Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study.

BACKGROUND: The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS: The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS: There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS: Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds.

Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

INTRODUCTION: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Open, combat-related loss, or disruption of the knee extensor mechanism: treatment strategies, classification, and outcomes.

OBJECTIVE: To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. DESIGN: Retrospective review. SETTING: Tertiary (Level/Role V) Military Treatment Facility. PATIENTS: Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. INTERVENTION: Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. MAIN OUTCOME MEASURES: Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. RESULTS: The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. CONCLUSIONS: High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Risk factors for infection and amputation following open, combat-related calcaneal fractures.

BACKGROUND: High-energy open calcaneal fractures are severe injuries complicated by high rates of infection, uncertain functional outcomes, and frequent need for later amputation. METHODS: We conducted a retrospective review of 102 consecutive combat-related open calcaneal fractures. Patient demographics, injury mechanisms, fracture and wound characteristics, associated fractures, and methods of fracture fixation were reviewed to determine risk factors for eventual amputation or infection. RESULTS: Eighty-nine patients, with a mean age of twenty-six years, sustained 102 open calcaneal fractures (thirteen bilateral). After a mean follow-up of four years (range, five to ninety-two months), 42% (forty-three limbs) underwent amputation. A delayed amputation (more than twelve weeks from the time of injury) was performed in 15% (fifteen) of 102 open calcaneal fractures. In a multivariate Cox proportional-hazards survival model with time to amputation as the end point, the blast mechanism of injury, plantar wound location, larger size of open wound (in square centimeters), and escalating Gustilo and Anderson classification types (p < 0.05 for all) were predictive of eventual amputation. At the time of the final follow-up, patients who had undergone amputation had lower visual analogue scale scores for pain (2.1 compared with 4.0; p < 0.0001) and higher Tegner activity levels (5.4 compared with 3.5; p < 0.0001) than limb salvage patients. CONCLUSIONS: Lower-extremity amputation following open calcaneal fractures is predicted by the injury mechanism, wound location and size, and open fracture type and severity. After short-term follow-up, patients with open calcaneal fractures eventually requiring amputation exhibit improved pain and activity levels compared with patients with continued, ostensibly successful limb salvage.

Evolution of orthopaedic rehabilitation care.

Rehabilitation following surgical reconstruction for combat-related extremity injuries sustained in the current conflicts in Iraq and Afghanistan has been challenging. The goal of rehabilitation is to restore limb function to facilitate the reintegration of patients with these severe injuries into society. The US Department of Defense has developed a network of rehabilitation centers of excellence within the military healthcare system in collaboration with the US Department of Veterans Affairs to optimize outcomes using technologic and systemic advances in prostheses in patients who have undergone limb salvage procedures or amputation. Managing pain during rehabilitation and optimizing function following high bilateral lower extremity amputation remains a clinical challenge. However, continued research is likely to improve outcomes in this severely injured patient population. To that end, two research consortia, the Bridging Advanced Developments for Exceptional Rehabilitation and the Center for Rehabilitation Sciences Research, have recently been created to address identified knowledge gaps.

Reprioritization of research for combat casualty care.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Combat-related hemipelvectomy.

Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. Second-look debridements and delayed wound closure are mandatory. A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries.

Outcomes associated with the internal fixation of long-bone fractures proximal to traumatic amputations.

BACKGROUND: Preservation of optimal residual limb length following a traumatic amputation can be challenging. The purpose of this study was to determine if acceptable results can be achieved by definitive fixation of a long-bone fracture proximal to a traumatic amputation. METHODS: We identified thirty-seven active-duty military service members who underwent internal fixation of a long-bone fracture proximal to a traumatic amputation. Functional status was assessed with the Tegner activity level scale and prosthesis use. Secondary outcome measures were the development of nonunion, infection, and heterotopic ossification. RESULTS: Twelve patients (32%) underwent amputation and fracture in the same osseous segment. Ten patients (27%) sustained bilateral traumatic amputations, and eight (22%) had a major fracture of the contralateral extremity. The median times to fracture fixation and amputation closure were twelve days and nineteen days, respectively, after the injury. The mean Tegner activity score was 3.32 (range, 1 to 6); patients with isolated extremity injuries had significantly higher Tegner scores than those with severe bilateral injuries (3.59 and 2.38, respectively; p = 0.04). Thirty-three patients (89%) developed an infection requiring surgical debridement. However, all fractures were treated until union occurred, and amputation level salvage was successful in all instances. Heterotopic ossification developed in twenty-eight patients (76%), with operative excision required in eleven patients (39%). CONCLUSIONS: High complication rates, but acceptable final results, can be achieved with internal fixation of a fracture proximal to a traumatic amputation to preserve functional joint levels or salvage residual limb length.