Donor Limb Functional Restoration via a Novel Clinical Care Pathway following Fibula Free Flap Harvest for Head and Neck Reconstruction.

Patients undergoing head and neck skeletal reconstruction (HNR) often require free tissue transfer from the extremities to ensure proper restoration of form and function. This requires a team-based, highly reliable medical system centered around the patient needs. Surgical intervention across multiple sites and harvesting of donor tissue results in short- and long-term physical impairments. There is a paucity of research objectively measuring impairments resulting from the graft donor site. There is a lack of research that objectively measures impairments and protocols for the management of these patients postoperatively. Patients undergo little, if any, formal approach to dealing with the vast impairments, which are sequelae to this surgery. This leads to large discrepancies in proposed functional progressions, return to duty timelines, and utilization of rehabilitative resources. At a major military medical center, an innovative clinical care pathway for patients undergoing HNR using free tissue transfer was implemented using a multidisciplinary model that focuses on early engagement with rehabilitation. This model, paired with a single surgery, will attempt to return service members to duty months earlier than the traditional approach. This report describes the conceptual framework and implementation of a new criteria-based, multidisciplinary clinical care pathway for HNR patients. The collaboration amongst the multidisciplinary care team has optimized the holistic health of the patient and communication with their support network, yielding faster return to normalization of daily life activities. The long-term goal is to further develop and formalize this pathway to best serve this patient population.

Running footstrike pattern effect on lower extremity work in an individual with transtibial amputation.

Asymmetrical loading favoring the intact limb during running has been associated with increased prevalence of reported knee pain and potential risk factors of knee osteoarthritis in that limb for patients with amputation. Footstrike pattern alterations have been suggested to help alleviate some overloading of the knee, but little is known about how it affects the rest of the limb. The purpose of this case study was to evaluate the effect of footstrike pattern on the distribution of loading throughout the lower extremities during submaximal running of an individual with transtibial amputation (TTA). This study compared loading distribution among the lower extremity joints in a male patient who sustained a TTA and ran using both a rearfoot (RFS) and forefoot strike (FFS) pattern. The results of this case demonstrated that altering footstrike pattern minimally alters the total mechanical work being done by the lower extremities but more so affects the relative amount of work contributed by the individual joints. In the intact limb, the ankle contributes the most to power absorption using a FFS pattern while the knee has a larger role using a RFS pattern. This case suggests that the footstrike pattern affects lower extremity loading distribution at the joint level, and adopting a FFS pattern may alleviate overloading the knee, whereas a RFS pattern may reduce loading at the ankle in individuals with TTA.

Common fall-risk indicators are not associated with fall prevalence in a high-functioning military population with lower limb trauma.

BACKGROUND: Persons with lower limb trauma are at high risk for falls. Although there is a wide range of measures used to assess stability and fall-risk that include performance measures, temporal-spatial gait parameters, and nonlinear dynamic stability calculations, these measures are typically derived from fall-prone populations, such as older adults. Thus, it is unclear if these commonly used fall-risk indicators are effective at evaluating fall-risk in a younger, higher-functioning population of Service members with lower limb trauma. METHODS: Twenty-one Service members with lower limb trauma completed a battery of fall-risk assessments that included performance measures (e.g., four-square-step-test), and gait parameters (e.g., step width, step length, step time) and dynamic stability measures (e.g., local divergence exponents) during 10 min of treadmill walking. Participants also reported the number of stumbles and falls over the previous 4 weeks. Negative Binomial and Quasibinomial Regressions were used to evaluate the strength of associations between fall-risk indicators and self-reported falls. FINDING: Participants reported on average stumbling 6(4) times and falling 2(3) times in the previous 4 weeks. At least one fall was reported by 62% of the participants. None of the fall-risk indicators were significantly associated with fall prevalence in this population of Service members with lower limb trauma (p > 0.1). INTERPRETATION: Despite the high number of reported falls in this young active population, none of the fall-risk indicators investigated effectively captured and quantified the fall-risk. Further research is needed to identify appropriate fall-risk assessments for young, high-functioning individuals with lower limb trauma.

Assessments of trunk postural control within a fall-prevention training program for service members with lower limb trauma and loss.

BACKGROUND: Trunk postural control (TPC) is critical in maintaining balance following perturbations (i.e., avoiding falls), and impaired among persons with lower extremity trauma, contributing to elevated fall risk. Previously, a fall-prevention program improved TPC in individuals with unilateral transtibial amputation following trip-inducing perturbations. However, it is presently unclear if these improvements are task specific. RESEARCH QUESTION: Do improvements to TPC gained from a fall-prevention program translate to another task which assesses TPC in isolation (i.e., unstable sitting)? Secondarily, can isolated TPC be used to identify who would benefit most from the fall-prevention program? METHODS: Twenty-five individuals (21 male/4 female) with lower extremity trauma, who participated in a larger fall-prevention program, were included in this analysis. Trunk flexion and flexion velocity quantified TPC following perturbation; accelerometer-based sway parameters quantified TPC during unstable sitting. A generalized linear mixed-effects model assessed training-induced differences in TPC after perturbation; a generalized linear model assessed differences in sway parameters following training. Spearman's rho related training-induced changes to TPC following perturbation (i.e., the difference in TPC measures at pre- and post-training assessments) with pre- vs. post-training changes to sway parameters during unstable sitting (i.e., the difference in sway parameters at pre- and post-training assessments) as well as pre-training sway parameters with the pre- vs. post-training differences in TPC following perturbation. RESULTS: Following training, trunk flexion angles decreased, indicating improved TPC; however, sway parameters did not differ pre- and post-training. In addition, pre- vs. post-training differences in TPC following perturbation were neither strongly nor significantly correlated with sway parameters. Moreover, pre-training sway parameters did not correlate with pre- vs. post-training differences in trunk flexion/flexion velocity. SIGNIFICANCE: Overall, these results indicate that improvements to TPC gained from fall-prevention training are task-specific and do not translate to other activities. Moreover, isolated TPC measures are not able to identify individuals that benefit most from the fall-prevention program.

Military Service Members with Major Lower Extremity Fractures Return to Running with a Passive-dynamic Ankle-foot Orthosis: Comparison with a Normative Population.

BACKGROUND: Lower extremity fractures represent a high percentage of reported injuries in the United States military and can devastate a service member's career. A passive dynamic ankle-foot orthosis (PD-AFO) with a specialized rehabilitation program was initially designed to treat military service members after complex battlefield lower extremity injuries, returning a select group of motivated individuals back to running. For high-demand users of the PD-AFO, the spatiotemporal gait parameters, agility, and quality of life is not fully understood with respect to uninjured runners. QUESTIONS/PURPOSES: Do patients who sustained a lower extremity fracture using a PD-AFO with a specialized rehabilitation program differ from uninjured service members acting as controls, as measured by (1) time-distance and biomechanical parameters associated with running, (2) agility testing (using the Comprehensive High-level Activity Mobility Predictor performance test and Four Square Step Test), and (3) the Short Musculoskeletal Function Assessment score. METHODS: We conducted a retrospective data analysis of a longitudinally collected data registry of patients using a PD-AFO from 2015 to 2017 at a single institution. The specific study cohort were patients with a unilateral lower extremity fracture who used the PD-AFO for running. Patients had to be fit with a PD-AFO, have completed rehabilitation, and have undergone a three-dimensional (3-D) running analysis at a self-selected speed at the completion of the program. Of the 90 patients who used the PD-AFO for various reasons, 10 male service members with lower extremity fractures who used a PD-AFO for running (median [range] age 29 years [22 to 41], height 1.8 meters [1.7 to 1.9], weight 91.6 kg [70 to 112]) were compared with 15 uninjured male runners in the military (median age 33 years [21 to 42], height 1.8 meters [1.7 to 1.9], weight 81.6 kg [71.2 to 98.9]). The uninjured runners were active-duty service members who voluntarily participated in a gait analysis at their own self-selected running speeds; to meet eligibility for inclusion as an uninjured control, the members had to be fit for full duty without any medical restrictions, and they had to be able to run 5 miles. The controls were then matched to the study group by age, weight, and height. The primary study outcome variables were the running time-distance parameters and frontal and sagittal plane kinematics of the trunk and pelvis during running. The Four Square Step Test, Comprehensive High-level Activity Mobility Predictor scores, and Short Musculoskeletal Function Assessment scores were analyzed for all groups as secondary outcomes. Nonparametric analyses were performed to determine differences between the two groups at p < 0.05. RESULTS: For the primary outcome, patients with a PD-AFO exhibited no differences compared with uninjured runners in median (range) running velocity (3.9 meters/second [3.4 to 4.2] versus 4.1 meters/second [3.1 to 4.8], median difference 0.2; p = 0.69), cadence (179 steps/minute [169 to 186] versus 173 steps/minute [159 to 191], median difference 5.8; p = 0.43), stride length (2.6 meters [2.4 to 2.9] versus 2.8 meters [2.3 to 3.3], median difference 0.2; p = 0.23), or sagittal plane parameters such as peak pelvic tilt (24° [15° to 33°] versus 22° [14° to 28°], median difference 1.6°; p = 0.43) and trunk forward flexion (16.2° [7.3° to 23°) versus 15.4° [4.2° to 21°), median difference 0.8°; p > 0.99) with the numbers available. For the secondary outcomes, runners with a PD-AFO performed worse in Comprehensive High-level Activity Mobility Predictor performance testing than uninjured runners did, with their four scores demonstrating a median (range) single-limb stance of 35 seconds (32 to 58) versus 60 seconds (60 to 60) (median difference 25 seconds; p < 0.001), t-test result of 15 seconds (13 to 20) versus 13 seconds (10 to 14) (median difference 2 seconds; p < 0.001), and Illinois Agility Test result of 22 seconds (20 to 25) versus 18 seconds (16 to 20) (median difference 4; p < 0.001). Edgren side step test result of 20 meters (16 to 26) versus 24 meters (16 to 29) (median difference 4 meters; p = 0.11) and the Four Square Step Test of 5.5 seconds (4.1 to 7.2) versus 4.2 seconds (3.1 to 7.3) (median difference 1.3 seconds; p = 0.39) were not different between the groups with an effect size of 0.83 and 0.75, respectively. CONCLUSION: The results of our study demonstrate that service members run with discernible differences in high-level mobility and demonstrate inferior self-reported patient functioning while having no differences in speed and biomechanics compared with their noninjured counterparts with the sample size available. This study is an early report on functional gains of highly motivated service members with major lower extremity injuries who use a PD-AFO and formalized therapy program to run. LEVEL OF EVIDENCE: Level III, therapeutic study.

Limb Salvage With Intrepid Dynamic Exoskeletal Orthosis Versus Transtibial Amputation: A Comparison of Functional Gait Outcomes.

OBJECTIVES: To determine if there is a difference in functional gait outcomes between patients with limb injuries treated with either transtibial amputation or limb preservation with the Intrepid Dynamic Exoskeletal Orthosis. DESIGN: Retrospective prognostic study. SETTING: Tertiary referral military hospital. PATIENTS: This study included 10 transtibial amputees and 10 limb preservation patients using the Intrepid Dynamic Exoskeletal Orthosis who were matched by body mass index after excluding for nontraumatic, proximal ipsilateral, contralateral, spine, or traumatic brain injuries. Transtibial amputation patients were also excluded if they did not have a gait study between 6 and 12 months after independent ambulation. Limb preservation were excluded if they did not complete the "Return to Run" program. INTERVENTIONS: An observational study of functional outcomes using instrumented gait analysis. OUTCOME MEASURES: Spatiotemporal, kinetic (vertical ground reaction force), unified deformable power, work, and efficiency. RESULTS: Limb preservation patients walked with a significantly slower cadence (P = 0.036) and spent less time on their affected limb in stance (P = 0.045), and longer in swing (P = 0.019). Amputees had significantly increased maximum positive power in both limbs (P = 0.004 and P = 0.029) and increased maximum negative power on the unaffected limb (P = 0.035). Amputees had significantly increased positive and negative work in the affected limb (P = 0.0009 and P = 0.014) and positive work in the unaffected limb (P = 0.042). There was no significant difference in the kinetic data or efficiency. CONCLUSIONS: Limb preservation patients spend less time on their affected limb as a percentage of the gait cycle. The unified deformable power demonstrated more dynamic gait in amputees, with peak values closer to normative data. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.