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Extremitätenerhalt und Amputation nach Trauma

Entscheidungskriterien und Managementmodule

Limb salvage and amputation after trauma

Decision criteria and management algorithm

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Zusammenfassung

Die klinische Entscheidungsfindung bei Patienten mit ausgedehnten Extremitätenverletzungen für eine primäre Amputation oder den Beginn aufwendiger rekonstruktiver Maßnahmen im besten Interesse des Patienten kann sehr komplex und schwierig sein. Zahlreiche Einflussfaktoren auf die Therapieentscheidung (lokale anatomische und pathomechanische, physiologische, psychosoziale und allgemeine Faktoren) werden dargestellt und diskutiert. Die Bedeutung von Scores zur Entscheidungsfindung Gliedmaßenerhalt vs. Amputation ist in der Vergangenheit stark überbewertet worden. In der LEAP-Studie konnte klar gezeigt werden, dass keiner der z. T. sehr komplexen Scores dieser Aufgabe gerecht werden kann. Es wird dargelegt, dass die Initiatoren von Scores durchweg bessere Werte für Sensitivität und Spezifität von Scores erreichen, als dies unter den standardisierten und kontrollierten Bedingungen der LEAP-Studie gelang.

Lange Zeit galt die aufgehobene Fußsensibilität als sicheres und verlässliches Kriterium zur Amputation, hier hat die LEAP-Studie erheblich zur Entmythologisierung als Leitsymptom beigetragen. Patienten mit schwerem Trauma im Bereich von Sprunggelenk und Fuß, die einen freien Lappen oder eine OSG-Arthrodese benötigten, haben 2 Jahre nach einem Unfall ein statistisch signifikant schlechteres Ergebnis als Patienten mit Unterschenkelamputation. Unter Berücksichtigung aller dieser Einflussfaktoren wird zur Erleichterung der Therapieentscheidung ein umfassender und differenzierter Algorithmus zum Gliedmaßenerhalt vs. Amputation angegeben, der 4 Module umfasst: 1) Entscheidungsfindung, 2) Notfallbehandlung, 3) Definitive Behandlung und 4) Feintuning. In das Modul Entscheidungsfindung werden nicht nur die lokale und allgemeine Verletzungsschwere, sondern erstmals auch das zu erwartende Resultat, der Allgemeinzustand, Begleiterkrankungen, die Compliance und der Patientenwille mit einbezogen.

Abstract

The clinical decision-making process for patients with severe trauma of the extremities for primary amputation or to initiate extensive reconstructive measures for limb salvage in the best interests of the patient can be complex and difficult. The many factors influencing the decision-making process, such as local anatomical, pathomechanical, physiological, psychosocial and general factors are demonstrated and discussed. In the past, the role of scores supporting the decision-making process for amputation or limb salvage has been overestimated. In the LEAP study it could clearly be demonstrated that none of the sometimes highly complex scores could fulfill the expectations to predict successful limb salvage or the need for amputation. In this article it is shown that initiators and authors of scores achieved much higher sensitivity and specificity in the inaugural studies compared to the standardized and controlled conditions used in the LEAP study. For a long time, a lack of feeling in the feet was considered a safe and reliable criterion for amputation but the LEAP study has made a substantial contribution to demythologizing this as a lead symptom. Patients with severe trauma of the ankle or foot requiring a free flap or ankle arthrodesis have a significantly worse outcome compared to patients with a below knee amputation. Taking all these influencing factors into consideration, a comprehensive algorithm is presented that facilitates, strengthens and standardizes decision-making for amputation or limb salvage. This algorithm consists of four modules: 1) decision-making, 2) emergency treatment, 3) definitive treatment and 4) fine tuning. In the decision-making module not only local and general injury severity are addressed but the expected result, the general condition, comorbidities, compliance and the will of the patient are also included.

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Authors and Affiliations

  1. Unfallchirurgische Klinik, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    C. Krettek FRACS, FRCSEd &  C. W. Müller

  2. Department of Orthopedic Surgery, Ziv Medical Center, Rambam st. Zefat, 13100, Zefat, Israel

    A. Lerner MD PhD

  3. Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK

    P. Giannoudis MD

  4. Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland

    C. Willy

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  1. C. Krettek FRACS, FRCSEd
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  2. A. Lerner MD PhD
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  3. P. Giannoudis MD
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  4. C. Willy
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Correspondence to C. Krettek FRACS, FRCSEd.

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C. Krettek, A. Lerner, P. Giannoudis, C. Willy und C.W. Müller geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Krettek, C., Lerner, A., Giannoudis, P. et al. Extremitätenerhalt und Amputation nach Trauma. Unfallchirurg 119, 358–373 (2016). https://doi.org/10.1007/s00113-016-0181-5

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