The Mangled Foot and Ankle: Results From a 2-Year Prospective Study

Objective: To determine the outcome of the mangled foot and ankle undergoing limb salvage surgery that required free tissue flaps for wound closure compared with a similar patient foot and ankle injury group that underwent early below knee amputation (BKA). Design: Prospective longitudinal study. Setting: Eight level 1 trauma centers. Patients/Participants: LEAP (Lower Extremity Assessment Project) study. One hundred seventy-four open severely injured hindfoot or ankle injuries (116 had salvage; 58 had a BKA). Intervention: Patients either required immediate amputation or salvage was attempted. Main Outcome Measurements: The Sickness Impact Profile (SIP) was the principal measure of outcome (higher SIP scores equal greater disability). Secondary outcomes included walking speed, number of rehospitalizations for injury-related complications, time to full weight-bearing, the visual analog pain scale, and return to work at 2 years. Results: When compared to patients treated with standard BKA, salvage patients who required free flaps and/or ankle arthrodesis had significantly worse 2-year outcomes. They had overall SIP scores that were 2.5 points higher and psychosocial SIP scores that were 8.4 points higher at 24 months (P = 0.014 and P = 0.013, respectively). Physical SIP scores were 3.7 points higher in the free flap and/or arthrodesis group but only approached statistical significance (P = 0.10). After adjusting for the need for free flap and/or arthrodesis, the salvage pathway had clinically, but not statistically, significantly better overall and psychosocial SIP scores than the standard BKA patients (P = 0.34 and P = 0.20, respectively). Conclusions: Patients with severe foot and ankle injuries who require free tissue transfer or ankle fusion have SIP outcomes that are significantly worse than BKA with typical skin flap design closure.