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1.
Artigo em Inglês | MEDLINE | ID: mdl-38516351

RESUMO

Background: For patients with transfemoral amputations and difficulty tolerating conventional socket-based prostheses, osseointegrated (OI) implants have enabled increased prosthetic use, improved patient satisfaction, and shown promising functional outcomes1,2. Although the use of OI implants effectively eliminates the soft-tissue-related challenges that have plagued socket-based prostheses, the presence of a permanent, percutaneous implant imparts a host of new soft-tissue challenges that have yet to be fully defined. In patients undergoing OI surgery who have redundant soft tissue, we perform a thighplasty to globally reduce excess skin and fat, tighten the soft-tissue envelope, and improve the contour of the residual limb. Description: First, the orthopaedic surgical team prepares the residual femur for implantation of the OI device. After the implant is inserted, the residual hamstrings and quadriceps musculature are closed over the end of the femur, and the subcutaneous tissue and skin are closed in a layered fashion. Although the anatomic location and amount of excess soft tissue are patient-dependent, we perform a standard pinch test to determine the amount of soft tissue that can be safely removed for the thighplasty. Once the proposed area of resection is marked, we proceed with longitudinal, sharp dissection down to the level of the muscular fascia. At this point, we use another pinch test to confirm the amount of soft-tissue resection that will allow for adequate resection without undue tension3. Excess subcutaneous fat and skin are carefully removed along the previously marked incisions, typically overlying the medial compartment of the thigh in the setting of patients with transfemoral amputations. The thighplasty incision is closed in a layered fashion over 1 or 2 Jackson-Pratt drains, depending on the amount of resection. Alternatives: Depending on the amount of redundant soft tissue, thighplasty may not be necessary at the time of OI surgery; however, in our experience, excess soft tissue surrounding the transcutaneous aperture can predispose the patient to increased shear forces at the aperture, increased drainage, and increased risk of infection4. Rationale: Although superficial infectious complications are most common following OI surgery, the need for soft-tissue refashioning and excision is one of the most common reasons for reoperation1,5. Our group has been more aggressive than most in our use of a vertical thighplasty procedure to globally reduce soft-tissue motion in the residual limb to avoid reoperation. Expected Outcomes: Although much of the OI literature has focused on infectious complications, recent studies have demonstrated reoperation rates of 18% to 36% for redundant soft tissue following OI surgery1,5. We believe that thighplasty at the time of OI not only reduces the likelihood of reoperation but may also decrease infectious complications by reducing relative motion and inflammation at the skin-implant interface4,6. Important Tips: The thighplasty procedure is ideally performed as part of the first stage of the OPRA (Osseointegrated Prosthesis for the Rehabilitation of Amputees) procedure to limit the likelihood of problematic ischemia-related complications.We utilize a confirmatory pinch test both before and throughout the thighplasty procedure to ensure adequate resection without undue tension.The thighplasty excision pattern utilizes a long vertical limb designed to decrease the circumferential laxity of the residual limb. Maximal tension is borne on the vertical limb and not on the transverse extensions, as these are prone to scar widening and distortion of surrounding tissues.Closed-suction drainage is utilized liberally to decrease the likelihood of a symptomatic seroma. Acronyms and Abbreviations: OI = osseointegratedOPRA = Osseointegrated Prosthesis for the Rehabilitation of AmputeesPVNS = pigmented villonodular synovitisT-GCT = tenosynovial giant-cell tumor.BMI = body mass indexPMH = past medical history.

2.
Plast Reconstr Surg Glob Open ; 12(2): e5602, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38328272

RESUMO

Background: Superficial infection is a common minor complication of transcutaneous implants that can be challenging to predict or diagnose. Although it remains unclear whether superficial infections progress to deep infections (which may require implant removal), predicting and treating any infection in these patients is important. Given that flap thinning during stage II surgery requires compromising vascularity for stability of the skin penetration aperture, we hypothesized that early skin temperature changes predict long-term superficial infection risk. Methods: We obtained standardized thermal imaging and recorded surface temperatures of the aperture and overlying flaps 2 weeks postoperatively for the first 34 patients (46 limbs) treated with the Osseointegrated Prosthesis for the Rehabilitation of Amputees transfemoral implant system. We used two-sided t tests to compare temperatures surrounding the aperture and adjacent soft tissues in patients with and without subsequent infection. Results: During median follow-up of 3 years, 14 limbs (30.4%) developed 23 superficial infections. At patients' initial 2-week visit, mean skin temperature surrounding the aperture was 36.3ºC in limbs that later developed superficial infections and 36.7ºC in uninfected limbs (P = 0.35). In four patients with bilateral implants who later developed superficial infection in one limb, average temperature was 1.5ºC colder in the infected limb (P = 0.12). Conclusions: Superficial infections remain a frequent complication of transfemoral osseointegration surgery. We did not find differences in early heat signatures between limbs subsequently complicated and those not complicated by superficial infection. Further research should explore more objective measures to predict, diagnose, and prevent infections after osseointegration surgery.

3.
J Hand Surg Am ; 2024 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-38219089

RESUMO

PURPOSE: Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population. METHODS: We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations. RESULTS: A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury. CONCLUSIONS: Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

4.
Mil Med ; 189(1-2): e235-e241, 2024 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-37515572

RESUMO

INTRODUCTION: Amputations at the hip and pelvic level are often performed secondary to high-energy trauma or pelvic neoplasms and are frequently associated with a prolonged postoperative rehabilitation course that involves a multitude of health care providers. The purpose of this study was to examine the health care utilization of patients with hip- and pelvic-level amputations that received care in the U.S. Military Health System. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent a hip- or pelvic-level amputation in the Military Health System between 2001 and 2017. We compiled and reviewed all inpatient and outpatient encounters during three time points: (1) 3 months pre-amputation to 1 day pre-amputation, (2) the day of amputation through 12 months post-amputation, and (3) 13-24 months post-amputation. Health care utilization was defined as the average number of encounter days/admissions for each patient. Concomitant diagnoses following amputation including post-traumatic stress disorder, traumatic brain injury, anxiety, depression, and chronic pain were also recorded. RESULTS: A total of 106 individuals with hip- and pelvic-level amputations were analyzed (69 unilateral hip disarticulation, 6 bilateral hip disarticulations, 27 unilateral hemipelvectomy, 2 bilateral hemipelvectomies, and 2 patients with a hemipelvectomy and contralateral hip disarticulation). Combat trauma contributed to 61.3% (n = 65) of all amputations. During the time period of 3 months pre-amputation, patients had an average of 3.8 encounter days. Following amputation, health care utilization increased in both the year following amputation and the time period of 13-24 months post-amputation, averaging 170.8 and 77.4 encounter days, respectively. Patients with trauma-related amputations averaged more total encounter days compared to patients with disease-related amputations in the time period of 12 months following amputation (203.8 vs.106.7, P < .001) and the time period of 13-24 months post-amputation (92.0 vs. 49.0, P = .005). PTSD (P = .02) and traumatic brain injuries (P < .001) were more common following combat-related amputations. CONCLUSIONS: This study highlights the increased health care resource demand following hip- and pelvic-level amputations in a military population, particularly for those patients who sustained combat-related trauma. Additionally, patients with combat-related amputations had significantly higher rates of concomitant PTSD and traumatic brain injury. Understanding the extensive needs of this unique patient population helps inform providers and policymakers on the requirements for providing high-quality care to combat casualties.


Assuntos
Amputação Traumática , Lesões Encefálicas Traumáticas , Hemipelvectomia , Serviços de Saúde Militar , Militares , Humanos , Desarticulação , Amputação Traumática/cirurgia , Atenção à Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Estudos Retrospectivos
5.
Artigo em Inglês | MEDLINE | ID: mdl-38030078

RESUMO

BACKGROUND: Medically ill adults are at elevated risk for suicide. Chronic pain and hopelessness are associated with suicide; however, few studies have examined the interaction between chronic pain and hopelessness in predicting suicide risk among hospitalized adults. OBJECTIVE: This study aimed to describe the association between chronic pain, hopelessness, and suicide risk, defined as recent suicidal ideation or lifetime suicidal behavior. In addition, we examined the interaction between chronic pain and hopelessness. METHODS: This was a secondary analysis of a multisite study to validate the Ask Suicide-Screening Questions (ASQ) among adult medical inpatients. Participants reported if they experienced chronic pain that impacted daily life and if they felt hopeless about their medical condition and provided their current pain rating on a 1 to 10 scale, with 10 being the most severe pain. A t-test compared pain severity scores by ASQ outcome. A binary logistic regression model described the association between chronic pain, hopelessness, and suicide risk; parameter estimates are expressed as odds ratios (OR) for interpretation. The interaction between chronic pain and hopelessness was examined in both the transformed (logit) and natural (probability) scales of the generalized linear model. RESULTS: The sample included 720 participants (53.2% male, 62.4% White, mean age: 50.1 [16.3] years, range = 18-93). On the ASQ, 15.7% (113/720) of patients screened positive. Half (360/720) of the sample self-reported chronic pain. Individuals who screened positive had higher pain rating scores than those who screened negative (t = -4.2, df = 147.6, P < 0.001). Among all patients, 27.2% (196/720) felt hopeless about their medical condition. In the logistic regression model, patients with chronic pain (adjusted OR: 2.29, 95% confidence interval [CI]: 1.21-4.43, P = 0.01) or hopelessness (adjusted OR: 5.69, 95% CI: 2.52-12.64, P < 0.001) had greater odds of screening positive on the ASQ. The interaction effect between pain and hopelessness was not significant in the transformed (B = -0.15, 95% CI: -1.11 to 0.82, P = 0.76) or natural (B = 0.08, 95% CI: -0.07 to 0.23, P = 0.28) scale. CONCLUSIONS: There were significant independent associations between (1) chronic pain and suicide risk and between (2) hopelessness and suicide risk. Future research should examine the temporality and mechanisms underlying these relationships to inform prevention efforts for medically ill adults.

6.
Mil Med ; 188(11-12): e3477-e3481, 2023 11 03.
Artigo em Inglês | MEDLINE | ID: mdl-37207668

RESUMO

INTRODUCTION: Traumatic hip and pelvic level amputations are uncommon but devastating injuries and associated with numerous complications that can significantly affect quality of life for these patients. While heterotopic ossification (HO) formation has been reported at rates of up to 90% following traumatic, combat-related amputations, previous studies included few patients with more proximal hip and pelvic level amputations. MATERIALS AND METHODS: We conducted a retrospective review of the Military Health System medical record and identified patients with both traumatic and disease-related hip- and pelvic-level amputations performed between 2001 and 2017. We reviewed the most recent pelvis radiograph at least 3 months following amputation to determine bony resection level and the association between HO formation and reason for amputation (trauma versus disease related). RESULTS: Of 93 patients with post-amputation pelvis radiographs available, 66% (n = 61) had hip-level amputations and 34% (n = 32) had a hemipelvectomy. The median duration from the initial injury or surgery to the most recent radiograph was 393 days (interquartile range, 73-1,094). HO occurred in 75% of patients. Amputation secondary to trauma was a significant predictor of HO formation (χ2 = 24.58; P < .0001); however, there was no apparent relationship between the severity of HO and traumatic versus non-traumatic etiology (χ2 = 2.92; P = .09). CONCLUSIONS: Amputations at the hip were more common than pelvic-level amputations in this study population, and three-fourths of hip- and pelvic-level amputation patients had radiographic evidence of HO. The rate of HO formation following blast injuries and other trauma was significantly higher compared with patients with non-traumatic amputations.


Assuntos
Amputação Traumática , Ossificação Heterotópica , Humanos , Qualidade de Vida , Amputação Cirúrgica , Ossificação Heterotópica/epidemiologia , Ossificação Heterotópica/etiologia , Amputação Traumática/complicações , Amputação Traumática/epidemiologia , Pelve
7.
J Surg Orthop Adv ; 32(1): 1-4, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37185068

RESUMO

With improved implants and younger patients undergoing total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA), there are increased expectations to return to high-impact activities. Recommendations regarding return to running following hip arthroplasty remain unclear. A search of the PubMed database was conducted, and all publications referencing running following THA or HRA published between January 1, 2000, and September 1, 2020, were included in the systematic review. Patient demographics, surgical variables, activity measures, and revision rates were recorded for each study. A total of 225 unique citations were identified, of which four manuscripts met the eligibility criteria. Eighty-nine of 121 (73.6%) preoperative runners returned to running postoperatively. All four studies reported mean postoperative UCLA activity scores of at least nine. More patients returned to running following HRA than THA with lower rates of revision. Further research with longer postoperative follow-up is necessary to provide definitive recommendations for running following arthroplasty procedures. (Journal of Surgical Orthopaedic Advances 32(1):001-004, 2023).


Assuntos
Artroplastia de Quadril , Prótese de Quadril , Corrida , Humanos , Artroplastia de Quadril/métodos , Resultado do Tratamento , Reoperação
8.
JBJS Case Connect ; 13(2)2023 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-37094026

RESUMO

CASE: This case demonstrates the attempted utilization of an osteochondral allograft for the prevention of bony overgrowth in a patient with fibular hemimelia and previous transtibial amputation with failure of Teflon capping. Additionally, we describe a novel technique to provide additional padding and increase the width of the residual limb using a dermal allograft. CONCLUSIONS: Bony overgrowth after pediatric amputations is common and often necessitates revision procedures secondary to infection, ulceration, pain, and discomfort with prosthesis use. Our use of an osteochondral allograft cap to prevent bony overgrowth ultimately failed 13 months following the procedure, and further research on various graft options and other treatment modalities is warranted, especially if the proximal fibula is unavailable or there is concern for donor site morbidity associated with harvesting autologous grafts.


Assuntos
Aloenxertos , Amputação Cirúrgica , Tíbia , Criança , Humanos , Fíbula/cirurgia , Transplante Homólogo , Tíbia/cirurgia
9.
J Orthop Trauma ; 37(7): 361-365, 2023 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-36750445

RESUMO

OBJECTIVES: To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014. INTERVENTION: We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS: Early and late amputation rates, time to amputation, reason for amputation. RESULTS: 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. CONCLUSIONS: This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas Ósseas , Traumatismos da Perna , Lesões do Sistema Vascular , Masculino , Humanos , Feminino , Salvamento de Membro , Retalhos Cirúrgicos , Traumatismos da Perna/diagnóstico , Traumatismos da Perna/cirurgia , Traumatismos da Perna/complicações , Extremidade Superior/cirurgia , Fraturas Ósseas/cirurgia , Lesões do Sistema Vascular/etiologia , Estudos Retrospectivos , Amputação Cirúrgica , Resultado do Tratamento
10.
J Orthop Trauma ; 37(6): 299-303, 2023 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-36728027

RESUMO

OBJECTIVES: To describe our clinical experience and surgical technique of transtibial amputation with fibulectomy and fibular collateral ligament-biceps reconstruction for management of, particularly short, transtibial amputations with proximal fibula prominence, overt instability, or inadequate soft-tissue coverage. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: Twelve consecutive patients who underwent transtibial amputation with fibulectomy and fibular collateral ligament-biceps reconstruction between 2008 and 2021. INTERVENTION: We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS: Complications, instability, and pain. RESULTS: Eight patients underwent acute transtibial amputation with fibulectomy and reconstruction, whereas 4 patients underwent amputation revision with fibulectomy and reconstruction for chronic pain. All 12 patients were men, with a median age of 39 years (interquartile range, 33-46). All injuries were due to high-energy mechanisms, including improvised explosive device (n = 8), rocket-propelled grenade (n = 2), gunshot wound (n = 1), and motor vehicle accident (n = 1). After a median follow-up of 8.5 years (interquartile range, 3.4-9.3), there was one complication, a postoperative suture abscess. No patients had subjective lateral knee instability after the procedure, and the average pain scores decreased from 4.75 to 1.54 ( P = 0.01). All patients returned to regular prosthesis wear and maintained independent functioning with activities of daily living. CONCLUSIONS: Our experience with fibulectomy and fibular collateral ligament-biceps reconstruction demonstrated no subjective or clinical postoperative instability and may be a useful adjunct for managing transtibial amputations with fibular instability or prominence, pain, or skin breakdown at the fibular head. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Ligamentos Colaterais , Instabilidade Articular , Ferimentos por Arma de Fogo , Masculino , Humanos , Adulto , Feminino , Atividades Cotidianas , Ferimentos por Arma de Fogo/complicações , Amputação Cirúrgica , Instabilidade Articular/etiologia , Dor/etiologia , Ligamentos Colaterais/cirurgia
11.
Foot Ankle Spec ; 16(4): 363-369, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35249403

RESUMO

An acute rupture of the Achilles tendon is a traumatic injury that can cause considerable morbidity and reduced function. Nonoperative intervention may put patients at higher risk of rerupture, whereas surgical intervention carries risk of infection, wound complications, and iatrogenic nerve injury. The mini-open Achilles tendon repair technique has been popularized in helping decrease complications. The goal of this study was to examine and compare the functional outcomes and rate of complications in patients treated with a mini-open repair technique versus a traditional open repair for acute Achilles tendon ruptures. A retrospective review was performed of all patients with a complete Achilles tendon rupture that were treated by a single foot and ankle fellowship-trained surgeon. Functional outcome scores were assessed using the American Orthopaedic Foot and Ankle scoring system (AOFAS) and the Achilles Tendon Rupture Score (ATRS). Eighty-one patients with a complete Achilles tendon rupture underwent mini-open repair and 22 patients underwent traditional open repair surgery between 2013 and 2020. The mean follow-up was 38.40 months (range, 12-71). Mean preoperative AOFAS and ATRS improved in the mini-open group from 45.60 and 47.18 respectively, to 90.29 and 87.97 after surgery (p < .05). Mean preoperative AOFAS and ATRS scores for the traditional open repair (n = 22) cohort were 44.02 and 42.27, respectively. Postoperatively, the AOFAS and ATRS scores improved to 85.27 and 86.64 (P value < .05), respectively. There was no statistically significant difference in postoperative ATRS scores. However, the mini-open repair group showed a statistically higher postoperative AOFAS score (90.30) than the traditional open-repair group (85.27) (P value < .05). The overall complication rate for our study was 2.9% (2 mini-open repair and 1 traditional open repair). The complication rate in the mini-open repair group and traditional open repair cohort were 2.4% and 4.5%, respectively (P value > .05). One patient in the mini-open repair cohort (1.2%) reruptured his Achilles tendon 4 months postoperatively. A second patient in the mini-open repair group (1.2%) developed a superficial skin infection and suture irritation. One patient (4.5%) in the traditional open repair group developed a superficial skin infection. There were no sural nerve injuries in our series. The mini-open approach to repair a ruptured Achilles tendon is a viable treatment option to decrease the incidence rate of postoperative complications and rerupture rates while also producing a superior cosmetic result.Level of Evidence: 3 (retrospective cohort study N ≥ 30).


Assuntos
Tendão do Calcâneo , Traumatismos do Tornozelo , Procedimentos Ortopédicos , Procedimentos de Cirurgia Plástica , Traumatismos dos Tendões , Humanos , Resultado do Tratamento , Estudos Retrospectivos , Tendão do Calcâneo/cirurgia , Tendão do Calcâneo/lesões , Procedimentos Ortopédicos/métodos , Ruptura/cirurgia , Traumatismos dos Tendões/cirurgia , Traumatismos dos Tendões/etiologia , Traumatismos do Tornozelo/cirurgia
12.
Mil Med ; 188(3-4): e584-e590, 2023 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-34591089

RESUMO

INTRODUCTION: As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. MATERIALS AND METHODS: We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. RESULTS: Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. CONCLUSION: Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.


Assuntos
Procedimentos de Cirurgia Plástica , Lesões dos Tecidos Moles , Humanos , Salvamento de Membro/métodos , Estudos Retrospectivos , Extremidades/cirurgia , Extremidades/lesões , Lesões dos Tecidos Moles/cirurgia , Resultado do Tratamento
13.
Mil Med ; 188(9-10): 2924-2931, 2023 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-35862000

RESUMO

INTRODUCTION: After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East. METHODS: A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes. RESULTS: The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques. CONCLUSION: These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.


Assuntos
Medicina Militar , Cirurgiões Ortopédicos , Ortopedia , Adulto , Humanos , Estudos Retrospectivos , Campanha Afegã de 2001- , Amputação Cirúrgica , Medicina Militar/métodos
14.
Artigo em Inglês | MEDLINE | ID: mdl-38282725

RESUMO

Background: The agonist-antagonist myoneural interface (AMI) technique at the time of transtibial amputation involves the use of agonist-antagonist muscle pairs to restore natural contraction-stretch relationships and to improve proprioceptive feedback when utilizing a prosthetic limb1. Description: Utilizing the standard incision for a long posterior myofasciocutaneous flap, the lateral and medial aspects of the limb are dissected, identifying and preserving the superficial peroneal and saphenous nerve, respectively. The tendons of the tibialis anterior and peroneus longus are transected distally to allow adequate length for the AMI constructs. After ligation of the anterior tibial vessels, the deep peroneal nerve is identified and tagged to create a regenerative peripheral nerve interface (RPNI). The tibia and fibula are cut approximately 15 cm from the medial joint line, facilitating dissection of the deep posterior compartment and ligation of the peroneal and posterior tibial vessels. The tendons of the lateral gastrocnemius and tibialis posterior are transected distally, and the amputation is completed. The extensor retinaculum is harvested from the residual limb along with multiple 2 × 3-cm free muscle grafts, which will be used for the RPNI constructs. The retinaculum is secured to the tibia with suture anchors, and AMI pairs of the lateral gastrocnemius and tibialis anterior as well as the tibialis posterior and peroneus longus are constructed. Separate RPNIs of the major lower-extremity nerves are performed, and the wound is closed in a standard layered fashion. Alternatives: An isometric myodesis of the gastrocnemius without coaptation of agonist-antagonist muscle pairs can be performed at the time of transtibial amputation. Rationale: The AMI technique restores natural agonist-antagonist relationships at the time of transtibial amputation to increase proprioceptive feedback and improve prosthetic control. These outcomes contrast with those of a traditional isometric myodesis, which prevents proprioceptive communication from the residual limb musculature to the central nervous system. Additionally, the AMI technique allows for concentric and eccentric muscular contractions, which may contribute to the maintenance of limb volume and aid with prosthetic fitting, as opposed to the typical limb atrophy observed following standard transtibial amputation1,2. With the development and availability of more advanced prostheses, the AMI technique offers more precise control and increases the functionality of these innovative devices. Expected Outcomes: Early clinical outcomes of the AMI technique at the time of transtibial amputation have been promising. In a case series of the first 3 patients who underwent the procedure, complications were minor and consisted of 2 episodes of cellulitis and 1 case of delayed wound healing1. Muscle activation measured through electromyography demonstrated an improved ability to limit unintended muscular co-contraction with attempted movement of the phantom limb, as compared with patients who underwent a standard transtibial amputation1. Additionally, residual limb volume was maintained postoperatively without the need for substantial prosthetic modifications. Important Tips: The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI3.Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available1. Acronyms & Abbreviations: RPNI = regenerative peripheral nerve interfaceAMI = agonist-antagonist myoneural interfaceEMG = electromyographic.

15.
Am J Sports Med ; 49(12): 3218-3225, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34494899

RESUMO

BACKGROUND: Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series. PURPOSE: To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients. RESULTS: A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care. CONCLUSION: Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.


Assuntos
Articulação Acromioclavicular , Fraturas Ósseas , Articulação Acromioclavicular/cirurgia , Clavícula/cirurgia , Processo Coracoide , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/cirurgia , Humanos , Ligamentos Articulares/cirurgia
16.
Clin Orthop Relat Res ; 479(11): 2388-2396, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34398852

RESUMO

BACKGROUND: Flap-based limb salvage surgery balances the morbidity and complexity of soft tissue transfer against the potential benefit of preserving a functional limb when faced with a traumatized extremity with composite tissue injury. These composite tissue injuries are well suited for multidisciplinary management between orthopaedic and plastic surgeons. Thus, it makes intuitive sense that a collaborative, orthoplastic approach to flap-based limb salvage surgery can result in improved outcomes with decreased risk of flap failure and other complications, raising the question of whether this orthoplastic team approach should be the new standard of care in limb salvage surgery. QUESTIONS/PURPOSES: (1) Is there an association between increased annual institutional volume and perioperative complications to include free and local flap failure (substantial flap viability loss necessitating return to the operating room for debridement of a major portion or all of the flap or amputation)? (2) Is an integrated orthoplastic collaborative approach to managing combat-related traumatic injuries of the extremities individually associated with a decreased risk of flap failure and overall flap-related complications? (3) What other factors, such as location of injury, injury severity score, and initial inpatient length of stay, were associated with flap necrosis and flap-related complications? METHODS: We performed a retrospective review of the electronic medical records of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System's National Capital Region between January 1, 2003 and December 31, 2012. In total, 307 patients underwent 330 flap procedures. Of the 330 flaps, 59% (195) were local or pedicled flaps and 41% (135) were free flaps. Patients were primarily male (99% [303]), with a median (interquartile range) age of 24 years old (IQR 21 to 29), and 87% (267 of 307) of injuries were sustained from a blast mechanism. We collected data on patient demographics, annual case volume involving flap coverage of extremities, mechanism of injury, flap characteristics, perioperative complications, flap failure, flap revision, isolated orthopaedic management versus an integrated orthoplastic approach, and other salvage procedures. For the purposes of this study, orthoplastic management refers to operative management of flap coverage with microvascular surgeons present for soft tissue transfer after initial debridement and fixation by orthopaedic surgery. The orthoplastic management was implemented on a case-by-case basis based on individual injury characteristics and the surgeon's discretion with no formal starting point. When implemented, the orthoplastic team consisted of an orthopaedic surgeon and microvascular-trained hand surgeons and/or plastic surgeons. In all, 77% (254 of 330) of flaps were performed using this model. We considered perioperative flap complications as any complication (such as infection, hematoma, dehiscence, congestion, or necrosis) resulting in return to the operating room for re-evaluation, correction, or partial debridement of the flap. We defined flap failure as a return to the operating room for debridement of a major portion of the flap or amputation secondary to complete or near-complete loss of flap viability. Of the flap procedures, 12% (40 of 330) were classified as a failure and 14% (46 of 330) experienced complications necessitating return to the operating room. Over the study period, free flaps were not more likely to fail than pedicled flaps (11% versus 13%; p = 0.52) or have complications necessitating additional procedures (14% versus 16%; p = 0.65). RESULTS: Our multiple linear regression model demonstrated that an increased number of free flaps performed in our institution annually in any given year was associated with a lower likelihood of failure per case (r = -0.17; p = 0.03) and lower likelihood of reoperation for each flap (r = -0.34; p < 0.001), after adjusting for injury severity and team type (orthoplastic or orthopaedic only). We observed a similar relationship for pedicled flaps, with increased annual case volume associated with a decreased risk of flap failure and reoperation per case after adjusting for injury severity and team type (r = -0.21; p = 0.003 and r = -0.22; p < 0.001, respectively). Employment of a collaborative orthoplastic team approach was associated with decreased flap failures (odds ratio 0.4 [95% confidence interval 0.2 to 0.9]; p = 0.02). Factors associated with flap failure included a lower extremity flap (OR 2.7 [95% CI 1.3 to 6.2]; p = 0.01) and use of muscle flaps (OR 2.3 [95% CI 1.1 to 5.3]; p = 0.02). CONCLUSION: Although prior reports of combat-related extremity trauma have described greater salvage success with the use of pedicled flaps, these reports are biased by institutional inexperience with free tissue transfer, the lack of a coordinated multiservice effort, and severity of injury bias (the most severe injuries often result in free tissue transfer). Our institutional experience, alongside a growing body of literature regarding complex extremity trauma in the civilian setting, suggest a benefit to free tissue coverage to treat complex extremity trauma with adequate practice volume and collaboration. We demonstrated that flap failure and flap-related complications are inversely associated with institutional experience regardless of flap type. Additionally, a collaborative orthoplastic approach was associated with decreased flap failures. However, these results must be interpreted with consideration for potential confounding between the increased case volume coinciding with more frequent collaboration between orthopaedic and plastic surgeons. Given these findings, consideration of an orthoplastic approach at high-volume institutions to address soft tissue coverage in complex extremity trauma may lead to decreased flap failure rates. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Retalhos de Tecido Biológico , Salvamento de Membro/métodos , Extremidade Inferior/lesões , Lesões dos Tecidos Moles/cirurgia , Extremidade Superior/lesões , Adulto , Amputação Cirúrgica/estatística & dados numéricos , Traumatismos por Explosões/cirurgia , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Lineares , Masculino , Militares , Traumatismos Ocupacionais/cirurgia , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Transplante de Tecidos/métodos , Resultado do Tratamento
17.
Cureus ; 13(4): e14544, 2021 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-34017659

RESUMO

Introduction Total knee arthroplasty (TKA) is one of the most common orthopedic procedures performed in the United States. Obtaining radiographs in the post-anesthesia care unit (PACU) has been the standard of care at most hospitals. The purpose of this study was to examine the utility and cost-effectiveness of immediate, postoperative radiographs in regards to operative decision-making to prevent complications within 90 days after primary TKA. Methods A retrospective review of 4,830 consecutive patients who underwent cemented or uncemented TKA between January 2016 and June 2019 at a large, regional medical center was performed. International Classification of Diseases, Tenth Revision (ICD-10) codes were used to track any readmissions within 90 days of TKA. If readmission was for a mechanical complication, including fracture, dislocation, or component loosening, PACU radiographs were reviewed for any abnormalities that may have prevented readmission. Results There were 195 readmissions (195 patients), of which 17 were due to mechanical complications. There was no evidence of fracture or abnormality appreciated on any of the reviewed PACU radiographs by either the reading radiologist or the senior authors. Assuming all fractures were noted on immediate, postoperative radiographs, the cost associated with identifying a single fracture in 2,415 patients was $1,072,260. Conclusion Routine radiographs in the recovery room after an uncomplicated primary TKA are not a reliable mechanism for preventing mechanical complications and do not alter patient care.

18.
Cureus ; 13(1): e13005, 2021 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-33659136

RESUMO

Background Routine analysis of bone specimens in total joint arthroplasty (TJA) is mandatory at many institutions. The purpose of this study was to determine if mandatory routine TJA specimen analysis alters patient care or if they represent an unnecessary healthcare expenditure. Methods A retrospective review was performed of all primary TJA patients between October 2015 and December 2017 at our institution. Pathology results were reviewed to ascertain the number of concordant, discrepant, and discordant results. A diagnosis was considered concordant if the preoperative and pathologic diagnosis matched, discrepant if the preoperative and pathological diagnosis differed but no change in the patient's plan of care occurred, and discordant if the preoperative and pathologic diagnosis differed and resulted in a change in the patient's plan of care.  Results 3,670 total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures (3,613 patients) met the inclusion criteria and were included in this study. All 3,670 specimens had a concordant diagnosis; there were zero discrepant and zero discordant diagnoses. During the study period, our institution spent $67,246.88 in routine analysis of TJA specimens by a pathologist, with no change in any postoperative patient care plans. Conclusion With bundled payment reimbursement models and hospitals trying to decrease unnecessary expenditures, the present study helps further demonstrate that routine analysis has limited cost-effectiveness due to the low prevalence of alteration in the management of patient care. The decision for pathological analysis should be left at the discretion of the surgeon in order to maximize the cost-efficiency of TJA procedures.

19.
Ann Surg ; 273(3): e108-e113, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33378296

RESUMO

OBJECTIVE: To demonstrate the role of advanced orthoplastic techniques in harnessing the full potential of elective amputation as a functionally restorative procedure. SUMMARY OF BACKGROUND DATA: Once considered the unfortunate consequence of failed reconstructive efforts, recent outcomes studies have prompted a re-evaluation of the role of amputation in the management of complex extremity trauma. However, even as amputation is appropriately afforded greater consideration as part of the reconstructive algorithm, reconstructive techniques that are commonly utilized in pursuit of limb salvage are rarely applied to amputation. METHODS: The following case demonstrates the successful application of orthoplastic reconstructive techniques to achieve optimal pain and functional outcomes in a 41-year-old active duty soldier who underwent an elective transtibial amputation after prolonged, limb salvage. RESULTS: The patient presented with a large osteocutaneous proximal tibial defect secondary to trauma and subsequent osteomyelitis. The patient underwent a free scapular-parascapular fasciocutaneous flap to provide soft tissue coverage and facilitate the skeletal reconstruction necessary for either continued limb salvage or amputation. Due to tibial allodynia and severely limited ankle function, the patient subsequently elected for amputation in favor of continued limb salvage. Thus, a transtibial amputation was performed concurrently with a pedicled vascularized fibula to address the proximal tibial defect. A modified agonist-antagonist myoneural interface procedure was used to maximize post-amputation function, with creation of regenerative peripheral nerve interface constructs to prophylax against neurogenic pain. After the operation, the patient achieved improved function of the extremity with the use of a prosthesis and reported substantially improved pain while remaining on active duty in a warfighting military occupational specialty. CONCLUSIONS: By addressing all of the reconstructive components commonly considered in limb salvage, an orthoplastic approach to amputation surgery can minimize pain and maximize the rehabilitative potential of the amputee.


Assuntos
Amputação Cirúrgica/tendências , Salvamento de Membro/tendências , Militares , Adulto , Humanos , Masculino , Manejo da Dor , Tíbia/lesões , Tíbia/cirurgia
20.
Plast Reconstr Surg ; 146(6): 1394-1403, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33234978

RESUMO

Interest in amputation surgery has increased in conjunction with rising public awareness about amputee care. To date, plastic surgeons have impacted the quality of life and functional potential of amputees through novel strategies for sensory feedback and prosthesis control and various techniques for neuroma treatment and prevention. Osseointegration, which involves the direct skeletal attachment of a prosthesis to bone, has the ability to further maximize amputee function. There exists a critical role for plastic surgeons to help optimize techniques for extremity osseointegration through improved wound care and soft-tissue management. An overview of current osseointegrated prostheses and their associated limitations, and potential avenues through which plastic surgeons can help mitigate these challenges, are discussed in this article.


Assuntos
Amputação Cirúrgica/efeitos adversos , Membros Artificiais , Osseointegração , Implantação de Prótese/métodos , Qualidade de Vida , Amputados/psicologia , Humanos , Papel Profissional , Cirurgiões , Resultado do Tratamento
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