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Kontopodis N, Tosounidis T, Kehagias E, Kouraki A, Tzirakis K, Ioannou CV. Concomitant vascular and orthopedic trauma: 10 points to consider. J Clin Orthop Trauma 2024; 51:102407. [PMID: 38681997 PMCID: PMC11053217 DOI: 10.1016/j.jcot.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
Although vascular injuries complicate only 1-2% of patients with orthopedic trauma, they may be encountered in a much higher rate of around 10 % in injuries around the knee and elbow joints following both fractures and dislocations. In case of vascular involvement, specific diagnostic and therapeutic challenges arise and there is a higher risk for significant morbidity (i.e. limb loss) or mortality. In the absence of randomized data, diagnostic and therapeutic algorithms are not always straightforward and clinical practice may be based on experience and local protocols rather than firm evidence. With this article we intend to review available literature regarding concomitant skeletal and vascular trauma in order to provide concise information and clear guidelines of when to operate with least investigations and when to go for a full spectrum of investigations in the absence of hard clinical signs. Additionally, other aspects concerning the manipulation of these patients are discussed, such as the indications of primary amputation, the potential role of endovascular techniques and the value of the Resuscitative Endovascular Balloon Occlusion of the Aorta. In summary, this scoping review summarizes current practices in the diagnostic and therapeutic management of patients with concomitant orthopedic and vascular injuries, discusses different treatment strategies and gives a practical perspective for implementation on every day practice.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Theodoros Tosounidis
- Orthopedic Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, University of Crete-Medical School, Heraklion, Crete, Greece
| | | | - Konstantinos Tzirakis
- Department of Mechanical Engineering, Hellenic Mediterranean University, Heraklion, Crete, Greece
| | - Christos V. Ioannou
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
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Chen K, Hynes KK, Dirschl D, Wolf JM, Strelzow JA. Depression, anxiety, and post-traumatic stress disorder following upper versus lower extremity fractures. Injury 2024; 55:111242. [PMID: 38044162 DOI: 10.1016/j.injury.2023.111242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Orthopaedic trauma has been linked to major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Post-injury rates of psychiatric diagnoses and their relationship to various injury characteristics are not well characterized. We aimed to determine the association between orthopaedic trauma and MDD, GAD, and PTSD diagnoses at 5-year follow-up. METHODS A national insurance claims database was used to create upper extremity fracture (UEF) and lower extremity fracture (LEF) cohorts, with further stratification by isolated versus multiple fractures. Patient undergoing elective upper or lower extremity orthopaedic procedures served as controls. Rates of post-injury psychiatric diagnoses were calculated. Univariate logistic regression was conducted after matching in a 1:1 ratio based on relevant comorbidities such as psychiatric history. All significant variables were included in multivariate analysis. RESULTS A total of 308,578 UEF patients and 360,510 LEF patients were identified. Within the UEF cohort, the diagnosis rates following either isolated or multiple fractures were identified: MDD (25% to 30%), GAD (10% to 11%), and PTSD (4%). LEF cohort rates were as follows: MDD (30% to 38%), GAD (11% to 14%), and PTSD (4% to 7%). Compared to non-injured controls, both the UEF and LEF cohorts were associated with higher rates of all psychiatric diagnoses. In comparing UEF and LEF cohorts, isolated UEF was associated with MDD, GAD, and PTSD; however, multiple UEF was associated with MDD and GAD, whereas multiple LEF was associated with PTSD. CONCLUSION Psychiatric pathology is prevalent following orthopaedic trauma. Even after controlling for psychiatric history, orthopaedic trauma is independently associated with post-injury psychiatric diagnoses and may be more predictive of PTSD and GAD than of MDD. Upper extremity fractures may portend higher psychiatric risk. With negative stigma surrounding mental health and the early role of orthopaedic surgeons in providing care, it is imperative to normalize psychiatric care with patients and discuss warning symptoms that may indicate the onset of psychiatric disorders. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Kevin Chen
- The University of Chicago, Pritzker School of Medicine, Biological Sciences Learning Center, 924 E. 57th St., Ste. 104, Chicago, IL 60637, USA.
| | - Kelly K Hynes
- The University of Chicago Medicine, Department of Orthopaedic Surgery and Rehabilitation Medicine, 5758 S. Maryland Ave., Dept. 4B, Chicago, IL, USA
| | - Douglas Dirschl
- Baylor College of Medicine, Department of Orthopaedic Surgery, 7200 Cambridge St., Ste. 10A, Houston, TX 77030, USA
| | - Jennifer Moriatis Wolf
- The University of Chicago Medicine, Department of Orthopaedic Surgery and Rehabilitation Medicine, 5758 S. Maryland Ave., Dept. 4B, Chicago, IL, USA
| | - Jason A Strelzow
- The University of Chicago Medicine, Department of Orthopaedic Surgery and Rehabilitation Medicine, 5758 S. Maryland Ave., Dept. 4B, Chicago, IL, USA
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Cohen-Tanugi S, Reid R, Loeffler BJ, Gaston RG. The Prevalence of Depression and PTSD in Adults With Surgically Managed Traumatic Upper-Extremity Amputations. Hand (N Y) 2024; 19:169-174. [PMID: 35656852 PMCID: PMC10786098 DOI: 10.1177/15589447221093671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Upper-extremity limb loss has been associated with serious psychological sequelae. Despite advancements in surgical procedures and prostheses for upper limb amputees, it is critical to recognize the psychosocial component of these patients' care. Although the role of psychological factors in outcomes is increasingly acknowledged, little is known about the prevalence of depression and post-traumatic stress disorder (PTSD) in the civilian population after traumatic upper-extremity amputation. METHODS In this retrospective observational single-center study, adult patients evaluated for traumatic upper limb amputations from 2016 to 2019 completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual Analogue Scale, the Center for Epidemiologic Studies Depression Scale, and the Primary Care PTSD Screen during visits. All data underwent descriptive statistical analysis. RESULTS Thirty-nine adult patients treated for upper-extremity traumatic amputation completed patient-reported outcomes (PROs) questionnaires. The median final follow-up time for our cohort was 17 months from amputation. Twenty patients (51%) screened positive for depression and 27 (69%) for PTSD during follow-up. The median time from amputation to first positive screening was 6.5 months for depression and 10 months for PTSD. The physical component score of Veterans RAND 12-Item Health Survey (VR-12) was significantly worse for patients with depression. The Median DASH and mental component score of VR-12 were significantly worse for patients with PTSD. CONCLUSION Upper-extremity limb loss has a significant impact on mental health, which in turn affects PROs. The high prevalence of depression and PTSD in traumatic upper-extremity amputees underscores the necessity for screening and multidisciplinary treatment.
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Affiliation(s)
| | - Risa Reid
- Atrium Health, Department of Orthopaedics, Charlotte, NC, USA
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Erwin ER, Ray KS, Han S. The hidden impact of orthopedic surgeries: Examining the psychological consequences. J Clin Orthop Trauma 2023; 47:102313. [PMID: 38196498 PMCID: PMC10772377 DOI: 10.1016/j.jcot.2023.102313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/23/2023] [Accepted: 12/08/2023] [Indexed: 01/11/2024] Open
Abstract
Orthopedic surgery is commonly considered "quality of life care," as most orthopedic procedures have been shown to provide excellent pain relief and successful surgical outcomes for patients. Although orthopedic surgeries continue to improve patients' functional outcomes through modern surgical techniques and preoperative psychological screening, variation in patient function persists in current studies. Sub-optimal function in patients has been shown to be associated with emotional health burdens, such as anxiety and depression. Previous research has found that preoperative psychological conditions could negatively affect patients' functional outcomes. However, these studies were limited in that they did not examine novel psychological repercussions in emotionally healthy patients following surgery. To address this gap in knowledge, a narrative review was conducted to differentiate specific orthopedic surgeries that have psychological consequences on patients and to determine the current psychological support available for these patients. Data was collected from the Medical Humanities sector of the Texas Medical Center Library and the National Library of Medicine. Studies were included that examined novel psychological effects on patients after undergoing orthopedic surgery. A total of 38 articles were identified, and the majority focused on orthopedic trauma surgery while the rest examined total joint arthroplasty and orthopedic sports procedures. A key finding was that orthopedic trauma surgeries, alone and compared to total joint arthroplasty, result in a greater risk of negative psychological effects, while there was limited data on the psychological effects of orthopedic sports procedures. This narrative review suggests a need to integrate psychosocial support for patients with traumatic orthopedic intervention, regardless of the patient's preoperative psychological state. Furthermore, more research examining the mental well-being of patients following elective orthopedic surgeries is necessary to determine if these operations would benefit from postoperative psychological support as well.
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Affiliation(s)
- Emily R. Erwin
- Department of Orthopedic Surgery, McGovern Medical School, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Keisha S. Ray
- McGovern Center for Humanities & Ethics, McGovern Medical School, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Shuyang Han
- Department of Orthopedic Surgery, McGovern Medical School, 6431 Fannin Street, Houston, TX, 77030, USA
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Rousseau E, Raman R, Tamir T, Bu A, Srinivasan S, Lynch N, Langer R, White FM, Cima MJ. Actuated tissue engineered muscle grafts restore functional mobility after volumetric muscle loss. Biomaterials 2023; 302:122317. [PMID: 37717406 DOI: 10.1016/j.biomaterials.2023.122317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
Damage that affects large volumes of skeletal muscle tissue can severely impact health, mobility, and quality-of-life. Efforts to restore muscle function by implanting tissue engineered muscle grafts at the site of damage have demonstrated limited restoration of force production. Various forms of mechanical and biochemical stimulation have been shown to have a potentially beneficial impact on graft maturation, vascularization, and innervation. However, these approaches yield unpredictable and incomplete recovery of functional mobility. Here we show that targeted actuation of implanted grafts, via non-invasive transcutaneous light stimulation of optogenetic engineered muscle, restores motor function to levels similar to healthy mice 2 weeks post-injury. Furthermore, we conduct phosphoproteomic analysis of actuated engineered muscle in vivo and in vitro to show that repeated muscle contraction alters signaling pathways that play key roles in skeletal muscle contractility, adaptation to injury, neurite growth, neuromuscular synapse formation, angiogenesis, and cytoskeletal remodeling. Our study uncovers changes in phosphorylation of several proteins previously unreported in the context of muscle contraction, revealing promising mechanisms for leveraging actuated muscle grafts to restore mobility after volumetric muscle loss.
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Affiliation(s)
- Erin Rousseau
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Ritu Raman
- Department of Mechanical Engineering, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA.
| | - Tigist Tamir
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA; Department of Biological Engineering, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Angel Bu
- Department of Mechanical Engineering, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Shriya Srinivasan
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Naomi Lynch
- Department of Mechanical Engineering, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Robert Langer
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Forest M White
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA; Department of Biological Engineering, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Michael J Cima
- Koch Institute for Integrative Cancer Research, MIT, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
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Varagur K, Sullivan J, Chiang SN, Skolnick GB, Sacks JM, Christensen JM. Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5345. [PMID: 37850199 PMCID: PMC10578671 DOI: 10.1097/gox.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 10/19/2023]
Abstract
Background Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries. Methods The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits. Results Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05]. Conclusion Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.
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Affiliation(s)
- Kaamya Varagur
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Janessa Sullivan
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Sarah N. Chiang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Gary B. Skolnick
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Justin M. Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Joani M. Christensen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
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Harrington CJ, Wade SM, Hoyt BW, Tintle SM, Potter BK, Souza JM. A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage. J Orthop Trauma 2023; 37:361-365. [PMID: 36750445 DOI: 10.1097/bot.0000000000002582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
- Uniformed Services University-Walter Reed Department of Surgery, 4301 Jones Bridge Road, Bethesda, MD; and
| | - Jason M Souza
- Departments of Plastic and Reconstructive Surgery and Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43212
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Chipman AM, Ottochian M, Ricaurte D, Gunter G, DuBose JJ, Stonko DP, Feliciano DV, Scalea TM, Morrison J. Contemporary management and time to revascularization in upper extremity arterial injury. Vascular 2023; 31:284-291. [PMID: 35418267 DOI: 10.1177/17085381211062726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.
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Affiliation(s)
- Amanda M Chipman
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Marcus Ottochian
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Daniel Ricaurte
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Grahya Gunter
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph J DuBose
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - David P Stonko
- Department of Surgery, 160877Johns Hopkins Hospital, Baltimore, MD, United States
| | - David V Feliciano
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas M Scalea
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jonathan Morrison
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
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Management of the Mangled Extremity. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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10
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Harbertson J, MacGregor AJ, McCabe CT, Eskridge SL, Jurick SM, Watrous JR, Galarneau MR. Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans. Qual Life Res 2023; 32:461-472. [PMID: 36301403 DOI: 10.1007/s11136-022-03263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories. METHODS Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression. RESULTS The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without. CONCLUSION Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.
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Affiliation(s)
- Judith Harbertson
- Leidos, Inc., San Diego, CA, USA. .,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA.
| | - Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA.,Axiom Resource Management, Inc., San Diego, CA, USA
| | - Cameron T McCabe
- Leidos, Inc., San Diego, CA, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA
| | - Susan L Eskridge
- Leidos, Inc., San Diego, CA, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA
| | - Sarah M Jurick
- Leidos, Inc., San Diego, CA, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA
| | - Jessica R Watrous
- Leidos, Inc., San Diego, CA, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106-3521, USA
| | - Michael R Galarneau
- Operational Readiness Research Directorate, Naval Health Research Center, San Diego, USA
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11
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Higgin RP, Palmer J, Qureshi AA, Hancock NJ. Patient reported outcomes after definitive open tibial fracture management. Injury 2022; 53:3838-3842. [PMID: 36153252 DOI: 10.1016/j.injury.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 02/02/2023]
Abstract
AIMS Open tibial fractures are often life-changing injuries and patient outcomes remain poor despite the introduction of national management guidelines. The longer-term impact to the patient can be considerable but this is often overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture. METHODS We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures that presented to our Major Trauma Centre (MTC) between September 2012 and April 2018. Each participant was interviewed and sent patient-reported outcome questionnaires, a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation. RESULTS The mean follow up was 43 months. 96% were grade IIIB and 4% grade IIIC. The response rate for our study was 72%. The mean LEFS was 42 (IQR 21.5-58.5). All total and sub-domain scores within both the SF-36 and SIP questionnaires were reduced when compared to normative population data. Only 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS >14 and those undergoing limb amputation. CONCLUSION Patients are at significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated to have the greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.
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Affiliation(s)
- Ryan Pc Higgin
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD, UK.
| | - Jon Palmer
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Amir A Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Nicholas J Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Tremona Road, Southampton SO16 6YD, UK
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12
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Rodrigue JR, Shenkel J, Boger M, Pomahac B, Fleishman A. Video Messaging to Increase Vascularized Composite Allograft Donation Willingness in United States Military Veterans. Transplant Direct 2022; 8:e1355. [PMID: 36204186 PMCID: PMC9531254 DOI: 10.1097/txd.0000000000001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022] Open
Abstract
Expansion of vascularized composite allograft (VCA) transplantation depends on the public's willingness to donate VCA organs, including face, extremities, and genitourinary organs. This study evaluated the effectiveness of video messaging on VCA donation willingness in US military veterans, a key stakeholder in VCA transplantation. Methods Participants (n = 556) were randomized to 1 of 3 VCA video messaging interventions (informational, testimonial, or blended), a general (non-VCA) organ donation video message, or a control (nondonation) video message. Questionnaires were completed at pre- and postintervention and at 3-wk follow-up. Results Veterans exposed to any VCA video messaging were more likely to express VCA donation willingness (69%, n = 203/296) than those exposed to general donation messaging (53%, n = 47 of 89; P = 0.006) or No Donation Messaging (37%, n = 36 of 97; P < 0.001). A significantly higher proportion of participants who received Blended VCA Messaging were willing to be VCA donors, compared with the Informational VCA Messaging group (79% versus 61%, P = 0.006). Each VCA messaging video resulted in a significant pre- to postintervention increase in the proportion of participants willing to donate their own face, hands, and legs (P < 0.03). Conclusions Brief educational videos focused on VCA transplantation can have a demonstrable and verifiable impact on rates of VCA donation willingness in veterans.
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Affiliation(s)
- James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Jessica Shenkel
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Bohdan Pomahac
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
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13
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Vogel M, Binneböse M, Wallis H, Lohmann CH, Junne F, Berth A, Riediger C. The Unhappy Shoulder: A Conceptual Review of the Psychosomatics of Shoulder Pain. J Clin Med 2022; 11:jcm11185490. [PMID: 36143137 PMCID: PMC9504378 DOI: 10.3390/jcm11185490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Chronic pain is a multifaceted disorder genuinely entangled with psychic and psychosomatic symptoms, which are typically involved in the processes of chronification. The impingement syndrome of the shoulder is no exception to this rule, but several studies have shown respective peculiarities among those with pain and impingement of the shoulder. Notably, chronic pain is a lateralized experience, and, similarly, its psychosomatic correlates may be attached to the hemispheres functionally. AIM The present review therefore gives an overview of the respective findings, with regard not only to psychopathology, but also to personality factors and psychologic trauma, since the latter are reportedly associated with chronic pain. Moreover, we acknowledge symmetry as a possible pathogenic factor. METHODS This narrative review followed the current standards for conducting narrative studies. Based on prior findings, our research strategy included the relevance of psychotraumatologic and symmetrical aspects, as well as comorbidity. We retrieved the relevant literature reporting on the impact of psychopathology as well as personality features on shoulder pain, as published up to January 2022 from the Medline database (1966-2022). Study selecton: We included numerous studies, and considered the contextual relevance of studies referring to the neuropsychosomatics of chronic pain. RESULTS Pain-specific fears, depression, and anxiety are important predictors of shoulder pain, and the latter is generally overrepresented in those with trauma and PTSD. Moreover, associations of shoulder pain with psychological variables are stronger as regards surgical therapies as compared to conservative ones. This may point to a specific and possibly trauma-related vulnerability for perioperative maladaptation. Additionally, functional hemispheric lateralization may explain some of those results given that limb pain is a naturally lateralized experience. Not least, psychosocial risk factors are shared between shoulder pain and its physical comorbidities (e.g., hypertension), and the incapacitated state of the shoulder is a massive threat to the function of the human body as a whole. CONCLUSIONS This review suggests the involvement of psychosomatic and psychotraumatologic factors in shoulder impingement-related chronic pain, but the inconclusiveness and heterogeneity of the literature in the field is possibly suggestive of other determinants such as laterality.
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Affiliation(s)
- Matthias Vogel
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
- Correspondence: ; Tel.: +49391-6714200; Fax: +49391-6714202
| | - Marius Binneböse
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Hannah Wallis
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Christoph H. Lohmann
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Alexander Berth
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Christian Riediger
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
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14
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Brown KV, Roberts DC, Wordsworth M, Duraku LS, Jose RM, Power DM, Stapley SA. Management of conflict injuries to the upper limb. Part 1: assessment and early surgical care. J Hand Surg Eur Vol 2022; 47:687-697. [PMID: 35579217 DOI: 10.1177/17531934221098916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Upper limb injuries are common in conflict zones. The functions of the upper limb are impossible to replicate with prosthetic replacement and wherever possible attempts should be made to preserve the limb with further secondary reconstruction aimed at restoration of function. Casualty assessment, haemorrhage control and resuscitation are simultaneously undertaken at the receiving medical facility. Primary surgical management involves decontamination and debridement, skeletal stabilization, restoration of vascularity, compartment fasciotomy where indicated and wound temporization with dressings. Operative findings and interventions should be documented and if evacuation of the casualty is possible, copies should be provided in the medical records to facilitate communication in the chain of care. Secondary procedures are required for further assessment and debridement prior to planning reconstruction and definitive fracture stabilization, nerve repair, wound cover or closure.
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Affiliation(s)
- Kate V Brown
- The Royal Centre for Defence Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Pulvertaft Hand Unit, Derby Royal Hospital, Derby, UK
| | - Darren C Roberts
- Queen Alexandra Hospital Hand Unit, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Matthew Wordsworth
- The Royal Centre for Defence Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,The Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Liron S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands.,The Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rajive M Jose
- The Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dominic M Power
- The Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,The Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah A Stapley
- The Royal Centre for Defence Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Queen Alexandra Hospital Hand Unit, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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15
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McDonald J, Liang SY, Li P, Stewart L, Tribble DR. DoD-VA Trauma Infection Research Collaboration. Mil Med 2022; 187:17-24. [PMID: 35512378 DOI: 10.1093/milmed/usab482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma. METHODS As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined. RESULTS Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time. CONCLUSIONS Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.
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Affiliation(s)
- Jay McDonald
- Infectious Diseases Section, Veterans Affairs St. Louis Health Care System, St. Louis, MO 63106, USA.,Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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16
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Hilgeman MM, Cramer DRJ, Hoch MC, Collins AN, Zabelski S, Heebner NR. A Pilot Study Comparing Two Measures of Perceived Health Services Access Among Military Veterans With Musculoskeletal Injuries and Mental Health Conditions. Mil Med 2022; 188:usac072. [PMID: 35311993 PMCID: PMC9383606 DOI: 10.1093/milmed/usac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Service members endure a number of musculoskeletal injuries (MSIs) during service (e.g., ankle sprains and chronic back pain). Musculoskeletal injuries can reduce engagement in physical activity after military service and contribute to a sedentary lifestyle that diminishes physical health and elevates the risk for psychological distress including suicide-related behaviors. Yet, little is known about barriers and facilitators to accessing care in veterans with co-occurring MSI and mental health conditions. The purpose of this study was to pilot two brief measures of barriers and facilitators to rehabilitation and mental health services in military veterans with musculoskeletal and mental health conditions. Self-report tools vary in their response formats in ways that can impact usability, data quality, and completeness. We examine two response styles (i.e., checklist vs. thermometer) for two health services (mental health and rehabilitation) to determine usability, patterns in item endorsement, and veteran preference. MATERIALS AND METHODS Barriers and facilitators informed by the Fortney Veterans Healthcare Access model were assessed by veterans (n = 31) on the newly developed 22-item, paper-and-pencil scale with separate ratings for mental health and rehabilitation services. All participants completed scales with both response styles and the order of administration was randomized (i.e., either the checklist first or the thermometer-style response first). Data also included self-reported demographics, musculoskeletal and mental health diagnoses, health-related quality of life, physical activity levels, mental health symptoms, suicide risk, and coronavirus disease of 2019 pandemic-related stress. RESULTS Veterans reported no differences in ease of use across response formats; however, 83.9% (n = 26) preferred the checklist style, with only 3.22% (n = 1) preferring the thermometer format. Checklist items also resulted in less missing data (i.e., range 0.00%-6.45%) than the thermometer-style option (i.e., range 6.45%-61.30%). On the checklist, total number of perceived barriers was low for mental health and rehabilitation services (i.e., M = 1.58 and M = 1.61, respectively). Distance to care and problems related to symptoms were the most frequently identified barriers for both services. Facilitators outnumbered barriers for mental and rehabilitation services, and nearness of the clinic/hospital was the top-rated facilitator for both. On the thermometer, the perceived strength of each mental health (M = 39.37) and rehabilitation (M = 39.81) service barrier was moderate (0-100 scale), while the average perceived strength of each mental health (M = 61.66) and rehabilitation service (M = 61.84) facilitator was higher. Associations between barrier and facilitator scores with mental and physical health indicators were small with exceptions. For instance, suicide attempt likelihood was positively correlated with rehabilitation services barriers; mental health burden was positively associated with both barriers and facilitators. CONCLUSIONS Results of this pilot comparing two measurement approaches identified actionable next steps. Brief barriers and facilitators checklists were viable for veteran ratings across type of health. The thermometer-based tool captured the perceived strength of barriers and facilitators but yielded problematic rates of missing data in its current form and was not preferred by veterans.
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Affiliation(s)
- Michelle M Hilgeman
- Clinical Research Psychologist, Research & Development Service (151), Tuscaloosa VA Medical Center, Tuscaloosa, AL 35404, USA
| | - Dr Robert J Cramer
- Department of Public Health Sciences, UNC Charlotte, Charlotte, NC 28223, USA
| | - Matthew C Hoch
- Sports Medicine Research Institute, University of Kentucky, Lexington, KY 40506, USA
| | - Amber N Collins
- Research & Development Service (151), Tuscaloosa VA Medical Center, Tuscaloosa, AL 35404, USA
| | - Sasha Zabelski
- Department of Public Health Sciences, UNC Charlotte, Charlotte, NC 28223, USA
| | - Nicholas R Heebner
- Sports Medicine Research Institute, University of Kentucky, Lexington, KY 40506, USA
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17
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Margolis DS, Figueroa G, Barron Villalobos E, Smith JL, Doane CJ, Gonzales DA, Szivek JA. A Large Segmental Mid-Diaphyseal Femoral Defect Sheep Model: Surgical Technique. J INVEST SURG 2022; 35:1287-1295. [DOI: 10.1080/08941939.2022.2045393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- David S. Margolis
- Orthopedic Research Laboratory, College of Medicine, University of Arizona, Tucson, Arizona
| | - Gerardo Figueroa
- Orthopedic Research Laboratory, College of Medicine, University of Arizona, Tucson, Arizona
| | | | - Jordan L. Smith
- Orthopedic Research Laboratory, College of Medicine, University of Arizona, Tucson, Arizona
| | | | - David A. Gonzales
- Orthopedic Research Laboratory, College of Medicine, University of Arizona, Tucson, Arizona
| | - John A. Szivek
- Orthopedic Research Laboratory, College of Medicine, University of Arizona, Tucson, Arizona
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18
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Barinaga G, Rodriguez-Feo C, Rasmussen E, Telfer S, Iannuzzi N. The Effect of Forearm Shortening on Forearm Range of Motion. J Hand Surg Am 2022; 47:87.e1-87.e7. [PMID: 34001411 DOI: 10.1016/j.jhsa.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 01/17/2021] [Accepted: 03/16/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening. METHODS A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model. RESULTS Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2-4 cm of shortening and in pronation at 4-6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow's location. CONCLUSIONS This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm. CLINICAL RELEVANCE This information may improve surgeons' and patients' understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.
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Affiliation(s)
- Gonzalo Barinaga
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA; Orthopedic Institute of Wisconsin, Wauwatosa, WI
| | - Charles Rodriguez-Feo
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.
| | - Elizabeth Rasmussen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Scott Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Nicholas Iannuzzi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
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19
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Sharrock M. The mangled extremity: assessment, decision making and outcomes. Acta Orthop Belg 2021; 87:755-760. [PMID: 35172444 DOI: 10.52628/87.4.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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20
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Effective assessments to identify overuse injuries in unaffected limbs of persons with unilateral upper limb amputations. J Hand Ther 2021; 34:298-308. [PMID: 34148738 DOI: 10.1016/j.jht.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Cross-sectional study. INTRODUCTION Overuse injuries (OI) present major health problems and oftentimes, permanent disability. Persons with unilateral upper limb diagnoses, such as amputation, are at-risk for developing OI in their unaffected limbs. Measures to identify high-risk populations are needed. PURPOSE OF THE STUDY Scores on 6 OI-assessments were compared for persons with unilateral upper limb amputations (UULA) and healthy participants. Cutoff values were proposed. METHODS Sixty-two persons with UULA and 62 healthy controls completed this study. Scores for hand volume (HV), visual analogue scale (VAS), multi-site Semmes Weinstein Monofilament for median and ulnar nerves (SWM-M/SWM-U), torque range of motion for wrist/finger extension and flexion (TROM-E/TROM-F), intrinsic tightness (IT), and differential flexor tendon gliding (DFTG) were collected before and after 15 minutes of repetitive and resistive exercise. When analyzing collected data, descriptive statistics, and ANOVA were used to identify differences between groups. Receiver operating characteristic curves (ROC), area under the curve (AUC), sensitivity, and specificity were calculated to determine acceptable cutoff scores. Cutoff values with significant AUC ≥ 0.60 and sensitivity ≥ 0.80 were accepted. RESULTS Statistically significant differences were found between HV by gender in both pre-exercise and post-exercise conditions. Gain scores for whole sample HV, female HV, and TROM-E were statistically different although differences were small and not meaningful. Significant AUC and acceptable pre-exercise cutoff values included 375 ml. for female HV (sensitivity 89%, specificity 87%), 505 ml. for male HV (sensitivity 81%, specificity 70%), 82 degrees for TROM-E (sensitivity 92%, specificity 71%), and 73 degrees of TROM-F (sensitivity 90%, specificity 89%). CONCLUSIONS Potential at-risk OI-related populations, especially unaffected limbs of UULA persons, are best identified by pre-exercise cutoff values using HV by gender, TROM, and single-site SWM 2.83.
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21
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Resnik L, Borgia M, Cancio J, Heckman J, Highsmith J, Levy C, Webster J. Upper limb prosthesis users: A longitudinal cohort study. Prosthet Orthot Int 2021; 45:384-392. [PMID: 34469939 DOI: 10.1097/pxr.0000000000000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 07/27/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND No previous studies have followed prosthesis users with upper limb loss or limb deficiency using their own prostheses to assess change over time. OBJECTIVES (1) To describe prostheses and terminal device types used at baseline and 1-year follow-up; (2) to examine changes in functional outcomes and device satisfaction over time; and (3) to examine whether changes in outcomes varied across level of amputation and type of prosthesis used. STUDY DESIGN Multisite, observational time series design with in-person functional performance and self-report data collected at baseline and 1-year follow-up. METHODS Baseline and follow-up outcome scores were compared using Wilcoxon signed-rank tests. Analyses were stratified by amputation level, time since amputation, prosthesis type, and change in device type. Published minimal detectable change (MDC) values were used to determine whether detectable change in outcome measures occurred. RESULTS The longitudinal cohort consisted of 64 participants (mean age 64 years, 56% body-powered users). The only significant differences in outcome measures between baseline and follow-up (after adjustment for false discovery) were hours/day of prosthesis use, which increased from 6.0 (4.4) to 7.3 (5.3) hours (P = 0.0022). Differences in prosthesis use intensity remained significant in analyses stratified by amputation level, time since amputation, prosthesis type, and change in device type. Between 14 and 20% of the sample had change in one or more outcome measures that was greater than the known MDC. CONCLUSIONS Most participants had stable outcomes over a year's time, whereas 14-20% experienced either improvement or decline in one or more tests indicating the importance of annual follow-up visits.
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Affiliation(s)
- Linda Resnik
- Research Department, Providence VA Medical Center, Providence, RI, USA
- Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Matthew Borgia
- Research Department, Providence VA Medical Center, Providence, RI, USA
| | - Jill Cancio
- Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX, USA
- Extremity Trauma and Amputation Center of Excellence, JBSA Ft. Sam Houston, TX, USA
- US Army Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Jeffrey Heckman
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jason Highsmith
- Rehabilitation & Prosthetic Services (10P4R), Orthotic, Prosthetic & Pedorthic Clinical Services, US Department of Veterans Affairs, Washington DC, USA
- School of Physical Therapy & Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Charles Levy
- Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Joseph Webster
- Department of Physical Medicine and Rehabilitation, School of Medicine at Virginia Commonwealth University, Richmond, VA, USA
- Staff Physician, Physical Medicine and Rehabilitation, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
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22
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Webster JB, Webster N, Borgia M, Resnik L. Frequency, severity, and implications of shoulder pain in people with major upper limb amputation who use prostheses: Results of a National Study. PM R 2021; 14:901-912. [PMID: 34219397 DOI: 10.1002/pmrj.12666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with upper limb amputation are potentially at increased risk of shoulder pain because they often perform compensatory movements to operate their prostheses and rely more heavily on their nonamputated limb for everyday activities. OBJECTIVE To describe the frequency, severity, associated factors, and implications of shoulder pain in people with unilateral major upper limb amputation who use prostheses. DESIGN Cross-sectional, observational design. SETTING National recruitment of people living in the community. PARTICIPANTS U.S. veterans and civilians (N = 107) with unilateral major upper limb amputation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Shoulder pain (any, ipsilateral and contralateral to amputation), activity performance (Activities Measure for Upper Limb Amputation), health-related quality of life (Veterans RAND 12-Item Health Survey mental component summary [MCS] and physical component summary [PCS]), and disability (Quick Version of the Disabilities of the Arm, Shoulder and Hand Score [QuickDASH]). RESULTS All participants completed a comprehensive in-person assessment. Participants were 97% male with a mean age of 57.1 years and a mean time since amputation of 23.4 years. The prevalence of any shoulder pain was 30% (15% ipsilateral, 25% contralateral, 10% bilateral). Shoulder pain intensity (0 to 10 scale) was moderate for both ipsilateral (mean 4.9, SD 2.0) and contralateral (mean 4.2, SD 2.0) pain. No significant difference in shoulder pain frequency was observed by amputation level. The prevalence of any shoulder pain was greater in those using a body-powered prosthesis (38% compared to 18% in externally powered users). Each additional year since amputation was associated with an increased likelihood of having contralateral shoulder pain (odds ratio: 1.05, confidence interval: 1.01, 1.10). In linear regression models, those with contralateral shoulder pain had worse PCS (β = -7.07, p = .008) and worse QuickDASH (β = 18.25, p < .001) scores. CONCLUSIONS In our sample of predominantly male veterans with major upper limb amputation, shoulder pain was a common condition associated with functional and quality of life implications. Among prosthesis users, the shoulder contralateral to the amputation was at greatest risk, with risk increasing with every year since amputation.
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Affiliation(s)
- Joseph B Webster
- Department of Physical Medicine and Rehabilitation, School of Medicine at Virginia Commonwealth University, Richmond, Virginia, USA.,Physical Medicine and Rehabilitation, Central Virginia VA Healthcare System, Richmond, Virginia, USA
| | | | - Matthew Borgia
- Research Department, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Linda Resnik
- Research Department, Providence VA Medical Center, Providence, Rhode Island, USA.,Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA
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Velmurugesan PS, Devendra A, Ramkumar S, Dheenadhayalan J, Rajasabapathy S, Rajasekaran S. Successful Limb Salvage Using an Orthoplastic Approach of Type IIIB Open Injuries of the Shoulder: A Report of 3 Cases. JBJS Case Connect 2021; 11:01709767-202106000-00130. [PMID: 34166253 DOI: 10.2106/jbjs.cc.20.00664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report 3 adult men (aged 28, 34, and 71 years) with successfully salvaged mangled injuries around the shoulder with high threshold for amputation. Assessment by Mangled Extremity Severity Score, Ganga Hospital Open Injury Severity Score, and Orthopaedic Trauma Association-Open Fracture Classification open injury scores predicted amputation. However, extended salvage was performed by orthoplastic approach. Two of them had superior shoulder suspensory complex (SSSC) injury. The QuickDASH score was high in 2 patients with SSSC injury and a good score in the third patient who achieved good shoulder motion. CONCLUSION "Orthoplastic approach" achieves successful limb salvage in severely mangled shoulder injuries. Volume of muscle crush injury and double disruption of SSSC injury were the main determinants of outcome.
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Affiliation(s)
| | - Agraharam Devendra
- Department of Orthopaedics, Ganga Medical Center and Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
| | - Sanjai Ramkumar
- Department of Plastic and Microreconstructive Surgery, Ganga Medical Center and Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
| | | | - Shanmuganathan Rajasabapathy
- Department of Plastic and Microreconstructive Surgery, Ganga Medical Center and Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
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24
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Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
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Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
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25
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Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study. J Orthop Trauma 2021; 35:e96-e102. [PMID: 33079837 DOI: 10.1097/bot.0000000000001921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN A retrospective cohort study. SETTING Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION Not applicable. MAIN OUTCOME MEASUREMENTS Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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26
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Yu L, Deng L, Zhu S, Deng K, Yu G, Zhu C, Qi B, Pan Z. Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites. Med Sci Monit 2021; 27:e927652. [PMID: 33431786 PMCID: PMC7812700 DOI: 10.12659/msm.927652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity. Materal/Methods From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed. Results External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery. Conclusions Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon’s best efforts.
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Affiliation(s)
- Li Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Linglong Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Shaobo Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Kai Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Guorong Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Chunquan Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Zhenyu Pan
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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27
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Saunders D, Rose L. Regenerative rehabilitation of catastrophic extremity injury in military conflicts and a review of recent developmental efforts. Connect Tissue Res 2021; 62:83-98. [PMID: 32552156 DOI: 10.1080/03008207.2020.1776707] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM OF THE REVIEW This review aims to describe the current state of regenerative rehabilitation of severe military extremity injuries, and promising new therapies on the horizon. DISCUSSION The nature of warfare is rapidly shifting with information operations, autonomous weapons, and the threat of full-scale peer adversary conflicts threatening to create contested environments with delayed medical evacuation to definitive care. More destructive weapons will lead to more devastating injuries, creating new challenges for limb repair and restoration. Current paradigms of delayed rehabilitation following initial stabilization, damage control surgery, and prolonged antibiotic therapy will need to shift. Advances in regenerative medicine technologies offer the possibility of treatment along the continuum of care. Regenerative rehabilitation will begin at the point of injury and require a holistic, organ-systems approach. CONCLUSIONS Both technological improvements and a rapidly advancing understanding of injury pathophysiology will contribute to improved limb-salvage outcomes, and shift the calculus away from early limb amputation.
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Affiliation(s)
- David Saunders
- US Army Medical Material Development Activity, Fort Detrick, MD , USA
| | - Lloyd Rose
- US Army Medical Material Development Activity, Fort Detrick, MD , USA
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28
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Haney LJ, Bae E, Pugh MJV, Copeland LA, Wang CP, MacCarthy DJ, Amuan ME, Shireman PK. Patency of arterial repairs from wartime extremity vascular injuries. Trauma Surg Acute Care Open 2020; 5:e000616. [PMID: 33409373 PMCID: PMC7768973 DOI: 10.1136/tsaco-2020-000616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability. METHODS Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency. RESULTS The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency. CONCLUSIONS Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Lauren J Haney
- Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Esther Bae
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Mary Jo V Pugh
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA,Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Daniel J MacCarthy
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Megan E Amuan
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Paula K Shireman
- Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,Surgery, South Texas Veterans Health Care System, San Antonio, Texas, USA
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29
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Haney LJ, Pugh MJV, Copeland LA, Wang CP, MacCarthy DJ, Amuan ME, Shireman PK. Persistent Pain, Physical Dysfunction, and Decreased Quality of Life After Combat Extremity Vascular Trauma. Ann Vasc Surg 2020; 71:167-180. [PMID: 32890646 DOI: 10.1016/j.avsg.2020.08.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. METHODS Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. RESULTS Eighty-one patients responded with an average time since injury of 129 months (SD: 31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P = 0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. CONCLUSIONS EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.
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Affiliation(s)
- Lauren J Haney
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Mary Jo V Pugh
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT; VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Daniel J MacCarthy
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Megan E Amuan
- VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Paula K Shireman
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX.
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