Traumatic Lower Extremity Injuries Research Articles

Single Tau-Shaped Anterolateral Thigh Free Flap on Bimalleolar Defect Acquired by Osteomyelitis in Lower Extremity Trauma: A Case Report

Soft tissue defects can cause serious issues in traumatic lower extremity injuries when limb salvage is the goal, especially when complicated by osteomyelitis. The distal lower extremities lack redundant soft tissue, necessitating free tissue transfer for complex injury reconstruction. For bimalleolar defects, a chimeric or double flap is an option, but harvesting such flaps can be challenging, and multiple arterial anastomoses risks distal limb ischemia. We present a case of a large bimalleolar defect with associated osteomyelitis covered with a single anterolateral thigh (ALT) free flap. Preoperative mapping identified perforator distribution allowing design of a single tau-shaped flap from the left thigh to minimize morbidity. The defects were covered successfully with no permanent complications. Given the ALT flap’s consistent anatomy, this case could guide future approaches for typical bimalleolar defects, including those with osteomyelitis.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After a Traumatic Lower-Extremity Injury: The Results of a Randomized Controlled Trial.

Lower-extremity injuries can result in severe impairment and substantial years lived with a disability. Persistent pain and psychological distress are risk factors for poor long-term outcomes and negatively influence the recovery process following a traumatic injury. Cognitive-behavioral therapy (CBT) interventions have the potential to address these risk factors and subsequently improve outcomes. This study aimed to evaluate the effect of a telephone-delivered cognitive-behavioral-based physical therapy (CBPT) program on physical function, pain, and general health at 12 months after hospital discharge following lower-extremity trauma. The CBPT program was hypothesized to improve outcomes compared with an education program. A multicenter, randomized controlled trial was conducted involving 325 patients who were 18 to 60 years of age and had at least 1 acute orthopaedic injury to the lower extremity or to the pelvis or acetabulum requiring operative fixation. Patients were recruited from 6 Level-I trauma centers and were screened and randomized to the CBPT program or the education program early after hospital discharge. The primary outcome was the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scale. The secondary outcomes were objective physical function tests (4-square step test, timed stair ascent test, sit-to-stand test, and self-selected walking speed test), PROMIS Pain Intensity and Pain Interference, and the Veterans RAND 12-Item Health Survey. Treatment effects were calculated using targeted maximum likelihood estimation, a robust analytical approach appropriate for causal inference with longitudinal data. The mean treatment effect on the 12-month baseline change in PROMIS PF was 0.94 (95% confidence interval, -0.68 to 2.64; p = 0.23). There were also no observed differences in secondary outcomes between the intervention group and the control group. The telephone-delivered CBPT did not appear to yield any benefits for patients with traumatic lower-extremity injuries in terms of physical function, pain intensity, pain interference, or general health. Improvements were observed in both groups, which questions the utility of telephone-delivered cognitive-behavioral strategies over educational programs. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury?

Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery. We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms? Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors. Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms. A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors. Level II, prognostic study.

Association of Pelvic Trauma With Rates of Cesarean Section, Sexual Dysfunction, and Genitourinary Dysfunction in a National Database

Pelvic fractures are severe injuries that can drastically affect a woman's quality of life through sexual dysfunction (SD), genitourinary dysfunction (GD), and increasing the potential need for future cesarean section (C-section). Limited research has captured long-term outcomes after pelvic fractures in women of childbearing age. This study aimed to determine the association between pelvic fractures and rates of C-section, SD, and GD. All women of childbearing age who sustained a pelvic fracture were identified in a national insurance database. A comparison group of patients with lower extremity long-bone fractures was selected. Patients who gave birth after injury were additionally identified. A minimum of 5 years of follow-up was required for inclusion. Rates of C-section, SD, and GD were compared between cohorts. Multivariate logistic regression analysis was conducted with the inclusion of diabetes, tobacco, hypertension, obesity, and advanced maternal age. A total of 6,174 patients with pelvic fracture and 27,154 control fracture patients were identified. 434 patients with pelvic fracture (7.0%) and 1,258 control fracture patients (4.6%) gave birth after fracture. Patients with pelvic fracture had a significantly higher rate of C-section (50.0% versus 38.8%, P < 0.001), SD diagnosis (10.9% versus 8.8%, P < 0.001), and urinary retention diagnosis (3.5% versus 2.8%, P < 0.001). No significant difference in global GD diagnosis was identified. Multivariate analyses showed that pelvic fracture was associated with C-section (odds ratio [OR]: 1.78; 95% confidence interval [95% CI]: 1.42 to 2.23, P < 0.001), SD diagnosis (OR: 1.23; 95% CI: 1.12 to 1.35, P < 0.001), and urinary retention diagnosis (OR: 1.35; 95% CI: 1.15 to 1.57, P < 0.001). Pelvic fractures confer an intrinsic level of risk of C-section, SD, and urinary retention that is elevated beyond what would be expected from a traumatic lower extremity injury alone. Treating orthopaedic surgeons should actively counsel women regarding increased risks, openly discuss postinjury sequelae, and coordinate interspecialty care beyond initial treatment of acute trauma.

Early Reconstruction Delivered Better Outcomes for Severe Open Fracture of Lower Extremities: A 15-Year Retrospective Study.

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.

Biceps femoris long head morphology in youth competitive alpine skiers is associated with age, biological maturation and traumatic lower extremity injuries.

Lower extremity injuries are common in competitive alpine skiers, and the knee and lower leg are often affected. The hamstring muscles, especially the biceps femoris long head (BFlh), can stabilize the knee and the hip and may counteract various adverse loading patterns during typical mechanisms leading to severe lower extremity injuries. The aim of the present study was to describe BFlh morphology in youth competitive alpine skiers in relation to sex, age and biological maturation and to investigate its association with the occurrence of traumatic lower extremity injuries in the upcoming season. 95 youth skiers underwent anthropometric measurements, maturity offset estimations and ultrasound assessment, followed by 12-months prospective injury surveillance. Unpaired t tests showed that the two sexes did not differ in BFlh morphology, including fascicle length (Lf), pennation angle (PA), muscle thickness (MT) and average anatomical cross-sectional area (ACSAavg). In contrast, U16 skiers had longer fascicles than U15 skiers (9.5 ± 1.3 cm vs 8.9 ± 1.3 cm, p < 0.05). Linear regression analyses revealed that maturity offset was associated with Lf (R 2 = 0.129, p < 0.001), MT (R 2 = 0.244, p < 0.001) and ACSAavg (R 2 = 0.065, p = 0.007). No association was found between maturity offset and PA (p = 0.524). According to a binary logistic regression analysis, ACSAavg was significantly associated with the occurrence of traumatic lower extremity injuries (Chi-square = 4.627, p = 0.031, RNagelkerke 2 = 0.064, Cohen f = 0.07). The present study showed that BFlh morphology is age- and biological maturation-dependent and that BFlh ACSAavg can be considered a relevant modifiable variable associated with lower extremity injuries in youth competitive alpine skiers.

Identifying the Potential Role of Regional Bone Mineral Density on the Degree of Malleolar Involvement in Acute Ankle Fractures

Ankle fractures are a common traumatic lower extremity injury and are generally classified and characterized by the rotational mechanism of injury. At each malleolus (i.e., posterior, medial, and lateral) a fracture can occur or a ligamentous injury may be sustained. The purpose of this retrospective study was to determine if bone mineral density is a contributing factor on the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were operatively treated by the foot and ankle team throughout our institutional facilities, from July 2017 to August 2019, and in which a preoperative computerized tomography scan was performed. Regional bone mineral density (BMD) was measured by calculating the average Hounsfield Unit (HU) on axial computerized tomography images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. One hundred eight patients met the study criteria. We identified statistically significant relationships between decreased BMD with increasing age (p < .01) and the male gender (p < .01). After adjusting for the covariates age and gender, no statistically significant relationship was identified between BMD and the number of malleoli involved in a given ankle fracture (p = .11). These findings suggest that while more investigation is required for ankle fracture patterns and BMD evaluation, increased age and biologic female gender is significantly related to decreased BMD as identified via HU.

Type of Turnout and Injury Rates in Elite Dancers: A Critically Appraised Topic.

Dancers commonly stand in hip external rotation due to the esthetics that ballet requires. Increased external rotation is desired which leads dancers to find ways to compensate to increase their external rotation, an action known as compensated turnout. Dancers commonly rotate at the tibiofemoral joint and/or the talocrural joint to increase external rotation of the entire lower body, placing increased stress on these joints. This critically appraised topic focuses on the relationship between types of turn out and lower-extremity injury in dancers. In elite dancers, does compensated, anatomical, or functional turnout influence lower-extremity injuries? Three studies met the inclusion criteria and were included in the analysis. One study demonstrated a relationship between compensated turnout and traumatic injuries, low back pain, and number of injuries in modern dancers. Greater compensated turnout in dancers was associated with a greater number of injuries. Two studies showed no relationship between anatomical or functional turnout and injuries in dancers. Based on 3 level 2b studies, there is level C evidence to suggest that increased compensated turnout is associated with increased traumatic lower-extremity injuries, low back pain, and number of injuries in university modern dancers compared with dancers with a reduced angle of compensated turnout. This relationship was not found between anatomical or functional turnout and lower-extremity injuries in elite dancers. There is weak evidence to suggest that compensated turnout, but not anatomical or functional turnout, is related to lower-extremity musculoskeletal injury. More research is needed to study compensatory mechanisms in a broader range of dancers and the relationship to lower-extremity injury.

Analysis of Anastomotic Venous Factors in Traumatic Lower Extremity Injuries Reconstructed by Free Flap.

BackgroundVenous thrombosis has been shown to be the most frequent cause of free flap failure in traumatic lower extremity injuries. However, the roles of various anastomotic venous factors, including venous anastomosis (end-to-end (ETE) or end-to-side (ETS)), venous outflow (one vein or two veins), and recipient venous selection (deep or superficial vein), remain unclear. This retrospective study aims to investigate factors contributing to microvascular complications in patients with lower extremity Gustilo type IIIB/IIIC injuries reconstructed by free flap with a focus on the three abovementioned venous factors.MethodsA total of 44 flap treatment outcomes of 41 patients with these injuries from 2015 to 2020 were assessed according to the three venous factors (type of anastomosis, venous outflow, and vein selection).ResultsThe average patient age was 52 years, with the majority (75.6%) being male. Eight patients (18.2%) returned to the operating room due to venous thrombosis, and five patients (11.4%) experienced total flap failure. The following factors were suspected to have contributed to venous thrombosis: vein size mismatch (n = 2) and recipient vein insufficiency possibly due to post-traumatic vessel disease (PTVD) (n = 6). End-to-side (ETS) anastomoses showed lower venous thrombosis rates than end-to-end (ETE) anastomoses (6.3% versus 25%, p = 0.22), two-vein outflows had lower rates than one (8.3% versus 30%, p = 0.07), and deep veins had the lowest thrombosis rates (7.7%), whereas superficial veins had the highest (38.5%).ConclusionThe key venous factors in preventing venous thrombosis include using as many two-vein ETS anastomoses as possible to deep recipient veins.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma).

Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.

The evolution of lower extremity reconstruction

Reconstruction of the lower extremity is a complex task that has evolved greatly in both technique and indication over the past century. Early advances in treating traumatic lower extremity injuries focused on primary amputation to avoid the high mortality of infection. The introduction of antibiotics improved surgical debridement and local reconstructive options, enhancing the viability of lower extremities with simple and proximal defects. With the advent of microvascular surgery, free tissue transfer techniques provided a means to reconstruct more distal and complex problems. As these surgical techniques have continued to evolve, so too have indications for reconstruction, patient management and post-operative care-now with a greater emphasis on patient quality of life and limb function. The purpose of this article is to outline the evolution of lower extremity reconstruction, and how the standard of practice has changed over time.

Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes.

Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.

The Value of an Orthoplastic Approach to Management of Lower Extremity Trauma: Systematic Review and Meta-analysis.

Background:Management of traumatic lower extremity injuries requires a skill set of orthopedic surgery and plastic surgery to optimize the return of form and function. A systematic review and meta-analysis was performed comparing demographics, injuries, and surgical outcomes of patients sustaining lower extremity traumatic injuries receiving either orthoplastic management or nonorthoplastic management.Methods:Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and GRADE certainty evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were systematically and independently searched. Nine studies published from 2013 through 2019 compared 1663 orthoplastic managed patients to 692 nonorthoplastic managed patients with traumatic lower extremity injuries.Results:Orthoplastic management, compared to nonorthoplastic management likely decreases time to bone fixation [standard mean differences: −0.35, 95% confidence interval (CI): −0.46 to −0.25, P < 0.0001; participants = 1777; studies = 3; I2 = 0%; moderate certainty evidence], use of negative pressure wound therapy [risk ratios (RR): 0.03, 95% CI: 0.00–0.24, P = 0.0007; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence] with reliance on healing by secondary intention (RR: 0.02, 95% CI: 0.00–0.10, P < 0.0001; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence), and risk of wound/osteomyelitis infections (RR: 0.37, 95% CI: 0.23–0.61, P < 0.0001; participants = 224; studies = 3; I2 = 0%; moderate certainty evidence). Orthoplastic management likely results in more free flaps compared to nonorthoplastic management (RR: 3.46, 95% CI: 1.28–9.33, P = 0.01; participants = 592; studies = 5; I2 = 75%; moderate certainty evidence).Conclusion:Orthoplastic management of traumatic lower extremity injuries provides a synergistic model to optimize and expedite definitive skeletal fixation and free flap-based soft-tissue coverage for return of extremity form and function.

Direct admission versus transfer to a tertiary hospital for definitive management of lower extremity injuries: Systematic review and meta-analysis.

Delays in definitive management for traumatic lower extremity injuries may result in morbidity. We compared patients with lower extremity injuries directly admitted to a tertiary hospital for definitive care with patients transferred to that hospital following initial treatment elsewhere. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were searched. Participants sustained lower extremity injuries, definitively treated at a tertiary hospital. Interventions were direct admission to a tertiary hospital for definitive care and patients transferred to that hospital for definitive care after initial management at another location. PRISMA, Cochrane, and grading of recommendations assessment, development and evaluation certainty-evidence guidelines were implemented. Nineteen studies published from 1991 to 2020 compared 3,367 patients directly admitted with 1,046 patients transferred to a hospital for definitive management of lower extremity injuries. Direct admission to a tertiary center, compared with transfer, decreased time to first definitive surgical procedure (standard mean difference, -0.36; 95% confidence interval [CI], -0.57 to -0.16; p = 0.0006; participants, 788; studies, 6; I2 = 34%; high-certainty evidence) and wound infections (risk ratio [RR], 0.38; 95% CI, 0.19-0.77; p = 0.007; participants, 475; studies, 7; I2 = 27%; high-certainty evidence). Risks for diabetic patients (RR, 0.87; 95%CI, 0.77-0.98; p = 0.03; participants, 2,973; studies, 4; I2 = 0%; moderate-certainty evidence), total number of surgeries (standard mean difference, -0.69; 95% CI, -1.02 to -0.36; p < 0.0001; participants, 259; studies, 4; I2 = 35%; moderate-certainty evidence), osteomyelitis (RR, 0.47; 95% CI, 0.28-0.80; p = 0.006; participants, 212; studies, 2; I2 = 0%; moderate-certainty evidence), and total complications (RR, 0.47; 95% CI, 0.32-0.67; p < 0.0001; participants, 729; studies, 5; I2 = 32%; moderate-certainty evidence) are likely lower for direct admits compared with transfers. Direct admission may reduce risks for systemic infections (RR, 0.08; 95% CI, 0.01-0.51; p = 0.007; participants, 198; studies, 2; I2 = 0%; low-certainty evidence), venous thromboembolism (RR, 0.09; 95% CI, 0.01-0.73; p = 0.02; participants, 94; studies, 1; low-certainty evidence), and postoperative bleeding (RR, 0.74; 95% CI, 0.59-0.93; p = 0.01; participants, 2,725; studies, 3; I2 = 0%; low-certainty evidence), compared with transfer. Earlier admission to a definitive tertiary center avoids morbidity associated with transfer delays. Systematic Review/meta-analysis, level III.

Decreasing Opioid Use in Pediatric Lower Extremity Trauma: A Quality Improvement Project.

Perioperative anxiety increases postoperative pain and the risk of complications in hospitalized children. Nonpharmacologic pain resources provided by Certified Child Life Specialists (CCLS) are a viable adjunct for pain management. A routine CCLS consult was implemented for patients admitted to the orthopedic service with traumatic lower extremity injuries requiring surgery. A retrospective chart review compared patients who did not receive a CCLS consult. Daily pain rating scores, total doses of opioid and nonopioid pain medication, number of physical therapy attempts, length of stay, and demographics were compared for both groups. A clinically significant improvement was seen for decreased pain rating scores and opioid use after a routine CCLS consult was implemented. Adopting a routine CCLS consult for children with unplanned admissions because of trauma reduces the number of opioids used, provides children with pain management resources, and promotes coping skills that may be used in the future.

A novel assessment for Readiness Evaluation during Simulated Dismounted Operations: A reliability study.

ObjectiveTo determine the intersession reliability of the Readiness Evaluation during Simulated Dismounted Operations (REDOp), a novel ecologically-based assessment for injured Service Members, provide minimal detectable change values, and normative reference range values. To evaluate the ability to differentiate performance limitations between able-bodied and injured individuals using the REDOp.DesignRepeated measures design and between group comparison.SettingOutpatient rehabilitative care setting.ParticipantsService Members who were able-bodied (n = 32) or sustained a traumatic lower extremity injury (n = 22).InterventionsDuring the REDOp, individuals walked over variable terrain as speed and incline progressively increased; they engaged targets; and carried military gear.Main outcome measuresEndurance measured using total distance traveled; walking stability measured using range of full-body angular momentum; and shooting accuracy, precision, reaction time and acquisition time.ResultsIntersession reliability analyses were conducted on a sub-group of 18 able-bodied Service Members. Interclass correlation coefficient values were calculated for distance traveled (0.91), range of angular momentum about three axes (0.78–0.93), shooting accuracy (0.61), precision (0.47), reaction time (0.21), and acquisition time (0.77). Service Members with lower extremity injury demonstrated significantly less distance traveled with a median distance of 0.89 km compared to 2.73 km for the able-bodied group (p < 0.001). Service Members with lower extremity injury demonstrated significantly less stability in the frontal and sagittal planes than the able-bodied group (p < 0.001). The primary performance limiter was endurance followed by pain for both groups. There was no evidence of ceiling effects.ConclusionsThe REDOp is a highly reliable, military-relevant assessment that can be used to measure performance and identify deficits across the domains of activity tolerance, gait stability, and shooting performance.

Effects of Perioperative Venous Thromboembolism on Outcomes in Soft Tissue Reconstruction of Traumatic Lower Extremity Injuries.

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a significant perioperative complication. However, the outcomes of lower extremity salvage in the setting of perioperative VTE are not well reported. A retrospective review of lower extremity trauma patients requiring soft tissue reconstruction between July 2007 and December 2015 at an urban trauma center was performed. Patients with clinically apparent VTE during inpatient stay were identified. Outcomes compared included success of limb salvage, flap survival, and flap complications. Comorbidities, injury characteristics and perioperative data were also compared between patients with and without VTE. One hundred ninety patients with lower extremity injuries underwent local and free flap procedures, with 12 (6.3%) patients developing clinically apparent VTE during hospitalization. Nine VTEs (75.0%) were diagnosed prior to soft tissue reconstruction, and 3 (25.0%) VTEs were diagnosed postreconstruction. The limb salvage rate in patients with VTE was 100%. There were no flap losses in patients with VTE, and the overall flap complication rate was similar between VTE and non-VTE groups (P = 0.26). However, there was an increased risk of postoperative hematoma in patients undergoing free flap transfer with diagnosed VTE compared with patients receiving free flaps without VTE (40.0% vs 2.6%, P = 0.02). Additionally, 1 patient died as a result of pulmonary embolism, and another patient experienced an ischemic stroke from a paradoxical embolism. These results suggest that successful limb salvage and flap survival may be achieved in the setting of perioperative VTE, although anticoagulation prophylaxis and treatment are critical in this population due to significant morbidity and mortality associated with VTE.

Feasibility and acceptability of telephone‐delivered cognitive‐behavioral‐based physical therapy for patients with traumatic lower extremity injury

AbstractPurposeTo determine feasibility and acceptability of a telephone‐based Cognitive‐Behavioral‐Based Physical Therapy program for patients following traumatic lower extremity injury (CBPT‐Trauma).MethodsPatients were screened for high psychosocial risk factors and then completed the 6‐week CBPT‐Trauma program. Physical function, pain, and psychosocial outcomes were assessed at baseline and 6‐months follow‐up. Descriptive statistics assessed change in outcomes.ResultsRecruitment rate was 59%. Twenty‐seven patients (73%) had a high psychosocial risk profile. Twelve patients completed the program and the follow‐up assessment at 6 months and found the program to be very or extremely helpful to their overall recovery. All demonstrated a clinically meaningful increase in physical function. Six patients demonstrated a clinically relevant decrease in pain intensity, pain catastrophizing, and fear of movement. Seven patients reported a clinically meaningful increase in pain self‐efficacy.DiscussionFindings suggest that recruitment is feasible for CBPT‐Trauma program. However, engagement in the CBPT‐Trauma study was low. For those that completed the program, patients were satisfied with the CBPT‐Trauma program and experienced meaningful improvement in psychosocial factors and patient‐reported outcomes. This open pilot study highlights the importance of targeted treatment for patients at high‐risk for poor outcomes and the potential for increased access to services through telephone‐delivery.

COULD LOWER EXTREMITY INJURIES INCREASE BMI IN CHILDREN?

PURPOSE: The purpose of this investigation is to examine the relationship between forced sedentariness attributed to the management of a lower extremity injury and change in BMI in pediatric patients. INTRODUCTION: Over the past 30 years, childhood obesity has significantly increased. Lack of physical activity and rising levels of sedentary living are associated with rising childhood obesity. As the effects of childhood obesity are long lasting, it is important to characterize childhood conditions that lead to increases in BMI. Traumatic lower extremity injuries in children commonly result in casting and forced immobilization. Children and adolescents who cease physical activity at a younger age are at a higher risk for weight gain and inactive lifestyles as adults. Presently, the data examining short term and longitudinal effects of injury on weight changes are lacking. Therefore, the purpose of this investigation is to examine the relationship between forced sedentariness attributed to the management of a lower extremity injury and change in BMI in pediatric patients. METHODS: Eighty eight subjects aged 5 to 18 with lower extremity fractures managed with non-weight bearing for a minimum of 6 weeks were identified. This group was compared to a cohort of controls, who presented to the pediatric orthopaedic clinic for upper extremity injuries. For each subject, BMI was calculated from height and weight data obtained at each clinic visit for which the data were available for a minimum of 6 months. Percent change in BMI was then calculated and compared between the lower extremity injury group and controls utilizing ANOVA. Logistic regression was then performed to determine if age, gender, and undergoing surgery were correleated with a BMI change of greater than 10%. RESULTS: The results of initial ANOVA analysis demonstrated no difference in BMI trends between children with lower extremity injuries and controls. On average, both groups showed a modest increase in BMI over time (lower extremity injuries = 3.40%, controls = 3.23%). Logistic analysis of the lower extremity revealed male gender to be associated with a 10% increase in BMI during the study period, though this was not significant (p = 0.153) CONCLUSIONS: Our investigation yielded a negative result. As there is limited literature on BMI trends in children, our power calculation may have underestimated the subjects needed to demonstrate a statistically significant difference between groups. SIGNIFICANCE: The increases observed in both groups may indicate that the experience of being injured is associated with increases in BMI regardless of the location of injury. Further investigation would involve assessing BMI trends prospectively to identify opportunities to obviate possible weight gain with injury.

Can a 2-Day Course Teach Orthopaedic Surgeons Rotational Flap Procedures? An Evaluation of Data From the Nepal SMART Course Over 2 years.

Traumatic lower extremity injuries requiring multidisciplinary treatment pose a challenge in low- and middle-income countries, where access to specialists may be limited. The surgical management and reconstructive training (SMART) course teaches orthopaedic surgeons muscle and fasciocutaneous flap procedures to address this scarcity. The purpose of this study is to assess the effectiveness of the SMART course in improving competency and comfort in performing common lower extremity flap procedures among participants. Sixty-four orthopaedic surgeons from different regions of Nepal and Bhutan participated in the Nepal SMART course in 2016 and 2017. A competency test-consisting of questions from US in-training plastic and orthopaedic surgery examinations-was administered to attendees before and after the course. Thirty-two participants from 2016 were asked to rate their comfort level in performing flap procedures both pre- and postcourse. Overall competency test scores, as well as scores in the plastic surgery section, increased significantly after the course (P < 0.01). The precourse competency test scores were higher in 2016 compared with 2017 (P = 0.02). There was a higher increase in overall competency test scores after the course in 2016 compared with 2017 (P = 0.03). The procedure comfort levels reported by attendees increased for all flaps (P < 0.01). These results demonstrate the ability of the SMART course to improve the competency and comfort levels of orthopaedic surgeons in performing common lower extremity flap procedures. Despite the differences in years in practice and previous experience in performing flaps, the course yielded significantly better results in 2017 compared with 2016, showing that the implementation of the course has been improving.