Severe Lower Limb Injuries Research Articles

Efficacy of damage control orthopedics strategy in the management of lower limb trauma

BackgroundLittle is known about the efficacy of damage control (DC) surgery in the management of lower limb trauma. Here we compared the clinical parameters and complication rates of such patients received either DC or emergency comprehensive (EC) surgery treatment. MethodsThis study is a retrospective study on patients with lower limb trauma that received surgical treatment. Data of 120 patients were divided into DC and EC surgery groups. Clinical parameters obtained at hospital admission and complications during follow-up were analyzed. Injury Severity Score (ISS), Gustilo classification and Mangled Extremity Severity Score (MESS) were used to assess trauma severity, open fractures and viability of injured limb, respectively. ResultsAge, sex, ISS, fracture type, injury site, MESS, operation time, blood loss, pulmonary and cranial injuries were compared. We found that patients in the DC group had more severe injury as reflected by the higher injury severity score (ISS) (28.1 ± 10.9 vs 21.3 ± 7.4, P < 0.001). ISS was also identified as a significant influencer for the treatment selection (P < 0.001). In addition, patients treated with DC surgery demonstrated less complications (7 cases vs 27 cases), which was supported by the propensity score logistic regression analysis (Odd ratio 4.667). ConclusionsDC surgery is more often selected to treat patients with more severe lower limb injuries, which leads to lower complication rates.

Prevalence of chronic pain after severe lower limb injury (SLLI): A systematic review and meta-analysis

BackgroundGlobally, severe lower limb injuries (SLLIs) are the predominant cause of long-term injury related disability and poor functional outcomes. Chronic pain is a major source of this morbidity, but the magnitude of the contribution is not clearly understood. The aim of this systematic review and meta-analysis was to determine the prevalence of chronic pain following SLLIs in civilian and military patients. MethodThis systematic review was prospectively registered with The International Prospective Register of Systematic Reviews (PROSPERO) with study ID CRD42022313615. A systematic literature search (Medline, Embase, Ovid, and Web of Science) was performed to identify original studies that reported chronic pain outcomes for adults who underwent surgical treatment for SLLIs in a civilian or military setting. Risk of bias in included studies was assessed using the ROBINS-E tool, and quality assessment was reported at study level using the Newcastle–Ottawa Scale, and at outcome-level using the GRADE framework. Absolute (proportional) and relative (odds ratio) outcome measures were calculated and pooled using a random effects model. ResultsForty-three studies reporting the outcomes of 5601 patients were included. Estimated overall prevalence of pain was 63 % (CI 55–70 %). The prevalence of chronic pain in amputees (64 % (CI 55–73 %)) was similar to those who underwent limb salvage (56 % (CI 44–67 %)). The prevalence of chronic pain in civilian populations was 70 % (CI 63–77 %) compared to military populations (51 % (CI 35–66 %)). In amputees, the prevalence of residual limb pain was similar to phantom limb pain (OR 1.06 [0.64–1.78], p = 0.81, I2 = 92 %). ConclusionMost people who sustain a SLLI will suffer from chronic pain. Healthcare systems must continue to research interventions that can reduce the incidence and severity of long-term pain and ensure adequate resources are allocated for this common and debilitating complication.

PREVENÇÃO, INTERVENÇÃO E GERENCIAMENTO DO TREINAMENTO FÍSICO NA REABILITAÇÃO DE LESÕES NOS MEMBROS INFERIORES

ABSTRACT Introduction Lower limb injuries are one of the main sports occurrences among athletes. Severe lower limb injuries will lead to the definitive end of the athlete’s professional career. Objective Explore the mechanisms of prevention and intervention against lower limb injuries in physical training and the rehabilitation management strategies for lower limb injuries. Methods In this study, 20 athletes were selected. Comparing the results of the lower limb FMS test and balance y test before and after rehabilitation training management, the effect of rehabilitation management on recovery from lower limb injuries in physical training was discussed. Results Lower limb injury is a common type of sports injury in physical training; however, better recovery utilization can be achieved through successful rehabilitation training. Rehabilitation training management can effectively improve the FMS test score of athletes’ lower limbs and the number of people who passed the Y balance test. However, the existing rehabilitation training program still has some limitations, which need to be corrected according to the individual conditions of athletes. Conclusion Through physical training and medical rehabilitation, athletes with lower limb injuries can recover their lower limb sports ability and prolong their sporting life. Therefore, it should be disseminated. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Occult deep vein thrombosis in lower limb trauma requiring microsurgical reconstruction—A retrospective cohort study

Delayed microsurgical reconstruction of lower extremity trauma is associated with increased risk of free flap loss, frequently following failure of the venous anastomosis. This has been attributed to thrombocytosis, but occult deep vein thrombosis (DVT) may contribute to this risk. We performed a retrospective cohort study of consecutive patients presenting to our service with lower limb injuries requiring microsurgical reconstruction between 2013 and 2017, and examined venous Duplex ultrasound reports, operation notes and free flap outcomes. A total of 165 free flap reconstructions for lower limb trauma were performed for 162 limbs in 158 patients. Seventy-two limbs (44.4%) underwent preoperative venous Duplex ultrasound identifying occult DVT in 14 (19.4%) patients. Occult DVT was identified intraoperatively in a further 7 cases. Bilateral lower limb injuries (p = 0.0002), the level of injury at or above the knee (p < 0.0001), multiple levels of injury within the affected limb (p = 0.0008) and critical care admission (p = 0.0008) were significant risk factors for DVT. All 7 cases of DVT diagnosed intraoperatively prompted a change in the surgical plan for the recipient vein; however, preoperative identification of occult DVT also lead to an adjustment in the microsurgical plan in 4 out of 14 cases. Prevalence of DVT is high in severe lower limb injury, potentially increasing the risk of free flap loss. Preoperative identification of occult DVT may influence the microsurgical plan and mitigate for this risk.

The ATLANTIC study: Anti-Xa level assessment in trauma intensive care

ObjectiveTo quantify the pharmacodynamic (PD) activity of daily subcutaneous (SC) enoxaparin as venous thromboembolism (VTE) prophylaxis in high-risk trauma patients admitted to the intensive care unit (ICU). MethodsThis was a prospective observational PD study conducted in the ICU of a state-wide major trauma referral centre. The study cohort included adult patients admitted to the ICU with a high risk of VTE, as defined by at least one of the following: age > 40 years, prior VTE, spinal cord injury (SCI), traumatic brain injury (TBI), major venous injury, pelvic fractures, spinal fractures requiring treatment, severe lower limb injuries, and major surgery >2 h in duration. Standard prophylactic enoxaparin dosing was 40 mg SC daily, unless amended by the treating clinician. Plasma anti-Xa activity was measured approximately 60 min before dosing (trough activity), and at 3–5 h after dosing (peak activity). Target peak and trough activity were defined as >0.2 IU/mL and >0.1 IU/mL respectively. Clinical data including the development of VTE and haemorrhagic complications were collected. ResultsTwenty-five patients were enrolled. Median [IQR] age, weight, and plasma creatinine were 59 years [36,70], 85 kg [76.5,93.5] and 70μmol/L [60.5,109] respectively. Median APACHE III and Injury Severity Score were 54 [42.5,66.5] and 27 [17,34] respectively. Thirteen patients suffered a TBI, in 12 cases surgery extended beyond two hours, and five patients had spinal fractures requiring treatment. Twenty-two patients received enoxaparin 40 mg SC daily, two 60 mg, and one 20 mg. Median peak and trough anti-Xa activity was 0.21 IU/mL [0.125,0.25] and 0.01 IU/mL [0,0.05] respectively. Twelve (12/25; 48%) patients had low peak activity ≤0.2 IU/mL. Twenty-one (21/23; 91%) patients had low trough activity (≤0.1 IU/mL) and in six (6/23; 26%) cases, these were undetectable. Eight (8/25; 32%) patients had documented VTE of whom seven had low trough activity. There were no major haemorrhagic complications. ConclusionsIn a cohort of high risk critically ill trauma patients receiving daily SC enoxaparin as VTE chemoprophylaxis, measured peak and trough plasma anti-Xa activity was inadequate in a significant proportion. On this basis, further systematic investigation concerning dose optimisation in this patient population appears warranted.

Clinical Outcomes with the Intrepid Dynamic Exoskeletal Orthosis: A Retrospective Analysis.

Severe lower limb injuries have a negative impact on many aspects of an individual's life. One rehabilitative option for patients who have undergone limb salvage is the Intrepid Dynamic Exoskeletal Orthosis (IDEO). The IDEO is a custom-made dynamic response device which is used to restore function for patients with a wide variety of injuries. Clinical outcomes were routinely collected on patients fit with IDEOs at the Center for the Intrepid, Brooke Army Medical Center. The purpose of this retrospective study was to analyze the clinical outcomes collection process and the patient outcomes collected as part of routine clinical care. The Brooke Army Medical Center IRB approved this study and granted waivers of informed consent and HIPAA authorization. Electronic medical records were reviewed over an 18-month period from July 2014 to January 2016. Records were examined to obtain the date of IDEO delivery, date of outcomes form completion, responses on the forms, and to verify diagnosis or injury. Data gathered included wear time, IDEO comfort, pain with and without the IDEO, Lower Extremity Functional Scale scores with and without the IDEO, and global rating of change questions for everyday activities and high impact activities. Wilcoxon signed-ranked tests were used to compare pain and function with vs. without the IDEO. During the 18-month period, new IDEOs were delivered to 156 unique patients. Outcomes forms were collected as part of routine clinical care from 90 of these 156 patients (58%). An additional nine forms were collected from patients who received their IDEOs prior to July 2014. In all, 99 outcomes forms were collected. Mean follow-up time from IDEO delivery to outcomes form completion was 35 ± 31 days for the original 90 patients. The most common patient diagnoses were fracture, nerve injury, arthritis, and fusion. Responses on the forms indicated that patients were generally comfortable wearing their IDEOs (8.3 ± 1.3 on a 0-10 scale) and wore them most of the day (10.7 ± 3.4 hours per day). Improvement in pain (from 5.2 ± 2.9 to 1.7 ± 1.6 points on a 0-10 scale) and Lower Extremity Functional Scale scores (from 29.7 ± 16.6 to 59.5 ± 13.6 points) with the IDEO were both more than the minimal clinically important difference and were statistically significant (p < 0.001). This descriptive retrospective study demonstrated that it was feasible to collect clinical outcomes data which were relevant for characterizing the effects of IDEO use and enabled quantification of improvements in self-reported function and walking pain with the IDEO. Due to the retrospective nature of this study, limitations include missing data and the lack of any performance measures to complement the self-reported data. Clinical outcomes collection continues as a routine part of clinical care and there remains an ongoing aim to collect information on all patients to obtain an accurate assessment of devices and services and ultimately better serve our patients.

Ten years retrospective study of using primary microsurgery technology to treat patients with severe lower extremities injury

Objective To clarify the role of microsurgery in limb salvage procedure and its efficiency in longterm functional results through a retrospective review of patients who sustained severe injury of lower extremities and had been treated Shanghai 6th people's hospital, in recent 10 years. Methods Patients who sustained severe injury of lower extremities and treated with microsurgical techniques in January, 2006 to January, 2016 were studied. Patients' general information, classification of open fracture, and MESS were noted. The enrolled patients were divided into two groups(group A: primary microsurgical reconstruction; group B: non-microsurgical reconstruction) according to whether primary microsurgical reconstruction was performed or not. Each group were also further divided into subgroup according to preoperative MESS(MESS<7 and MESS≥7). The reconstruction methods, hospitalization days, operation times, postoperative complications, as well as the SIP were then recorded for each groups. The differences of these data among each groups were analyzed and compared. Results The main objection was patient with Gustilo grade III open fracture, totally 548 patients were admitted, with 312 males and 236 females. The main age was 35.6 years old. The main etiology was road traffic accident (79.7%). There were 211 patients (38.5%) in group A, and 337 patients (61.5%) in group B. In group A, there were 37 patients in subgroup one (MESS<7), and 174 patients in subgroup two(MESS ≥7). The rate of delayed amputation was 2.8%, while the complication rate was 11.8%. In group B, there were 181 patients in subgroup one(MESS<7), and 156 patients in subgroup two (MESS≥7). The rate of delayed amputation was 4.0%, while the complication rate was 13.3%. In long-term survey, the average VAS score of group B was higher than that of group A, but no significant difference was noted. The average VAS scores in 2 year postoperatively in the subgroups (MESS≥7) were higher than those in the other subgroups(MESS<7). The results of SIP scores were similar with VAS scores in two groups. Conclusion The techniques of microsurgery has been promoting the successful rates and outcomes for limb salvage procedure over the recent decades. Meanwhile, the current evaluating system for severe limb injury needs to be updated to meet the demands of ever-developing limb salvage techniques. Key words: Severe lower limb injury; Limb salvage; MESS; Microsurgical technique

Impacts of age and ground surface on injury caused by fall from heights

Objective To investigate the impacts of age and ground surface on the injury caused by fall from heights. Methods A retrospective study was carried out to analyze the 1, 230 patients who had been treated at our department for injury caused by falling from heights from January 1996 to December 2006. They were 925 males and 305 females, aged from 1 to 86 years (average, 38.5 years). The injury was evaluated by revised injury severity score (RISS). The impacts of age ( 50 years) and ground surface (soft ground and hard ground) on the injury were analyzed. Results Of the 287 patients of 50 years, 43.44% had craniocerebral and maxillofacial injury, 22.17% spinal injury, 26.70% chest injury, 33.48% lower limb injury, and 16.74% upper limb injury. There were significant differences among the 3 age groups regarding injury location and RISS score (P < 0.05). The proportions of patients falling on the soft ground with multi-injury [23.91% (22/92)] and with RISS≥ 16 [28.26% (26/92)] were significantly lower than those falling on the hard ground [46.15% (36/78) and 52.56% (41/78)] (P < 0.05). Conclusions Moderate craniocerebral and maxillofacial injury were common in the patients of <15 years old. Patients of ≥ 15 years old were commonly afflicted by moderate to severe spinal, chest and lower limb injuries. Falling on a hard ground caused a much more severe injury than falling on a soft ground. Key words: Wounds and injury; Fall injury; Revised injury severity score

CORR Insights(®): To What Degree Do Pain-coping Strategies Affect Joint Stiffness and Functional Outcomes in Patients With Hand Fractures?

T he influence of psychological factors on functional outcomes in clinical orthopaedics is becoming increasingly recognized. The World Health Organization has concluded that depression better predicts general health status than angina, asthma, diabetes, or arthritis [5]. In musculoskeletal health, depression has been demonstrated to predict self-reported upper extremity health status for multiple diagnoses [7]. Depression, pain catastrophizing, and other psychological factors are the best available predictors of severity of pain and disability after ACL reconstruction, knee arthroplasty, and minor hand surgery [6, 8, 9]. Psychological symptoms are prevalent and inadequately recognized on clinical impression alone. After orthopaedic trauma, 45% of patients have clinically relevant symptoms of depression [1]; in spine patients, 64% have psychological distress on screening questionnaires [2], and after severe lower limb injuries, 48% of patients screen positive for a likely psychological disorder [3]. Controversies remain regarding the relationships among psychological factors associated with physical impairment (as opposed to perceived disability), the degree to which psychological factors can be modified in the orthopaedic patient, and whether this is practical to achieve. Roh et al. have focused on the role of pain-coping strategies on ROM and grip strength after hand fractures. They found that poor coping skills before surgery, as measured by high catastrophization and anxiety, were associated with weaker grip strength, decreased ROM, and increased disability after surgical treatment for hand fracture in the first 3 months after injury.

Cross‐sectional study to investigate the health‐related quality of life in children with severe lower limb trauma in Victoria

The aim of this study is to investigate the health-related quality of life in children with severe lower limb trauma after at least 12 months post-injury and to assess patient and injury characteristics in association with the health-related quality of life scores. All children in the state of Victoria, who were 18 years of age or younger, suffering from severe lower limb injury before 2006 were studied. Patient and injury characteristics were abstracted from medical records. The health-related quality of life (HRQOL) scores were obtained using the Paediatric Quality of Life Inventory. Thirty-two out of 64 eligible patients participated in this study. All aspects of health-related quality of life in children with severe lower limb trauma after at least 12 months post-injury were significantly poorer compared with non-affected children, particularly in the physical health domain (difference: -12.51 ± 7.43: P < 0.05). It was observed that bilateral limb involvement and the need for soft tissue management were related to poor physical functioning (P < 0.05). Other characteristics such as traumatic amputation, gender, growth plate injury, joint bony injury and accident mechanism did not affect the overall HRQOL scores (P > 0.05). The HRQOL in children with severe lower limb trauma was significantly impaired even after 12 months post-injury, notably in patient group with bilateral limb involvement and need for soft tissue management. Traumatic amputation, gender, growth plate injury, joint bony injury and accident mechanism did not have an impact on quality of life.

PTSD and Combat-Related Injuries: Functional Neuroanatomy

PTSD and Combat-Related Injuries: Functional Neuroanatomy

Lower limb amputation following injury: a survey of long-term functional outcome

Although there have been significant advances in surgical methods of limb preservation and various injury scores produced to predict the outcome after severe lower limb injury, there is common belief amongst surgeons that patients rehabilitate rapidly and well after amputation. There is however little evidence in the literature supporting this view of functional outcome of amputation following injury. A subjective assessment of post-injury lower limb amputees implied that there was a similar functional outcome in above- and below-knee amputations. Furthermore, there was little functional difference between early and delayed amputations, the delayed group being more satisfied with the end result.