Decision-making in patients facing limb salvage versus amputation after lower extremity trauma: A scoping review.

Abstract

To review the psychosocial and clinical factors influencing patient decision-making between limb salvage and amputation after major lower extremity trauma (MLET), and to identify strategies to support shared, informed decision-making. Patients with MLET must often rapidly decide between limb salvage and amputation, a decision with major functional and psychosocial consequences. Existing clinical tools emphasize anatomic and physiologic criteria but overlook patient values and quality-of-life considerations. Prior work suggests outcomes are often similar between salvage and amputation, and that psychosocial adaptation drives satisfaction more than surgical choice. Narrative literature review synthesizing evidence from trauma surgery, orthopedic surgery, plastic surgery, psychology, and economics sources to characterize psychosocial and clinical barriers to informed decision-making in MLET. Grief responses, cognitive biases (loss aversion, bounded rationality, sunk-cost fallacy), and decision fatigue were identified as key psychosocial barriers. Traumatic brain injury, opioid analgesia, and substance use were identified as clinical factors impairing cognition and capacity. These factors can impair communication and the pursuit of informed, shared decision-making. Decision-making in MLET is shaped by overlapping psychosocial and clinical barriers to informed choice. Addressing these through trauma-informed communication, multidisciplinary consistency, and structured decision aids may improve shared decision-making. Prospective, MLET-specific research is needed.