A modified passive-dynamic ankle-foot orthosis: can it prevent amputation and arthrodesis in patients with ankle-foot trauma?

INTRODUCTION: High-energy lower extremity trauma (HELET) may cause severe damage within the foot-ankle complex. Occasionally, arthrodesis or amputation are the only remaining options to increase activity levels. The modified passive dynamic ankle-foot orthosis (PDAFO) may prove to be a nonsurgical alternative. This study evaluated the effect of a modified PDAFO with a 6-week training program on pain and performance in patients after HELET. MATERIALS AND METHODS: A retrospective cohort study was conducted on seventeen patients who considered an arthrodesis or an amputation after HELET. In an attempt to avoid surgery, the modified PDAFO with a 6-week training program was provided. Pain scores was measured with the Numeric Rating Scale and administered at the start of testing, immediately after the two performance tests and at the end of the day of testing. Performance was evaluated with the 6-min walk test (6MWT) and the Comprehensive high-level activity mobility predictor (CHAMP). RESULTS: A significant pain reduction was achieved after the treatment procedure. At the start of the test days (p = 0.002), after the 6MWT (p = 0.001), after the CHAMP (p < 0.001) and at the end of the day (p < 0.001). In addition, a significant improvement on performance was observed in the 6MWT (p < 0.001) and the CHAMP (p = 0.01). None of the patients considered a surgical intervention anymore. CONCLUSIONS: Patients after HELET show a decrease in pain and an improvement in performance after a 6-week training program with modified PD-AFO. The results suggest that the modified PDAFO is an effective alternative for a surgical approach.

Combat-related foot injuries: impact on gait and functional outcome.

INTRODUCTION: Prior to deployment of the Netherlands Army Task Force Urozgan in Afghanistan, the Dutch Military and civilian healthcare systems had limited experience in treating blast injuries and their long-term consequences. This meant that guidelines for treatment and rehabilitation were lacking. The aim of this cohort study was to quantify kinematic and kinetic abnormalities in service members with foot injuries in relation to functional outcome using gait analysis. METHOD: In nine service members with combat-related talus, calcaneus and/or navicular bone (TCN) fractures and nine controls, gait parameters were measured using Gait Real-Time Analysis Interactive Lab system. High-level mobility was evaluated by the Comprehensive High-Level Activity Mobility Predictor (CHAMP), and functional ability was assessed by Lower Extremity Functional Scale (LEFS) questionnaire. RESULTS: Significant differences were found for LEFS and CHAMP scores (P<0.01), comfortable walking speed and ankle joint range of motion (ROM) (P<0.05), all lower in the group with TCN fractures. For this group, a trend (0.1>P>0.05) for higher step width and lower stride duration and peak power was found. A strong correlation (0.6>r>0.79) is shown between LEFS and comfortable walking speed and CHAMP and ankle joint ROM. The correlations between LEFS and stride duration, step width, ankle joint ROM and peak power, and between CHAMP and comfortable walking speed and stride duration, were moderate (0.4>r>0.59). CONCLUSIONS: This study demonstrated that service members with TCN fractures, compared with healthy controls, have altered gait characteristics, specifically lower walking speed and ankle joint ROM, both related to lower physical functioning. Patients with bilateral depressed Böhler's angle had the worse functional performance, and further research is recommended to evaluate the relationship between Böhler's angle and physical performance. CLINICAL TRIAL: The Dutch Ministry of Defence (MOD) and the Institutional Review Board and Medical Ethics Review Committee Brabant, The Netherlands, approved this study (P1550).

Postdeployment reintegration attitude of injured Dutch service members: a longitudinal study.

OBJECTIVE: After deployment, service members can experience difficulties reintegrating. Sustaining injuries on the battlefield can disrupt the reintegration period. The first aim was to follow-up the reintegration attitude towards family, work and on a personal level after deployment in Dutch battlefield casualties (BCs). The second was to compare their postdeployment reintegration attitude with that of healthy controls. METHODS: A questionnaire concerning reintegration attitude, the Postdeployment Reintegration Scale (PDRS), was provided to all service members who received rehabilitation after sustaining injuries in Op TASK FORCE URUZGAN. The questionnaire was administered in 27 BCs at a median of 2 years post incident and 5.5 years post incident. At 5.5 years post incident, the PDRS of the BCs was compared with a control group consisting of service members from the same combat units. RESULTS: A significant difference was found for the BCs with an increased negative personal attitude (p=0.02) and a decreased negative attitude towards work (p=0.02) at 5.5 years compared with 2 years post incident. No differences in postdeployment reintegration attitude was observed between the BCs and controls at 5.5 years post incident. CONCLUSIONS: The results showed that for the BCs the personal attitude becomes more negative in time. However, the negative attitude towards work decreases in time after deployment. Particular attention should be paid to traumatic stress and aftercare.

A longitudinal study of health related quality of life and functioning in severely injured Dutch service members.

BACKGROUND: Optimal health is demanded for service members in military operations. However, the strains of deployment can result in a deterioration, moreover when combat-related injuries are sustained, affecting level of participation and health related quality of life (HRQOL). Secondary health conditions may occur in time, however existing studies measure coping, level of activity and participation and HRQOL at one point in time. AIM: To assess the change over time concerning coping, mobility, level of participation and HRQOL in Dutch service members with combat-related injuries sustained during operation Task Force Uruzgan (TFU). METHODS: The lower extremity functional scale (LEFS), the cognitive emotion regulation questionnaire (CERQ), the assessment of life habits short version (LIFE-H) and the EuroQol-5D (EQ-5D), measuring HRQOL, were administered in 2010 and 2014. Change of scores between the two time points was tested with the Wilcoxon signed rank test. RESULTS: The response rate was 53% (28/53). The score on the coping strategy self-blame showed a significant increase over time with low scores on both occasions. The coping strategies positive reappraisal and acceptance showed the highest scores. No significant change is shown in mobility, the level of participation or HRQOL. CONCLUSION: service members with combat-related injuries remain stable in level of activity and participation and HRQOL in time and they use adaptive coping strategies.

Coping strategies of Dutch servicemembers after deployment.

BACKGROUND: This study examines the relationship between coping strategies and symptoms of anxiety or depression among Dutch servicemembers deployed to Afghanistan. METHODS: Coping strategies were assessed in 33 battlefield casualties (BCs) and the control group (CTRLs) of 33 uninjured servicemembers from the same combat units using the Cognitive Emotion Regulation Questionnaire. A factor analysis was performed, and two clusters of coping strategies were derived, namely, adaptive and maladaptive coping. Symptoms of anxiety and depression were evaluated using the depression and anxiety subscales of the Symptom Checklist-90-Revised. Correlations between coping and symptoms of anxiety and between coping and symptoms of depression were calculated, and a logistic regression was performed. RESULTS: A moderate correlation was observed between maladaptive coping and symptoms of anxiety in the BC group (r = 0.42) and among the CTRLs (r = 0.56). A moderate correlation was observed between maladaptive coping and symptoms of depression in both groups (r = 0.55). The statistical analysis for the total sample (BCs and CTRLs) demonstrated no association between coping and symptoms of anxiety or depression. CONCLUSIONS: A correlation but no association was observed between maladaptive coping and mental health disorders in deployed Dutch servicemembers. Further research should focus on constructing cluster profiles of coping strategies and associating them with mental health outcomes and reintegration into society.

Amputation: Not a failure for severe lower extremity combat injury.

INTRODUCTION: The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life. PATIENTS AND METHODS: All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation. RESULTS: In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery. CONCLUSION: Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.

Long-term impact of battle injuries; five-year follow-up of injured Dutch servicemen in Afghanistan 2006-2010.

OBJECTIVES: Units deployed to armed conflicts are at high risk for exposure to combat events. Many battle casualties (BCs) have been reported in the recent deployment to Afghanistan. The long-term impact of these combat injuries, at their five-year end point, is currently unknown. To date, no systematic inventory has been performed of an identified group of BCs in comparison to non-injured service members from the same operational theatre. DESIGN: Observational cross-sectional cohort study. SETTING: Open online survey among Dutch BCs that deployed to Afghanistan (2006-2010). PARTICIPANTS: The Dutch BCs (n = 62) were compared to two control groups of non-injured combat groups (battle exposed [n = 53], and non-battle exposed [n = 73]). MAIN OUTCOME MEASURES: Participants rated their impact of trauma exposure (Impact of Events [IES]), post deployment reintegration (Post Deployment Reintegration Scale [PDRS]), general symptoms of distress (Symptom Checklist 90 [SCL-90]), as well as their current perceived quality of life (EuroQol-6D [EQ-6D]). Also cost effectiveness (Short From health survey [SF-36]) and care consumption were assessed (Trimbos/iMTA questionnaire). RESULTS: Over 90% of BCs were still in active duty. The mean scores of all questionnaires (IES, EQ-6D, SF-36, and SCL-90) of the BC group were significantly higher than in the control groups (p<0.05). The PDRS showed a significantly lower (p<0.05) outcome in the negative subscales. The mean consumption of care was triple that of both control groups. A lower score on quality of life was related to higher levels of distress and impact of trauma exposure. CONCLUSIONS: This study showed a clear long-term impact on a wide range of scales that contributes to a reduced quality of life in a group of BCs. Low perceived cost effectiveness matched with high consumption of care in the BC group in comparison to the control groups. These results warrant continuous monitoring of BCs.

[Dutch military casualties of the war in Afghanistan--quality of life and level of participation after rehabilitation]. / Nederlandse militaire oorlogsslachtoffers uit Afghanistan--kwaliteit van leven en participatieniveau na revalidatie.

OBJECTIVE: To describe the distribution of injuries and the quality of life and functioning at activity and participation level of rehabilitated Dutch military personnel who were wounded during the mission to Afghanistan. DESIGN: Retrospective, descriptive. METHOD: The study population consisted of military war casualties who followed multidisciplinary rehabilitation treatment for injuries sustained in combat in Afghanistan. Distribution and degree of injuries were classified according to the 'Abbreviated Injury Scale' (AIS) and the 'Injury Severity Score' (ISS). Quality of life and functional disabilities were assessed with a semi-structured interview, and the following questionnaires: EuroQol-5D with an extra dimension 'cognition' (EQ-6D), the 'Assessment of Life Habits' shortened version 3.0 (LIFE-H 3.0) and the 'Lower Extremity Functional Scale'(LEFS). Coping style was assessed with the Cognitive Emotion Regulation Questionnaire' (CERQ). RESULTS: A total of 48 servicemen cooperated. A total of 248 injuries; 54% of which affected the extremities. In 9 victims an amputation of the lower extremity was performed; 4 of them had to have a double amputation. 31 servicemen were still receiving specialist medical care at the time of the interview. 39 servicemen had to adjust their career plans. The mean quality of life, measured by EQ-5D, had an index score of 0.72 (Dutch population norm: 0.88). The mean score on the LEFS was 58 (maximum score 80). Changes in mobility and occupation appeared to be predictive factors for quality of life. CONCLUSION: The quality of life and functional level of Dutch military personnel who were injured in combat in Afghanistan seemed to be lower than in the general population after 2.3 years. For a large part this could be explained by the level of mobility and occupation.