Severe Limb Trauma Research Articles

Association of clinical characteristics with decision making in patients with severe lower extremity trauma

Severe lower limb trauma represents a challenge for both the emergency department physicians and the surgeons. These injuries are associated with significant incidence of limb loss and it is not uncommon for the treating physician to make the hard decision between limb salvage, amputation or stump closure for a patient in critical condition. Our aim was to evaluate the epidemiology of traumatic lower extremity amputations and to analyze the factors which may have effect on patient resuscitation, limb salvage and efficient patient management. Patients who were admitted to our institution’s emergency department for traumatic lower extremity amputation over an 8 years’ period (2012 to 2020) were retrospectively analyzed. Patient files with the possibility of severe lower limb trauma and mangled extremity were retrieved and analyzed using ICD codes recorded/registered during the emergency department admission. Mean time from emergency admission to transfer to operating theater was 184,5 minutes. Replantation of the amputate was performed in 4 patients (19%). 25% of the amputations at the ankle level (1 out of 4) and 37.5% of the transtibial amputates (3 out of 8) were replanted. A multidisciplinary approach is necessary in every aspect of patient management; however, this does not justify a delay in treatment. Time spent during conclusion of necessary consultations does not have negative effects on patient outcome as long as patient is closely monitored and resuscitated in the emergency department.

Treatment of acute bone defects in severe lower limb Trauma

PurposeTo present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames. Patients and methodsDuring a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) ResultsThe mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues. Discussionbased on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.

Bionic reconstruction after severe limb trauma and limb loss

Severe brachial plexopathies, massive soft tissue damage of the forearm, electrocution injuries, acute compartment syndrome with consequent Volkmann’s Contracture and many other mutilations of the arm and hand may lead to a more or less functionless hand. These defects pose a major reconstructive challenge and currently there are only a few therapeutic options with very moderate outcome Depending on the cause of injury either the neurological deficit, the actual loss of functional tissues or the poor trophic state of the hand do not allow meaningful biological reconstruction. We have now developed different strategies that combine complex prosthetic systems with sophisticated surgical techniques to create novel neurological landscapes so that patients can interact with complex mechatronic devices in an intuitive and natural way. For this purpose we selectively transfer nerves that have lost their targets to free functional muscles transplants in the forearm to provide a new neurological surface to express lost hand function. These muscles then act as bioamplifiers of peripheral nerve signals that can power specific movements of a prosthetic device with several degrees of freedom. Here we present our experience with this new concept of “bionic reconstruction” in various scenarios of challenging upper extremity defects.

Very long-term results of post-traumatic bone defect reconstruction by the induced membrane technique

IntroductionThe induced membrane technique for bone defect reconstruction is now well recognized, and short-term results for bone healing are consistent between published reports. ObjectivesTo assess very long-term functional results in post-traumatic reconstruction using the induced membrane technique. MethodResults for 18 patients undergoing bone defect reconstruction by induced membrane were retrospectively analyzed at 10 to 22years’ follow-up. Initial lesions were multitissue with infection in 14 cases. Reconstruction concerned the tibia in 14 cases, and the humerus, elbow, radius or ulna in 1 case each. Soft-tissue reconstruction was performed in 17 cases, by free flap (n=8) or pedicle flap (n=9). Fixation used a single-plane external fixator in 15 cases, screwed plate in 1 case (humerus), or intramedullary nail in 1 case (ulna). There was 1 crossover from external fixator to internal plate fixation (radius). Assessment comprised radiology, functional assessment, clinical examination and patient satisfaction. All patients were followed up in individual consultation. ResultsEight of the 14 patients with lower limb lesions had unrestricted walking distance; 4 resumed leisure sports. Limb shortening ranged from 0.5 to 4cm and was well-tolerated, although dorsiflexion was abolished or limited in most cases. Several patients underwent second procedures to improve limb function: ankle fusion, Achilles lengthening, tendon transfer, or realignment osteotomy. Radiology found a neotubular aspect, indicating peripheral densification and central resorption. Despite the multiple procedures, no patients regretted the original limb-conserving surgery. All reported that it took 2 to 3years after consolidation and resumption of walking to achieve stable final functional improvement. No recurrent sepsis in the reconstruction zone was found. ConclusionThe present results encourage implementing limb-conserving strategies in young patients after severe multitissue limb trauma, on condition that lesions are properly assessed, notably in terms of infection, and that the reconstruction protocol is feasible and has the patient's consent. Level of evidenceIV, retrospective series.

More words about repair and reconstruction of severe limb trauma

More words about repair and reconstruction of severe limb trauma

Managing soft tissues in severe lower limb trauma in an ageing population

PurposeWith an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. MethodPatients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. ResultsBetween January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67–95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4–85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). ConclusionAlthough the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.

Cost-Utility Analysis of Reconstruction Compared With Primary Amputation for Patients With Severe Lower Limb Trauma in Colombia

To establish, from the health system perspective, the cost-utility relationship of limb reconstruction compared with primary amputation for patients older than 32 years with grade IIIB and IIIC severe lower limb trauma in Colombia, S.A. A Markov model was built including different short-term and long-term states that represent the main events that a patient could experience after a lower limb amputation or a reconstruction. A 42-year time horizon was considered for the base case. Transition probabilities were obtained from a systematic review of the clinical literature. The health outcome selected was the quality-adjusted life years. Costs were determined by expert consensus using the standard case methodology, and valuation of resources was conducted with national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted. In the base case, the reconstruction of the limb compared with primary amputation was a dominant strategy; that is, reconstruction provides more quality-adjusted life years at a lower cost. This result changed only when the time horizon was less than 6 years or when the probability of a secondary amputation was >65%. Limb reconstruction is a dominant strategy compared with primary amputation, which is a conclusion that holds in most scenarios this study examined. Therefore, it should be considered in patients who, according to the clinical criteria and the severity and characteristics of their trauma, can benefit from this technique. Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Invited Commentary related to: Cost-Utility Analysis of Reconstruction Compared With Primary Amputation for Patients With Severe Lower Limb Trauma in Colombia.

Invited Commentary related to: Cost-Utility Analysis of Reconstruction Compared With Primary Amputation for Patients With Severe Lower Limb Trauma in Colombia.

The role of microvascular tissue transfer in severe limb trauma

Background: Lower extremity reconstruction is an essential part of plastic surgery and focuses on the treatment of wounds. The restoration of an intact covering is the primary surgical requisite following trauma of the lower extremity because deep healing can be no better than the surface covering. Present study will review the field of lower extremity reconstruction focusing on the micro-vascular tissue transfer for severe limb traumatic injuries.Methods: Patients were fully evaluated and defect was assessed depending on the defect requirement free micro- vascular flap was planned. 20 micro vascular flaps in 18 males and 2 females were used for the wound / defect of lower limbs following trauma.Results: There were 18 men and 2 women with a mean age of 43.6 years (range, 18-62 years) in the present study. The overall survival of the flaps was 95% (19/20).Conclusions: The free flap is an effective method of lower-extremity reconstruction. Good outcomes can be achieved with complete debridement and the selection of appropriate recipient vessels and flaps according to the recipient site.

Comparing the analgesic effect of intranasal with intravenous ketamine in isolated orthopedic trauma: A randomized clinical trial

ObjectivesKetamine is commonly used in anesthetic and sedation before surgical procedures and acts as an analgesic in smaller doses. The aim of this study was to assess the effects of intranasal (IN) ketamine in patients with moderate to severe limb trauma (visual analog scale (VAS) > 60 mm). MethodsIn a triple-blind randomized controlled clinical trial; 154 patients with isolated orthopedic trauma and visual analog scale (VAS) ≥60 mm were included on the basis of inclusion and exclusion criteria. Patients were divided into two groups of ketamine-IN (0.4 mg/kg IN ketamine and an equal volume of placebo saline intravenously (IV)) and ketamine-IV (0.2 mg/kg ketamine IV with 0.5 ml saline IN) on the basis of balanced block randomization method. At 5, 10, 20, and 30 min, patients were assessed for VAS measurement and adverse events. Repeated measure ANOVA, independent t-test and chi square test were employed. The level of statistical significance was considered to be less than 0.05. ResultsMean VAS in IN ketamine and IV group at minute 30 was 31.50 ± 13.40 and 29.35 ± 11.73, respectively. At minute 30, 31 patients (20.39%) required a low-dose of morphine as rescue analgesia (P = 0.427). The results showed that mean change score of VAS (difference of time 0 and time 30) in IN ketamine and IV ketamine VAS were 43.8 (95% confidence interval: 41.1–46.5) and 46.4 (95% confidence interval: 42.8–50.1) and there is no difference between two groups in case of score change of VAS (P = 0.245). Adverse events in nasal and intravenous ketamine in both groups were mild and transient. ConclusionIN ketamine is associated with few side effects and appropriate analgesic effects in isolated orthopedic trauma patients, and it may be used in cases where there is no need for venipuncture of peripheral vessels, especially in crowded EDs.

Multifunctional polyHIPE wound dressings for the treatment of severe limb trauma

Trauma suffered in combat is frequently of greater severity than that faced in the civilian sector and access to advanced care is often limited. Therefore, multifunctional wound dressings, capable of high absorption, hemostatic activity and antimicrobial drug delivery, are of significant interest in improving point-of-injury care. Here, polymeric foams composed of poly(ethylene glycol) diacrylate, sodium/calcium polyacrylate and PNIPAM, were synthesized via high internal phase emulsion (HIPE) templating and demonstrated exceptional material properties and biological performance for application as wound dressing materials. The polyHIPE foams exhibited typical HIPE hierarchical microstructure, a high capacity for fluid absorption and excellent cytocompatibility. Furthermore, the materials were highly effective at clotting whole blood and capable of loading/delivering active antibiotics. Porous polymeric foams prepared via high internal phase emulsions (HIPEs) offer an exciting method for the rational design of wound dressing materials that are highly absorptive, hemostatic and capable of antimicrobial drug delivery.

Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study

Open fractures are severe, complex, limb-threatening and high-energy injuries, often involving lesions of both bone and soft tissues. Traditionally, treatment has been piecemeal by orthopaedic and plastic surgeons. This study aimed to prospectively investigate whether combining orthopaedic and plastic surgery in treating these injuries is more effective than the conventional orthopaedic care. A prospective multi-centre cohort study was conducted. Differences in the type of approach to severe limb trauma allowed a comparison between combined orthoplastic and traditional exclusively orthopaedic treatment. Time for fracture and soft tissue healing and the recovery of limb function were the main outcome measures studied. All patients suffering from a severe open tibial fracture were prospectively included between January 2012 and December 2013 and followed until December 2014. Recruiting units were as follows: (1) an established orthoplastic centre, (2) a unit without experience in the orthoplastic approach and (3) a unit where the orthoplastic approach has been recently introduced in a developing country (Pakistan). A total of 160 patients were included in the study. Of these, 70% were treated with an orthoplastic approach, whereas 30% were treated by an orthopaedic team. All outcome measures were statistically improved by the orthoplastic approach. A coordinated, combined pathway to both the bony and the soft tissue components of open tibial fractures through orthoplastic surgery can be successfully delivered with attention to important timelines to achieve better patient outcomes in different socio-economic settings.

Single stage management of Gustilo type III A/B tibia fractures: Fixed with nail & covered with fasciocutaneous flap

PurposeTo evaluate the role of immediate and definitive management of Gustilo type III A/B tibia fractures with intramedullary nailing and fasciocutaneous flap. MethodsFrom August 2010 to July 2012, 22 patients with Gustilo Grade III A/B tibia fractures were managed with a single stage treatment of ipsilateral fasciocutaneous flap & reamed intramedullary nailing and were included in the study. The severity of the injury was calculated with Ganga Hospital injury severity score. ResultsThe mean age of patients was 41 years and the follow-up time ranged from six months to one year. Among the 22 patients, 73% were type III B fractures with upper leg involved in 55% of them. The time interval from injury to completion of surgery was 8–14 h. The incidence of bone infection requiring secondary procedure was 9%; the major and minor soft tissue complication rate was 9% and 14% respectively. The limb salvage rate was 100%. ConclusionMultidisciplinary management of severe lower limb trauma is important and provides good outcomes. Intramedullary nailing and immediate flap fixation can achieve early bone union and good soft tissue coverage, leading to good outcomes in patient with Grade III A & B tibia fractures.

Application progress of special form of perforator flaps for repair of severe limb trauma

Application progress of special form of perforator flaps for repair of severe limb trauma

Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes.

Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury

Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Therapeutic Whole-body Hypothermia Protects Remote Lung, Liver, and Kidney Injuries after Blast Limb Trauma in Rats.

Severe blast limb trauma (BLT) induces distant multiple-organ injuries. In the current study, the authors determined whether whole-body hypothermia (WH) and its optimal duration (if any) afford protection to the local limb damage and distant lung, liver, and kidney injuries after BLT in rats. Rats with BLT, created by using chartaceous electricity detonators, were randomly treated with WH for 30 min, 60 min, 3 h, and 6 h (n = 12/group). Rectal temperature and arterial blood pressure were monitored throughout. Blood and lung, liver, and kidney tissue samples were harvested for measuring tumor necrosis factor-α, interleukin-6 and interleukin-10, myeloperoxidase activity, hydrogen sulfide, and biomarkers of oxidative stress at 6 h after BLT. The pathologic lung injury and the water content of the lungs, liver, and kidneys and blast limb tissue were assessed. Unlike WH for 30 min, WH for 60 min reduced lung water content, lung myeloperoxidase activity, and kidney myeloperoxidase activity by 10, 39, and 28% (all P < 0.05), respectively. WH for 3 h attenuated distant vital organs and local traumatic limb damage and reduced myeloperoxidase activity, hydrogen peroxide and malondialdehyde concentration, and tumor necrosis factor-α and interleukin-6 levels by up to 49% (all P < 0.01). Likewise, WH for 6 h also provided protection to such injured organs but increased blood loss from traumatic limb. Results of this study indicated that WH may provide protection for distant organs and local traumatic limb after blast trauma, which warrants further study.

A study on musculoskeletal disorders distribution and health-seeking behavior among geriatric people in the field practice area of rural health and training center of a tertiary care hospital

Background: The World Health Organization (WHO) Technical Report 2003 stated that musculoskeletal disorders (MSDs) include osteoporosis, osteoarthritis, rheumatoid arthritis, spinal disorders, severe limb injury, trauma, or fracture. The burden of MSDs is global and looking at the gravity of the situation, WHO declared 2000–2010 as the bone and joint decade. As the geriatric people are more vulnerable to osteoporotic changes, there is a possibility that prevalence of MSDs will be more. So this cross-sectional study has been carried out among the geriatric people. Objective: To assess the sociodemographic profiles of geriatric people, to find out the prevalence of MSDs among study participants, and to assess their health-seeking behavior toward MSD. Materials and Methods: A total of 400 geriatric people were included in the study as study participants. Systematic sampling was followed to identify the household. The semi-structured questionnaire from the SJH Report was used to gather information regarding MSD problems. Result: A total of 43% of the study participants belonged to lower middle class family, 48% participants had joint pain, and 21% had backache. Knee joint was the most commonly affected joint. Backache was more common in women (67%) than in men (33%) and was found to be statistically significant. A total of 31% of the participants had osteoarthritis, 2% had rheumatoid arthritis, 7% had soft tissue rheumatism, 1% had monoarticular joint pain and gout, 4.75% had severe limb injury, trauma, and fracture, 26% had pain at any site, and 13.3% had no complaint at all. Overall prevalence of MSD was 61%. A total of 45% were seeking treatment from local RMP, whereas 28% did not seek any treatment for MSD problem. Conclusion: The geriatric people should undergo investigations such as serum calcium, vitamin D-3, and bone marrow density.

Died of wounds: a mortality review

ObjectivesCombat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the...

Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial

IntroductionOpen fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in...