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.

Functional and Radiological Outcome after Internal Fixation of Intra-articular Calcaneal Fractures.

Introduction: Calcaneal fractures are rare injuries constituting 2% of all fractures. Fractures of calcaneum correspond to nearly 60-75% of the tarsal bone fractures. The calcaneum is the most commonly fractured tarsal bone 90% occur in males between 21 and 45 years of age. The calcaneal fracture may be extra-articular (sparing the subtalar joint) and intra-articular involving the subtalar joint. Intra-articular fractures account for approximately 75% of calcaneal fractures and have been associated with poor functional outcomes. In this study, we aim to assess the functional outcome of internal fixation in displaced intra-articular calcaneal fractures. Materials and Methods: A prospective interventional study was conducted on patients with only intra-articular calcaneal fractures admitted to Chettinad Hospital and Research Institute, Kelambakkam during the period from May 1, 2022, to February 29, 2024, and a total of 32 patients were considered. The functional outcome was assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scoring System. Results: The average age of the patients in our study was 39 years of which all were male. Fall from height is the most common mode of injury. The right calcaneum is more commonly involved than the left. The mean duration of hospital stay was around 10 days. The fracture classification was based on the sanders and Essex-Lopresti classification of which 17 patients were sanders type 3 and 13 patients were sanders type 2 and 1 patient was sanders type 4. The mean time for radiological union is 12 weeks. The Bohler's angle and Gissane's angle preoperatively 16.16 ± 8.87 and 121.48 ± 7.47 restored to near normal values after fixation 27.77 ± 6.02 and 113.485 ± 44, respectively. Heel height and heel width restored to near normal values of (pre-operative heel height - 24.74 ± 3.71 and heel width - 39.97 ± 4.11 and post-operative heel height - 31.55 ± 3.38 and heel width - 34.0 ± 3.1), respectively. The most common complications were wound-related complications (superficial wound infection - 9.7%, deep wound infection - 3.2%, and wound margin necrosis and wound dehiscence 6.4%) and the most common late complications were complex regional pain syndrome - 9.7% and subfibular lateral impingement with peroneal tendinitis - 6.5%. AOFAS grading of functional outcome had shown good to excellent results in 83.8% (26 patients) of the cases. The mean AOFAS score was 83.39 in our study. Conclusion: The present study shows that open reduction and internal fixation give superior radiographic results as shown by the restoration of Bohler's and Gissane's angle and height and width of the calcaneus to near normal values, indicating anatomical restoration of calcaneal shape. The functional outcome by AOFAS score showed good to excellent results in most of the patients with minimal wound complications.

Compartment Syndrome of the Lower Limb in Adults and Children and Effective Surgical Intervention and Post-surgical Therapies: A Narrative Review.

Compartment syndrome (CS) can be defined as an acutely painful condition that occurs due to increased pressure within a compartment, resulting in reduced blood flow and oxygen to nerves and muscles within the limb. It is considered a surgical emergency, and a delayed diagnosis may result in ischemia and eventual necrosis of the limb. The majority of cases in adults are associated with high-energy trauma, more specifically, long bone fractures of the lower limb, while supracondylar fractures of the humerus are highly associated with CS in pediatric patients. CS may also develop gradually as a result of prolonged and ongoing physical activity such as running. In this narrative review, we discuss the anatomy, pathophysiology, methods of diagnosis, and effective management of CS in adults and children.

Associations of musculoskeletal dysfunction, time to brake, and patient reported outcomes following lower extremity trauma.

INTRODUCTION: Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB. METHODS: A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys. RESULTS: Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p<0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased. DISCUSSION: Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements. LEVEL OF EVIDENCE: II.

Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report.

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.

Protocolo de estudo para relatar a eficácia da terapia de realidade virtual em combinação com o protocolo de fisioterapia para melhorar o equilíbrio em amputados traumáticos de membros inferiores / Study protocol to report the effectiveness of virtual reality therapy in combination with physical therapy protocol for improving balance in traumatic lower limb amputees: A parallel, open-label, randomized controlled trial

INTRODUÇÃO: A intervenção em realidade virtual (RV) foi viável em amputados de membros inferiores (AMI). Até onde sabemos, não existe um estudo controlado randomizado disponível sobre a reabilitação do AMI usando RV. As evidências sugerem que são necessárias mais pesquisas para reabilitação de amputados usando VR. OBJETIVO: Comparar a eficácia da terapia de RV como um complemento terapêutico adicional com o protocolo de fisioterapia nos limites de estabilidade e estabilidade postural, dor e qualidade de vida entre os AMI. MÉTODOS: Um total de 100 AMI foi recrutado por amostragem aleatória simples (gerador de número aleatório) do JPN Apex Trauma Center, AIIMS, para participar de um ensaio clínico randomizado. O AMI recrutado foi dividido aleatoriamente em dois grupos: terapia de realidade virtual juntamente com o grupo protocolo de fisioterapia (VRT-PTP) e o grupo protocolo de fisioterapia (PTP). A duração do tratamento será de 30 minutos em uma sessão / dia, durante 4 dias / semana, durante 3 semanas. Assim, cada AMI receberá 12 sessões no total. O Sistema de Equilíbrio Biodex para medir o equilíbrio dinâmico, NPRS para dor e qualidade de vida pelo WHOQOL-BREF da OMS (WHOQOL-BREF) são as medidas de resultado que serão registradas na linha de base, no final do período pós-intervenção de três semanas. O acompanhamento será realizado na 6ª e 9ª semana após a inscrição. RESULTADOS: A normalidade dos dados coletados será confirmada pelo teste de Kolmogorov-Smirnov. A significância estatística intra e inter grupos será determinada por testes apropriados. O tamanho do efeito e a análise de potência serão realizados. CONCLUSÃO: Este estudo apresentará dados para a eficácia do VRT na melhora do equilíbrio e da marcha, além do PTP.

INTRODUCTION: Virtual reality (VR) intervention was found to be feasible in lower limb amputees (LLA). To best of our knowledge, only there is no randomized controlled trial available regarding the rehabilitation of LLA using VR. Evidence suggest that more researches for amputee rehabilitation using VR is warranted. OBJECTIVE: To compare the effectiveness of VR therapy as an additional therapeutic adjunct with physical therapy protocol on limits of stability and postural stability, pain and quality of life among LLA. METHODS: A total of 100 LLA will be recruited by the simple random sampling (random number generator) from JPN Apex Trauma Centre, AIIMS to participate in randomized controlled trial. Recruited LLA will be randomly divided into two groups, virtual reality therapy along with physical therapy protocol (VRT-PTP) group and physical therapy protocol (PTP) group. Duration of the treatment will be 30 minutes in one session/day for 4 days/week for 3 weeks. Thus, each LLA will receive 12 sessions in total. The Biodex Balance System for measuring dynamic balance, NPRS for pain and quality of life by WHO Quality of Life-BREF (WHOQOL-BREF) are the outcome measures will be recorded at baseline, end of 3-week post-intervention period. The follow-up will be taken at 6th and 9th week after enrollment. RESULTS: Normality of the collected data will be confirmed by Kolmogorov-Smirnov test. Statistical significance within and between the groups will be determined. Effect size and power analysis will be performed. CONCLUSION: This study will present data for the efficacy of the VRT in improving balance and gait in addition to PTP.