Indications and Decision Making in Lower Extremity Amputations: Has Anything Changed in the Era of Microvascular Soft Tissue and Bone Regeneration Techniques?

Abstract

This review focuses on the decision making in lower extremity amputations with a special focus on the impact of microvascular techniques and bone regeneration options. In patients with severe extremity injuries, the decision to amputate critical and sustain a severe impact on the further quality of life. While inevitable in certain situations, more and more effort has been taken to try and salvage limbs, and algorithms were developed to facilitate the decision making process. The progresses in microsurgery as well as tissue engineering challenge the decision making processes and the algorithms towards limb salvage. Since the first replantation in 1962 and the development of microsurgery in the 1970s, countless body parts have been reattached leading to growing awareness in the medical community as well as the population about this possibility. The rates of major amputation declined in the years following the diffusion of distal bypass surgery. The downwards trend of the reconstructive ladder of treatment of soft tissue damages shows a better understanding of lower leg vascular anatomy and improved use of wound care technology. With deeper understanding of translational cellular biology, non-union treatment experienced a big step forward with the use of mesenchymal stem cells. With the RIA device, harvesting of autologous bone marrow became easier, and new treatment options of non-unions or osteomyelitis rose. This review highlights and compares scoring and algorithm systems that try supporting the decision process for amputation. It further discusses the current developments in treatments of non-unions and the role of microsurgery prior and during the amputation process.