Severe Lower Limb Trauma Research Articles

Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multi-centre randomised clinical trial.

Hyperbaric oxygen treatment (HBOT) is sometimes used in the management of open fractures and severe soft tissue crush injury, aiming to reduce complications and improve outcomes. Patients with open tibial fractures were randomly assigned within 48 hours of injury to receive standard trauma care or standard care plus 12 sessions of HBOT. The primary outcome was the incidence of necrosis or infection or both occurring within 14 days of injury. One-hundred and twenty patients were enrolled. Intention to treat primary outcome occurred in 25/58 HBOT assigned patients and 34/59 controls (43% vs 58%, odds ratio (OR) 0.55, 95% confidence interval (CI) 0.25 to 1.18, P = 0.12). Tissue necrosis occurred in 29% of HBOT patients and 53% of controls (OR 0.35, 95% CI 0.16 to 0.78, P = 0.01). There were fewer late complications in patients receiving HBOT (6/53 vs 18/52, OR 0.22, 95% CI 0.08 to 0.64, P = 0.007) including delayed fracture union (5/53 vs 13/52, OR 0.31, 95% CI 0.10 to 0.95, P = 0.04). Quality of life measures at one and two years were superior in HBOT patients. The mean score difference in short form 36 was 2.90, 95% CI 1.03 to 4.77, P = 0.002, in the short musculoskeletal function assessment (SMFA) was 2.54, 95% CI 0.62 to 4.46, P = 0.01; and in SMFA daily activities was 19.51, 95% CI 0.06 to 21.08, P = 0.05. In severe lower limb trauma, early HBOT reduces tissue necrosis and the likelihood of long-term complications, and improves functional outcomes. Future research should focus on optimal dosage and whether HBOT has benefits for other injury types.

Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

BackgroundComplex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy.MethodsBetween January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up.ResultsAll 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm2. The flap sizes ranged from 14 × 7.5 to 24 × 21 cm2. The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed.ConclusionsThe modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.

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.

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.

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.

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.

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...

Answers to CME questions based on the Mini-Symposium on “Severe Lower Limb Trauma”

Answers to CME questions based on the Mini-Symposium on “Severe Lower Limb Trauma”

Elective spare parts free flap-calcaneal fillet of foot flap.

Severe lower limb trauma with significant soft tissue injury can be managed with reconstruction or, if this is impossible, amputation. If amputation is considered, below-knee amputation preserving limb length is optimal for long-term functional outcome. At times, soft tissue/bony injury can limit the ability to preserve limb length, particularly with proximal tibial injuries. We present a case of elective below-knee amputation where leg length and adequate soft tissue coverage was only possible by using an osteocutaneous fillet of foot and lower leg spare parts free flap, maintaining the tibial nerve pedicle for sensation and the posterior tibial artery for vascularity of the nerve. The procedure was technically challenging and required follow-up debulking operations. However, the technique provided the significant advantage of immediate sensation of robust glabrous distal stump cover and optimising leg length to enhance functional outcome.

Long-term follow-up of patients undergoing free tissue transfer to the lower limb following trauma

Free flap transfer reconstruction following severe lower limb trauma has become an increasingly used tool over the past four decades. However, little is known about the long-term outcome of these complex and costly procedures. The aim of this work is to assess the long-term outcomes in patients undergoing free flap transfer reconstruction of Gustillo IIIB lower limb injuries at the John Radcliffe Hospital, Oxford (UK). Forty-two potential participants were identified and contacted after review of operation records between 1990 and 2000. Physical and psychosocial outcomes were assessed using SIP, WOMAC and study-specific questionnaires. Eighteen participants responded, with a median follow-up time of 14 years since reconstruction. Road traffic collisions were the most common cause of trauma (12/18). The majority of participants (13/18) had SIP physical and psychosocial sub-scores equivalent to the general population (<5), and half the participants reported normal function in the study specific questionnaire (9/18). Two participants reported SIP physical sub-scores of ≥20, implying severe physical disability, associated with higher pain and stiffness scores in the WOMAC and study-specific questionnaire. The participants considered in this cohort generally have excellent long-term outcomes, in terms of function, aesthetic appearance and psychosocial well-being. The cohort presented here sets a standard by which other long-term studies can be measured. Level of Evidence: Level IV; therapeutic study.

CME questions based on the Mini-Symposium on “Severe Lower Limb Trauma”

CME questions based on the Mini-Symposium on “Severe Lower Limb Trauma”

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.

Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation

ABSTRACT The decision of either preserving a member or primary amputation (PA) in severe extremity trauma, especially in the presence of fractures, vascular injuries or serious injuries of soft tissues has always been a challenge for the trauma surgeon. The initial assessment with objective criteria like indexes, such as the Mangled Extremity Severity Score (MESS) or the PSI, can aid in the differentiation of members that can be saved or should be amputated primarily. We report on the design and preliminary results of our ongoing prospective study analyzing laboratory test as predictors of amputation in severe lower limb trauma. Materials and methods All patients treated in our emergency department with severe lower limb trauma and open fractures (classified as Gustilo III) were included in this study. We collected blood for laboratory test of all patients at admission. All injured limb were photographed for posterior analysis and MESS classification. Results From March 15, 2012, to June 10, 2012, n = 20 patients were included in our study. PA was performed in eight (40%) and preserving procedures (PP) in 12 (60%). Mean age was 30 in PP group and 40.5 in PA. Mean systolic pressure at the emergency room was 130 mm Hg in PP and 107 mm Hg in PA. MESS index was calculated for all patients and the means were 5 for the PP group and 8 for the PA group. Laboratory test of the two groups were compared and statistically analyzed. Acidosis, arterial lactate levels and hemoglobin levels at admission had a statistical difference between the two groups: pH = 7.36 PP vs 7.18 PA (p = 0.001); lactate: PP = 25 vs PA = 63 (p &lt; 0.001); hemoglobin: PP = 13.6 vs PA = 7.85 (p = 0.03). Conclusion Laboratory results of tests collected during initial assessment of patients with severe lower limb trauma are different between those submitted to PA or a PP. How to cite this article Garcia DFV, de Sá RRC, Bernini CO, Rasslan S . Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):58-61.

Application of lower extremity injury severity scores in children

Severe lower extremity trauma presents challenges in decision-making in terms of reconstruction or amputation. While injury severity scores have been developed to aid decision-making in adults, evaluation of their use in children is limited. Children presenting with severe lower limb trauma from 2000 to 2010 in a major trauma centre were identified from a trauma registry. Records were reviewed for details of the injury, surgical intervention, amputation and scores for the Mangled Extremity Severity Score, Limb Salvage Index, Predictive Salvage Index, Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock, Age System and the Hanover Fracture Scale 1998. Twenty children (average age 8.7 years) were eligible for inclusion. There were three primary amputations and no secondary amputations. All of the scoring systems had poor specificity and would have recommended amputation in several limbs that were successfully reconstructed. Currently available injury severity scores behave differently in children and adults. In their current format, these scores should not be used as an absolute indication for early amputation in children.

Costs and coding—Free-flap reconstruction in lower-limb trauma

Introduction The provision of a complex lower-limb trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. Methods We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex lower limb trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. Results A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12 792 ± £970 SEM (SFT) and £10 953 ± £650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p < 0.05). Conclusions Our study highlights the considerable disparity between the cost of managing patients with severe lower-limb trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral.

Comparison of Quality of Life and Functionality in Patients with Traumatic Unilateral below Knee Amputation and Salvage Surgery

The aim of this study was to compare the functionality during daily activities and quality of life of patients with transtibial amputation vs. salvage surgery after severe lower limb trauma. Ten patients with unilateral below knee amputation and nine patients with salvage surgery after severe lower limb trauma were enrolled. Functional Ambulation Scale (FAS), Visual Analogue Scale (VAS), Short Form 36 (SF-36) Energy Expenditure Index (EEI), 6-Minute Walking Test (6MWT) and 10-Meter Walking Test (10MWT) were used for the evaluation of subjects. Patients in the salvage group were also evaluated radiologically with Graves' radiological assessment method and Freiburg ankle scoring system. All patients were classified as grade 5 according to FAS. All SF-36 subgroup values were higher in the amputation group whereas only those of general health and vitality reached statistical significance (p < 0.05). The visual analogue scale (VAS) has been used to assess the efficacy of pain management. Mean VAS scores were found to be statistically higher in the salvage group (p < 0.005). Reoperation rates were one in 10 amputee and six in nine salvage patients. Mean Freiburg ankle scores of the patients in the salvage group were 55.33 +/- 15.51 which was consistent with moderate functionality. According to Graves' radiological assessment; four patients had grade 3 degeneration, four had grade 2 and one had grade 1 degeneration in the ankle joints. Mean EEI values, 6-MWT and 10-MWT results were not significantly different between the groups (p values > 0.05). Although amputation still remains as the last resort both for patients and the physicians, our results demonstrated that reoperation rates, quality of life (general health and vitality) and pain scores were better in amputee patients.

Long-term Persistence of Disability Following Severe Lower-Limb Trauma: Results of a Seven-Year Follow-up

Long-term Persistence of Disability Following Severe Lower-Limb Trauma: Results of a Seven-Year Follow-up

The Biopsychosocial Approach: Past, Present, and Future

Back to table of contents Previous article Next article Book ReviewsFull AccessThe Biopsychosocial Approach: Past, Present, and FutureDaniel Bradford, M.D., M.P.H.Daniel BradfordSearch for more papers by this author, M.D., M.P.H.Published Online:1 Nov 2005https://doi.org/10.1176/appi.ps.56.11.1466-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The basic tenet of the biopsychosocial model—that health outcomes affect and are affected by biological, psychological, and social factors—is understandable and even intuitive for many in the health care field. In fact, the biopsychosocial model makes for good "common sense" and thus could easily be disregarded as simplistic. However, the intricacies of the biopsychosocial approach are belied by the model's accessibility. The biopsychosocial clinician's task is no easy one—he or she must assess the interrelationships of multiple systems as they constantly affect and are affected by presenting—as well as nonpresenting—medical problems and must use skill and finesse in working with the patient to choose appropriate interventions, knowing that all systems will then be further affected. The Biopsychosocial Approach: Past, Present, and Future is a comprehensive work that explicates the complexities and richness of the biopsychosocial model and its implications in clinical practice, education, and administration.The book is organized into six parts. The introduction presents the basic components of the biopsychosocial model, which was developed by George Engel, M.D., as an application of systems theory to medical practice. Part 1 discusses clinical applications, emphasizing the importance of a communicative, empowering relationship between the physician and the patient. Part 2 examines research in psychoneuroimmunology, relationship-centered health care, and the patient-centered clinical method. Part 3 considers educational and administrative issues. Of note, the University of Rochester's "Double Helix" curriculum for medical students is presented here. Another fascinating chapter explains how the biopsychosocial model can be applied to organizational management in a health care setting, increasing employee satisfaction and, consequently, patient care. Part 4 discusses the development of the biopsychosocial model and includes an ethnographic study of Engel's correspondence. Finally, the editors conclude by considering the future of the biopsychosocial approach.This text will benefit professionals in a variety of health service disciplines. Most chapters are relatively free of medical jargon, although having a background in health services would certainly make for easier reading. In particular, readers without a medical background may find the chapter on psychoneuroimmunology less than accessible.Some patients may find the book helpful. As one of the contributing authors suggests, "The patient must understand her illness at a level of technical sophistication concordant with her needs." The same could be said for understanding the treatment model. In addition, understanding the approach will help patients become empowered in their own care, which is integral to the biopsychosocial model.For community psychiatrists, this text is virtually "required reading." The problems that our patients face are compounded by breakdowns across so many systems—biological, family, housing, and employment—and the distrust that many patients have for mental health practitioners is so overwhelming that effective treatment practically mandates a biopsychosocial approach.In short, The Biopsychosocial Approach is informative, clearly written, and inclusive. However, one of its most important attributes may be that it is thought provoking. By explaining the origins and implications of the biopsychosocial approach, the authors force us to critically examine the origins and implications of our own beliefs about medicine. This self-examination can help us identify areas for growth in our own practices.Dr. Bradford is a Robert Wood Johnson clinical scholar at the University of North Carolina School of Medicine in Chapel Hill and a clinical instructor in the department of psychiatry at the university.edited by Richard Frankel, Timothy Quill, and Susan McDaniel; Rochester, New York, Boydell and Brewer, 2003, 298 pages, $65 FiguresReferencesCited byDetailsCited ByCross-sectional study to investigate the health-related quality of life in children with severe lower limb trauma in Victoria21 January 2013 | Journal of Paediatrics and Child Health, Vol. 49, No. 2 Volume 56Issue 11 November 2005Pages 1466-a-1467 Metrics History Published online 1 November 2005 Published in print 1 November 2005

Prediction of amputation after severe lower limb trauma

The Mangled Extremity Severity Score was applied to 152 patients with severely injured lower limbs. All cases with a score of seven or more required amputation; some with scores of less than seven eventually came to amputation. These observations are discussed.