Cost-effectiveness analysis of routine computed tomography angiography (CTA) for lower extremity penetrating trauma.

BACKGROUND: Routine evaluation with CTA for patients with isolated lower extremity penetrating trauma and normal ankle-brachial-indices (ABI) remains controversial. While prior literature has found normal ABI's (≥0.9) and a normal clinical examination to be adequate for safe discharge, there remains concern for missed injuries which could lead to delayed surgical intervention and unnecessary morbidity. Our hypothesis was that routine CTA after isolated lower extremity penetrating trauma with normal ABIs and clinical examination is not cost-effective. METHODS: We performed a decision-analytic model to evaluate the cost-effectiveness of obtaining a CTA routinely compared to clinical observation and ABI evaluation in hemodynamically normal patients with isolated penetrating lower extremity trauma. Our base case was a patient that sustained penetrating lower extremity trauma with normal ABIs that received a CTA in the trauma bay. Costs, probability, and Quality-Adjusted Life Years (QALYs) were generated from published literature. RESULTS: Clinical evaluation only (no CTA) was cost-effective with a cost of $2056.13 and 0.98 QALYs gained compared to routine CTA which had increased costs of $7449.91 and lower QALYs 0.92. Using one-way sensitivity analysis, routine CTA does not become the cost-effective strategy until the cost of a missed injury reaches $210,075.83. CONCLUSIONS: Patients with isolated, penetrating lower extremity trauma with normal ABIs and clinical examination do not warrant routine CTA as there is no benefit with increased costs.

Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients.

PURPOSE: Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma-specific assessment of the lower extremities for injuries. This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase. METHODS: This diagnostic, prognostic observational cohort study was performed on trauma patient treated at one level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g., open fracture), active elevation of the leg, and cautious elevation of the lower extremity from the heel. SILENT was considered positive when obvious fracture was present and painful or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity, and receiver operating characteristic testing. RESULTS: 403 trauma bay patients were included, mean age 51.6 (SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity was 75% (95%CI 64 to 84%), and overall specificity was 99% (95%CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. AUC was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99). CONCLUSION: The SILENT test is a clinical applicable and feasible rule-out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging. Further large-scale prospective studies might be required to corroborate the beneficial effects of the SILENT test.

Efficacy of rehabilitation after provision of ICRC lower limb prostheses in low-income and middle-income countries: A quantitative assessment from Myanmar.

BACKGROUND: Low-income and middle-income countries (LMICs) have poorly resourced health services. Lack of access to assistive devices, such as prosthetics, may limit the functional outcomes of persons with amputation and affect quality of life (QoL). OBJECTIVE: The objective of this study was to assess the functional level and QoL of prosthetic users in LMICs when prescribed a prosthesis made from International Committee for Red Cross (ICRC) components. STUDY DESIGN: The study design included a quantitative descriptive methodology assessing functional outcomes and QoL after prosthetic provision. METHODS: Participants were identified from the prosthetic service in Mandalay, Myanmar. Included participants were those with unilateral, traumatic, lower limb amputations, with ICRC devices delivered at least 6 months earlier. Participants attended the prosthetic service and were assessed using the Amputee Mobility Predictor with Prosthesis tool and the World Health Organization Quality of Life Brief and Disability modules. RESULTS: Thirty-five participants completed the study; of them, 63% were persons with transtibial level amputation and 37% were with transfemoral level amputation. Approximately 83% achieved a score of more than 37 using the Amputee Mobility Predictor with Prosthesis. There is a strong positive correlation between QoL and physical health (r = 0.55; p < 0.001), social relationships (r = 0.66; p < 0.001), and inclusion (r = 0.53; p < 0.001). Participants had a better QoL and overall health when they had better psychological health. CONCLUSION: The patient-based results presented within this study could be considered as a contribution to the evidence base and importance of provision of prosthetic services in LMICs. It was observed that participants with an amputation were able to achieve a high level of physical function with the ICRC prostheses while also reporting a high QoL.

Bumping to a rollator walker: How pretibial hematomas create more costs than pretibial lacerations.

Pretibial lacerations (PL) and pretibial hematomas (PH) are debilitating traumas among the elderly and infirm. The injuries are frequently grouped together despite differences in treatment and symptoms. Patients are known to have multiple contacts in health care, perhaps because of inadequate treatment. Despite the burden, financial costs have not been assessed. Calculate and compare the treatment costs of PLs and PHs for differences and provide economic incentives to treat and diagnose patients optimally. From linkage to ICD10 diagnoses, we analysed NordDRG product invoices generated by the treatment of the patients. We calculated and compared the costs of treatment in both cohorts from the invoices. This method has not been previously used for analysing wound care costs. Mean treatment costs were 1800€ (PL) and 3300€ (PH). The total costs, emergency room, surgical treatment, and inpatient care of PHs were higher than PLs (P = .0486, P = .0002, P = .0058, P = .6526). PLs generate more costs from the outpatient clinic but were not statistically significant (P = .6533). PHs cause a higher economic burden than PLs. Costs arise from repeat ER visits and the need for surgeries because of delayed treatment. PLs have multiple contacts in the wound clinic. Improvement in the diagnosis and treatment of both injuries is needed.

Mangled Extremity Severity Score in the Assessment of Extremity Injuries - Is it Reliable?

The mangled extremity severity score (MESS) was established 28 years ago to decide performing an amputation in cases of limb trauma. It assigns points for 4 aspects of the injury: the extent of soft tissue and skeletal injury, limb ischemia and ischemic duration, shock, and age. A score of 7 or higher indicates that primary amputation is required. Thirty-one patients with MESS scores of 7 to 8 underwent limb salvage surgeries, with 13 limbs being saved and 18 limbs being amputated. Upper extremities trauma had a salvage rate of 62.5%, whereas lower extremity trauma had a salvage rate of 20%. MESS is not a sensitive predictor of amputation in upper limb trauma, but it is useful in lower limb injuries.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Risk assessment in delayed free flap reconstruction for severe lower extremity trauma.

PURPOSE: This study aims to identify serum biomarkers that contribute to vascular thrombosis and complete flap failure in delayed reconstruction with free flaps, as well as to develop a scoring system of risk assessment including these biomarkers. METHODS: A retrospective review of the database was conducted for lower extremity open fractures reconstructed between 7 and 90 days from injury, from March 2014 to February 2022. We investigated changes in platelet count (PLT), D-dimer, creatine phosphokinase (CPK), and C-reactive protein (CRP) and then, developed a risk assessment system including these biomarkers as risk factors. RESULTS: A total of 62 free flaps were enrolled, and vascular thrombosis occurred in 14 flaps (22.6%), 9 of which (14.5%) developed complete flap failure. The risk assessment score was set to a maximum of 6 points for 6 items: age ≤ 40 years, time from injury to coverage ≥ 14 days, zone of injury from middle to distal leg, D-dimer on the day of injury ≥ 60 µg/mL, maximum value of CPK ≥ 10,000 U/L, and maximum value of CRP ≥ 25 mg/dL. The best cutoff score was 3 in the vascular thrombosis model (sensitivity: 0.79, specificity: 0.77) and 4 in the complete flap failure model (sensitivity: 0.78, specificity: 0.92). CONCLUSIONS: Our risk assessment system showed that the risk of vascular thrombosis was high at ≥ 3 points and that of complete flap failure was high at ≥ 4 points. Significantly, elevated levels of D-dimer, CPK, and CRP require more caution during reconstruction using free flaps.

What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury?

OBJECTIVE: To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND: The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS: Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS: A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS: Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.

Identifying Patients at Risk for Venous Thromboembolic Events After Isolated Upper Extremity Trauma: A Predictive Scale.

Previous studies have defined risk factors for development of venous thromboembolisms (VTEs) among patients with lower extremity orthopedic trauma. Limited data exist on this risk after upper extremity orthopedic trauma. A total of 269,137 incidents of upper extremity orthopedic trauma (fractures of the clavicle, scapula, humerus, elbow, or lower arm) were identified in the State Inpatient Database for 4 states included in the analysis (California, Florida, New York, and Washington) from 2006 to 2014. These patients were split into 2 cohorts, a derivation cohort (California and New York) and a validation cohort (Florida and Washington). Univariate and multivariate logistic regression analyses of risk factors for VTE within 90 days of discharge in the derivation group were used to develop the Thromboembolic Risk after Upper Extremity Trauma (TRUE-T) scale. Linear regression was used to determine fit of the TRUE-T scale to the 2 cohorts. We found that 2.61% of patients in the derivation cohort and 2.72% of patients in the validation cohort had a VTE within 90 days of discharge. Risk factors associated with increased rates of VTE were age older than 40 years, Medicare payer, anemia, chronic lung disease, coagulopathy, heart failure, malignancy, obesity, renal failure, head injury, chest injury, abdominal injury, rib fracture, humerus fracture, elbow fracture, and closed reduction. Application of the TRUE-T scale to the validation cohort showed an R2 value of 0.88. The patient factors, concomitant injuries, and fracture treatment modalities included in the TRUE-T scale can be used to identify patients at increased risk for VTE after upper extremity orthopedic trauma. [Orthopedics. 2022;45(6):345-352.].

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures-A cost analysis and description of the surgical technique.

INTRODUCTION: Current surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. METHODS: All open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. RESULTS: Nine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. CONCLUSION: In suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia: A linked data analysis.

BACKGROUND: Lower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes. METHODS: This retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011-2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA. RESULTS: A total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01-1.94); chronic anaemia (OR 2.19, 95% CI 1.41-3.39); current/ex-smoker (OR 1.60, 95% CI 1.21-2.12); emergency admission (OR 2.77, 95% CI 1.35-5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95% CI $27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95% CI $9,131- $13,059). CONCLUSIONS: Unplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission.

Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries.

BACKGROUND: Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. QUESTIONS/PURPOSES: We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? METHODS: We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. RESULTS: We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). CONCLUSION: The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. LEVEL OF EVIDENCE: Level III, prognostic study.

Assessment of muscle volume using magnetic resonance imaging (MRI) in football players after hamstring injuries.

Muscle injuries of the hamstrings are among the most frequent in football and a main cause for significant time away from training and competition. The purpose of this study was to prospectively evaluate the loss of muscle volume in recreational football players three and six weeks after initial trauma. We hypothesized that significant muscle volume loss occurs within 6 weeks after the initial injury event. Twenty recreational football players (mean-age=25 ± 4years; mean-height=181 ± 8cm; mean-weight=81 ± 10kg) with type3a (minor partial muscle tear) and type3b (moderate partial muscle tear) injuries were included. Muscle volume was determined using established methods for the hamstrings and the quadriceps femoris muscle within 3 days and after 3 and 6 weeks following the initial injury. The injured hamstrings lost 6.5% (mean=64 cm3(95%CI=31-98 cm3), p<0.001), the healthy hamstrings lost 2.1% (mean=21 cm3(3-44 cm3),p=0.096) of muscle volume after six weeks. The quadriceps in the injured leg lost 3.8% (mean=78 cm3(51-104 cm3), p<0.001) and 4.5% (83 cm3 (45-121 cm3), p<0.001) in the healthy leg. Muscle volume loss inversely correlated with activity levels in the healthy leg for the quadriceps (r=0.96 (0.90-0.98); R2=0.92; p<0.001) and the hamstrings (r=0.72 (0.40-0.88); R2=0.51; p<0.001), as well as the quadriceps in the injured leg (r=0.70 (0.37-0.87); R2=0.49; p<0.001), but not the injured hamstrings. Muscle volume ratio of hamstrings to quadriceps in the control limb was 0.52 ± 0.06 and 0.53 ± 0.06 in the injured leg. The rehabilitation period of six weeks did not have a relevant negative or a positive effect on ratios. Significant muscle volume loss in the upper thigh occurs in recreational soccer players within three, and within six weeks after a hamstring injury and lies between 2% and 7%.

Disability, pain, and wound-specific concerns self-reported by adults at risk of limb loss: A cross-sectional study using the World Health Organization Disability Assessment Schedule 2.0.

INTRODUCTION: There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). MATERIALS AND METHODS: We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress. RESULTS: We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p<0.001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress. DISCUSSION: The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.

The nationwide epidemiological and health insurance disease burden of knee and lower leg injuries in Hungary / A térd- és lábszársérülések okozta országos epidemiológiai és egészségbiztosítási betegségteher Magyarországon.

Összefoglaló. Bevezetés: A térd és a lábszár sérülései jelentos terhet jelentenek az egyén és a társadalom számára. Célkituzés: Elemzésünk célja volt a térd- és lábszársérülés okozta éves epidemiológiai és egészségbiztosítási betegségteher vizsgálata Magyarországon. Adatok és módszerek: Az elemzésben felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelo (NEAK) finanszírozási adatbázisából származnak, és a 2018. évet fedik le. Vizsgáltuk az éves egészségbiztosítási kiadásokat, azok megoszlását, az éves betegszámot, valamint a 100 000 lakosra vetített prevalenciát korcsoportok és nemek szerinti bontásban. A térd és a lábszár sérülései kórképeket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S80-S89-es kóddal azonosítottuk. Eredmények: A legköltségesebb ellátási forma az aktívfekvobeteg-szakellátás volt, amelynek országos betegszáma összesen 18 398 fo (9868 fo férfi, 8530 fo no) volt. Az aktívfekvobeteg-szakellátás betegforgalmi adatai alapján a 100 000 fore eso prevalencia a férfiaknál 211,2 fo, a noknél 167,0 fo, együtt 188,1 fo volt. A NEAK 8,808 milliárd Ft-ot költött 2018-ban a térd- és lábszársérülések kezelésére, ami 32,59 millió USD-nak, illetve 27,62 millió EUR-nak felelt meg. Az aktívfekvobeteg-szakellátás a teljes egészségbiztosítási kiadás 61,4%-ával volt a legmeghatározóbb költségelem. A kiadások 52,0%-a férfiaknál, míg 48,0%-a noknél jelent meg. A 49. életévig a férfiak, míg az 50. életév feletti korosztályban a nok sérüléseibol származó ellátások betegszámai és költségei a magasabbak. Következtetés: Az aktívfekvobeteg-szakellátás bizonyult a fo költségtényezonek. A betegség elofordulási gyakorisága 26%-kal volt magasabb a férfiak esetében, mint a noknél. Orv Hetil. 2021; 162(Suppl 1): 54-60. INTRODUCTION: Injuries to the knee and lower leg pose a great burden for the individual and society. OBJECTIVE: The aim of our study was to determine the annual epidemiological disease burden and the health insurance treatment cost of knee and lower leg injuries in Hungary. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual health insurance costs and their distribution and annual patient numbers and prevalence per 100 000 population calculated for age groups and sex. Patients with knee and lower leg injuries were identified with the following code of the International Classification of Diseases, 10th revision: S80-S89. RESULTS: The most expensive insurance treatment category was acute inpatient care, presenting 18 398 patients in total (9868 men, 8530 women). Based on patient numbers in acute inpatient care, the prevalence in 100 000 population among men was 211.2 patients, among women 167.0 patients, in total 188.1 patients. In 2018, NHIFA spent 8.808 billion HUF on the treatment of patients with knee and lower leg injuries (32.59 million USD, 27.62 million EUR). Acute inpatient care with 61.4% of the total health insurance expenditure was the main cost driver. 52.0% of the costs was spent on the treatment of male, while 48.0% on female patients. Until the age of 49, the number of patients and their costs were higher for men, while those over the age of 50 were higher for women. CONCLUSION: Acute inpatient care was the major cost driver. The prevalence of the disease was by 26% higher in men compared to women. Orv Hetil. 2021; 162(Suppl 1): 54-60.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

The mangled extremity: assessment, decision making and outcomes.

The management of the mangled extremity continues to pose a significant challenge for ortho- paedic trauma surgeons. This article provides a comprehensive, up-to-date literature review on the assessment of complex limb injuries, and the variables that affect decision-making and outcomes in both limb salvage and amputation. Initial assessment involves using a systematic approach, saving life before limb, with early involvement of the relevant surgical specialities and multidisciplinary team. The decision to attempt limb salvage or perform amputation can be extremely difficult. Scoring systems can be used as a guide but should not be wholly relied upon; instead more emphasis should be placed on the surgeon's experience, extent of soft tissue damage, and patient factors and wishes. Outcomes following amputation versus limb salvage are comparable, with some studies suggesting amputation may be favourable. It is important to advise patients and families on what treatment is in their best interest so they can make an informed decision, and this must utilise a multidisciplinary approach.

Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya.

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

Cost-utility analysis of standard dressing compared with incisional negative-pressure wound therapy among patients with closed surgical wounds following major trauma to the lower limb.

AIMS: To compare the cost-utility of standard dressing with incisional negative-pressure wound therapy (iNPWT) in adults with closed surgical wounds associated with major trauma to the lower limbs. METHODS: A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective based on data collected from the Wound Healing in Surgery for Trauma (WHiST) multicentre randomized clinical trial. Health resource utilization was collected over a six-month post-randomization period using trial case report forms and participant-completed questionnaires. Cost-utility was reported in terms of incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analysis was conducted to test the robustness of cost-effectiveness estimates while uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. RESULTS: The incremental cost of standard dressing versus iNPWT over six months was £2,037 (95% confidence interval (CI) £349 to £3,724). There was an insignificant increment in QALYs gained in the iNPWT group (0.005, 95% CI -0.018 to 0.028). The probability of iNPWT being cost-effective at £20,000 per QALY was 1.9%. The results remained robust in the sensitivity analysis. CONCLUSION: The within-trial economic evaluation suggests that iNPWT is unlikely to be a cost-effective alternative to standard dressing in adults with closed surgical wounds to their lower limbs. Cite this article: Bone Joint J 2020;102-B(8):1072-1081.