Limb salvage versus primary amputation in Gustilo-Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis.

Abstract

The last systematic review on this topic was published in 2008. With advances in surgical techniques, patients with mangled extremities may now be potentially salvageable with comparable outcomes. This review aims to evaluate the outcomes of limb salvage compared to primary amputation in patients with severe open tibial fractures. A comprehensive search on PubMed, MEDLINE, Embase, Web of Science, Scopus, CENTRAL and CINAHL was performed from inception to 19 January 2022. The primary outcome was to evaluate clinical and functional outcomes. Secondary outcomes were to evaluate pain, patient preference, quality of life, and patient preferences. Methodological quality was evaluated using the MINORS criteria. Pooled estimates of relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) were used as a summary statistic for dichotomous variables and continuous variables, respectively. Sixteen studies with 645 patients met inclusion criteria. The methodological quality was moderate based on the MINORS score. The majority were male. Mean age was 36.3years. There was no significant differences in the length of hospitalization (n = 8), return to work rates (n = 9), return to sport rates (n = 4) and quality of life scores (n = 4). Patients with primary amputation had a significantly lower risk of total complications (RR 0.21, 95% CI 0.08-0.53, p = 0.001) (n = 10), infections (RR 0.46, 95% CI 0.25-0.85, p = 0.01) (n = 9), and number of surgeries (MD -4.17, 95% CI -6.49 to -1.85, p = 0.0004) (n = 6). Patients with primary amputation were able to ambulate significantly earlier (MD -4.06, 95% CI -7.65 to -0.46, p = 0.03) (n = 3). Three studies found a significantly higher cost of hospitalization in limb salvage patients. Functional outcomes were similar in both groups. While patients with primary amputation had better clinical outcomes in the short-term, functional outcomes were not significantly different in both groups. Despite the heterogenicity of the results in this review, surgeons need to contextualize the decision making for their patients and incorporate these findings. III. PROSPERO CRD42022303357.