The Influence of Tobacco Use, Alcohol Consumption, and Weight Gain on Development of Secondary Musculoskeletal Injury After Lower Limb Amputation.

OBJECTIVES: To evaluate whether tobacco use, alcohol consumption, and weight gain are associated with the diagnosis of overuse musculoskeletal injuries within the first 12 months after lower limb amputation. DESIGN: Retrospective cohort study. SETTING: Military treatment facilities. PARTICIPANTS: Service members (N=681) with a deployment-related lower limb amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical diagnosis codes associated with musculoskeletal overuse injuries of the lower limb, upper limb, and low back regions. RESULTS: In the first three months after amputation, tobacco use and alcohol consumption were reported in 55.7% and 72.0%, respectively, of the retrospective sample. The overall mean weight change was 22.9±23.6 pounds. The prevalence of reporting at least 1 overuse injury within 4 to 12 months after amputation was 57.0% in the sample, with prevalence rates of lower limb, upper limb and low back pain diagnoses at 28.3%, 21.7%, and 21.1%, respectively. Service members reporting tobacco use in the first 3 months after amputation were nearly twice as likely to be diagnosed with a lower limb musculoskeletal injury 4 to 12 months after amputation. Similarly, service members reporting alcohol consumption within the first 3 months after amputation were more than twice as likely to be diagnosed with at least 1 overuse musculoskeletal injury 4 to 12 months after amputation. However, weight change or maximum weight after amputation were not associated with the diagnosis of an overuse musculoskeletal injury. CONCLUSIONS: Development of secondary overuse musculoskeletal injury appears to be related to tobacco use and alcohol consumption, but not to weight gain. These findings warrant focused research efforts toward developing preventive interventions.

Do Gait and Functional Parameters Change After Transtibial Amputation Following Attempted Limb Preservation in a Military Population?

BACKGROUND: Surgical attempts at lower limb preservation after trauma may be complicated by pain and gait disturbances, which can impact the activity level of a military service member. It is unclear how later transtibial amputation (TTA) might affect patients who elect this option after attempts at limb preservation. QUESTIONS/PURPOSES: The purposes of the study were to compare preamputation and postamputation (1) the numeric rating scale for pain and pain medication use; (2) self-reported activity level, Four Square Step Test (FSST) results, and assistive device use; and (3) spatiotemporal variables measured with instrumented gait analysis in individuals who elected TTA after multiple attempts at limb preservation. METHODS: Retrospective review revealed 10 patients with unilateral lower extremity injuries who underwent late TTA between 2008 and 2016. All patients had undergone multiple limb preservation attempts and had completed instrumented gait evaluations as part of their routine care before and after TTA. One patient was excluded as a result of short followup. The remaining nine patients (eight men, 29 ± 6 years) averaged five surgeries before amputation. Injuries were from improvised explosive devices (six), motorcycle accidents (two), and one training accident. Strict indications for amputation were pain, difficulties performing activities of daily living, limited physical function, and medication dependence. Data for the aforementioned purposes were collected by gait laboratory staff before and 8 to 17 months after amputation. Time to TTA after initial injury was 5 ± 3 years. At the start of the gait analysis study, pain was assessed at rest, activity level was recorded by patient report, and the FSST was administered. RESULTS: After TTA, there was a decrease in pain scores from 4 ± 2 to 1 ± 1 and patients using narcotics decreased from four to only one patient. Self-reported walking endurance increased from 1 ± 1 mile to 7 ± 8 miles and patients able to run increased from one patient to eight with the ninth having no desire to run but bicycled. Patient FSST times improved from 12 ± 10 seconds to 5 ± 1 seconds. No patients required assistive devices after TTA. There were improvements in velocity (108 ± 16 cm/s to 142 ± 7 cm/s), stride length (129 ± 14 cm to 154 ± 8 cm), cadence (101 ± 9 steps/min to 111 ± 7 steps/min), and step width (16 ± 3 cm to 12 ± 2 cm) between pre- and postassessments. Asymmetric single-limb stance time was measured both pre- and postamputation; this did not worsen with the increase in walking velocity. CONCLUSIONS: The findings of this study show that TTA after attempted limb preservation in a young, motivated group of service members after traumatic injuries can be successful in decreasing pain and narcotic use and can allow for high-level functional activities. Future studies will be needed to compare this cohort with patients who underwent early TTA after traumatic injury. However, we acknowledge that the resources and support structure available for this population are unique and may not be readily available to the general population. LEVEL OF EVIDENCE: Level IV, therapeutic study.