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Orthopaedics
Mangled Extremity
Built from Orthopedic Trauma Essentials
What’s inside
5 sections · 85 slides
Overview
- Four questions this answers
- What we mean by a mangled extremity
- Why the decision cannot wait
- What has changed in twenty years
- What stays unpredictable
- What drives the decision
- Management strategy for a mangled extremity
Salvage or amputation?
What the trials and cohorts actually found
- The headline finding
- Two paths after a wrecked leg
- Where amputation came out ahead
- Where reconstruction came out ahead
- Why the return-to-work edge is shaky
- Going back to work is not just surgery
- A second meta-analysis, severe open tibia
- A severe tibial shaft fracture
- A displaced fracture of the leg bones
- OUTLET: mangled foot and ankle injuries
- OUTLET: what it found
- LEAP: the landmark prospective cohort
- 47.6%
- LEAP complications analysis
- The delayed cost of keeping the limb
- A circular external fixator holding the leg
- The same frame seen on X-ray
- Internal fixation of the tibia
- METALS: the military experience
- METALS: but nobody escaped unharmed
- The trade-off in one view
- Salvage or amputation: the take-home
- Salvage versus amputation, and what settles it
Do the scores decide it?
Injury severity scoring systems, tested against reality
- Why anyone invented a score
- The scores you will hear named
- MESS: the original
- LSI and PSI: what they count
- NISSSA and the Hannover scale
- How the Hannover scale performed
- Then the scores met a real cohort
- ≈ 0.45
- What those numbers mean at the bedside
- Scores also miss the thing patients care about
- The insensate foot is not a death sentence
- Modern registries say the same
- GHOISS: what it measures
- How well GHOISS performs
- So can a score make the call?
- Scores: the take-home
- Where injury severity scores actually fit
When salvage is failing
Timing of amputation after a failed attempt to save the limb
- What failed salvage looks like
- How a failing salvage unfolds
- What good timing is trying to achieve
- Secondary amputation is a known complication
- Failures declare themselves early
- 77%
- Delay in blunt polytrauma
- Why losing knee level matters
- Beyond the first days the picture blurs
- Early versus late in a modern cohort
- The reason for amputation changes with time
- Combat data point at infection
- What patients say afterwards
- Late does not mean hopeless
- Learning to walk again
- Timing: the take-home
- Early versus delayed conversion after failed salvage
New ways to amputate
Targeted muscle reinnervation and bone-anchored prostheses
- Amputation surgery has moved on
- The problem TMR was built to solve
- The randomised trial of TMR
- ≈ 2.0
- What that meant for painkillers
- Osseointegration: the idea
- What the pooled evidence shows
- What did not improve
- The catch with bone-anchored limbs
- Walking again on a prosthetic limb
- Two advances, two grades of evidence
- Advanced techniques: the take-home
- Five things to carry away
- How to run the decision in practice
- References
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- Orthopedic Trauma Essentials 2026