Epidemiology and Mortality of Surgical Amputations in Severely Injured Patients with Extremity Injuries—A Retrospective Analysis of 32,572 Patients from the TraumaRegister DGU®

<b>Background:</b> Extremity fractures are common injuries in polytraumatized patients. Concomitant injuries to the soft tissue, vessels and nerves in these fractures are defined as mangled extremities. The decision for or against limb salvage is dependent on the patient's physiology and the limb status. In severely injured patients with critical physiological status, limb salvage may be contraindicated. International data on the epidemiology and management of mangled limbs in severely injured patients are lacking. Thus, the aim of this study was to assess the incidence of polytraumatized patients with severe injuries to either upper (UL) or lower limb (LL) as well as their management. <b>Methods:</b> A retrospective cohort analysis was conducted of patients aged 16 years and above with an Injury Severity Score (ISS) ≥ 16 who sustained fractures to the limbs and were admitted to a certified trauma center of the TraumaRegister DGU^® (TR-DGU) between 2009 and 2019. <b>Results:</b> In total, we assessed 32,572 patients (UL: 14,567, mean age 48.3 years, 70% male and LL: 18,005, mean age 47.0 years, 70.5% male) The mean ISS in UL was 28.8 (LL 29.3). Fractures to the humerus (<i>n</i> = 4969) and radius (<i>n</i> = 7008) were predominantly assessed in UL, and fractures to the femur (<i>n</i> = 9502) and tibia (<i>n</i> = 8076) were most common in LL. In both groups, the most frequent injury mechanism was motor vehicle accidents, and more than half (UL: 9416 and LL: 11,689) of the patients had additional severe Abbreviated Injury Scale (AIS) ≥ 3 chest trauma. 915 patients in UL and 1481 in LL died within 24 h of the index admission. Surgical amputation occurred in 242 (UL) and 422 (LL) cases with a peak ratio in patients with an ISS above 50 in both groups. In both groups, patients with severe concomitant chest trauma were more often surgically amputated. In both groups, fewer patients with surgical amputations died within 24 h of admission (3.3% vs. 6.3% UL; 6.4% vs. 8.3% LL) compared to patients without amputation, but more patients with surgical amputations died within the overall hospital admissions (15.7% vs. 11.9% UL; 19.2% vs. 14.2%). In both groups, hemodynamical shock as well as the administration of Packed Red Blood Cells (PRBCs) were associated with a higher amputation rate. <b>Conclusions:</b> Surgical amputations after major trauma seem to be rare. Hemodynamical instability seems to play a key role in the management of mangled limbs. Patients with life-saving surgical amputation still have an increased overall in-hospital mortality.