (2013) The military extremity trauma amputation/limb salvage (metals) study. Outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Jt Surg 95(2):138–145CrossRefGoogle Scholar
  12. 12.
    Fairhurst M (1994) The function of below-knee amputee versus the patient with salvaged grade-III tibial fracture. Clin Orthop Relat Res 301:227–232Google Scholar
  13. 13.
    Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ (1992) Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 89(3):478–487CrossRefPubMedGoogle Scholar
  14. 14.
    Hertel R, Strebel N, Ganz R (1996) Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 10(4):223–229CrossRefPubMedGoogle Scholar
  15. 15.
    Hoogendoorn JM, van Der Werken C (2001) Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction. Injury 32(4):329–334CrossRefPubMedGoogle Scholar
  16. 16.
    Hutchins PM (1981) The outcome of severe tibial injury. Injury 13(3):216–219CrossRefPubMedGoogle Scholar
  17. 17.
    Lange HR, Bach AW, Hansen ST, Johansen KH (1985) Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma Inj Infect Crit Care 25(3):203–208CrossRefGoogle Scholar
  18. 18.
    MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF et al (2005) Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Jt Surg 87(8):1801–1809Google Scholar
  19. 19.
    Penn-Barwell JG, Myatt RW, Bennett PM, Sargeant ID (2015) Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation. Injury 46(2):288–291CrossRefPubMedGoogle Scholar
  20. 20.
    Puno RM, Grossfeld SL, Henry SL, Seligson D, Harkess J, Tsai TM (1996) Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia. Microsurgery 17(3):167–173CrossRefPubMedGoogle Scholar
  21. 21.
    Seekamp A, Regel G, Ruffert S, Ziegler M, Tscherne H (1998) Amputation or reconstruction of IIIB and IIIC open tibial fracture. Decision criteria in the acute phase and late functional outcome. Der Unfallchirurg 101(5):360–369CrossRefPubMedGoogle Scholar
  22. 22.
    Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL (1993) Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Jt Surg 75(10):1431–1441CrossRefGoogle Scholar
  23. 23.
    Giannoudis PV, Harwood PJ, Kontakis G, Allami M, Macdonald D, Kay SP et al (2009) Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 40(2):213–219CrossRefPubMedGoogle Scholar
  24. 24.
    Chung KC, Saddawi-Konefka D, Haase SC, Kaul G (2009) A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 124(6):1965–1973CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX et al (2007) Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Jt Surg 89(8):1685–1992CrossRefGoogle Scholar
  26. 26.
    Rüedi T (2000) AO principles of fracture management, 1st edn. Thieme, Stuttgart, p 864Google Scholar
  27. 27.
    Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AH (2016) The radiographic union scale in tibial (RUST) fractures: reliability of the outcome measure at an independent centre. Bone Jt Res 5(4):116–121CrossRefGoogle Scholar
  28. 28.
    Loge JH, Kaasa S, Hjermstad MJ, Kvien TK (1998) Translation and performance of the Norwegian SF-36 health survey in patients with rheumatoid arthritis. Data quality, scaling assumptions, reliability, and construct validity. J Clin Epidemiol 51(11):1069–1076CrossRefPubMedGoogle Scholar
  29. 29.
    Ware JE, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36): conceptual framework and item selection. Med Care 30(6):473–483CrossRefGoogle Scholar
  30. 30.
    Patel AA, Donegan D, Albert T (2007) The 36-item short form. J Am Acad Orthop Surg 15(2):126–134CrossRefPubMedGoogle Scholar
  31. 31.
    Brazier JE, Harper R, Jones NM, O’Cathain A, Thomas KJ, Usherwood T et al (1992) Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ 305(6846):160–164CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Enright PL (2003) The six-minute walk test. Respir Care 48(8):783–785PubMedGoogle Scholar
  33. 33.
    Medical Outcomes Trust (1994) SF-36 health survey: scoring manual for english language adaptation: Australia/New Zealand, Canada, United Kingdom. Medical Outcomes Trust, BostonGoogle Scholar
  34. 34.
    Bland JM, Altman DG (2015) Statistics notes: bootstrap resampling methods. BMJ 350:h2622CrossRefPubMedGoogle Scholar
  35. 35.
    Caudle RJ, Stern PJ (1987) Severe open fractures of the tibia. J Bone Jt Surg Am 69(6):801–807CrossRefGoogle Scholar
  36. 36.
    Mackenzie EJ, Bosse MJ, Kellam JF, Pollak AN, Webb LX, Swiontkowski MF et al (2006) Early predictors of long-term work disability after major limb trauma. J Trauma Inj Infect Crit Care 61(3):688–694CrossRefGoogle Scholar
  37. 37.
    Francel TJ (1994) Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction. Plast Reconstr Surg 93(5):1028–1034CrossRefPubMedGoogle Scholar
  38. 38.
    O’Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ (2008) Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Jt Surg 90(6):1206–1211CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  • C. Frisvoll
    • 1
    • 2
  • J. Clarke-Jenssen
    • 1
  • J. E. Madsen
    • 1
    • 2
  • G. Flugsrud
    • 1
  • F. Frihagen
    • 1
  • G. S. Andreassen
    • 1
  • T. Bere
    • 1
    Email author
  1. 1.Division of Orthopaedic SurgeryOslo University HospitalOsloNorway
  2. 2.Institute of Clinical MedicineUniversity of OsloOsloNorway

Personalised recommendations