An Argument for Salvage in Severe Lower Extremity Trauma with Posterior Tibial Nerve Injury

Abstract

BACKGROUND Absence of plantar sensation is a critical factor considered in favor of amputation for patients with lower limb-threatening injuries. This study aims to assess outcomes of limb salvage in a group of patients with severe lower extremity injuries associated with posterior tibial nerve transection. METHODS We studied eight cases of limb salvage after traumatic injuries with documented tibial nerve laceration managed at Ganga Hospital, India. Functional and health-related quality of life outcomes were assessed. Outcomes from this case series were compared to outcomes of studies from a systematic literature review on salvage of the severely injured lower extremity. RESULTS Patients in this case series reported mild pain (median score 20 on a 100 scale visual analog scale) with some return of plantar sensation in patients with tibial nerve repairs (median score 2/5). Patients demonstrated a decrease in ankle motion (27.5 degrees plantar flexion, 10 degrees extension) and muscle strength (median heel flexor score 3/5). All patients could ambulate independently. Quality of life and function measured by validated instruments revealed minimal disability. We identified 1,767 articles on lower extremity trauma and 14 articles were systematically reviewed. Relative to the case series, published articles reported similarly diminished ankle motion and muscle strength, with reports of mild pain in select studies. Patient reported outcome instruments found variations in the degree of physical disability based on time from the injury. CONCLUSIONS Though limited in number, this case series demonstrates the value of limb salvage even for patients with posterior tibial nerve injury.

Amputations versus Salvage: Reconciling the Differences

“…1 summarizes injury characteristics that surgeons must assess and consider in making their decision to reconstruct. [12][13][14][15][16][17][18][19][20] In lower extremity trauma reconstruction, the surgeon must consider all options on the reconstructive ladder, or more recently elevator, to provide the patient with optimum function. 13,21 However, the lower rungs of the ladder, such as primary closure or skin grafting, are often inadequate in the setting of lower extremity trauma due to vast tissue deficits and Fig.…”

“…Replantation is rarely pursued, except if the surgeon is well-versed. [12][13][14][15][16][17][18][19][20] vascular compromise that preclude available local soft tissue. 13,22,23 Therefore, we will be focusing on free tissue transfer (FTT) for the purposes of this review.…”

Reconstruction of Sole of Foot: A Retrospective Study of 26 Consecutive Cases

“…Similar findings were noted by authors of larger studies. 6 it is also notable that, the sensation in the plantar foot as a deciding factor for attempts at limb salvage are being questioned by well-performed studies and newer limb salvage indices 7. This is probably due to improvement in allied technologies like orthotics and podiatry.…”

Progressive trends in timing and imaging of lower extremity reconstruction

“…Despite the multitude of wound assessment and grading scales (discussed in more detail below), there remain no hard and fast rules regarding when a severely damaged limb should be amputated [ Figure 1]. Despite previous orthodoxy, damage to posterior tibial nerve, and an insensate foot are no longer absolute contra-indications for limb salvage [6,7] . Instead, reconstruction should be evaluated and approached on a case by case basis and must be in line with the ultimate goals of the patient.…”