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Rivero S, Stevens NM. The nonsalvageable tibia: amputation and prosthetics. OTA Int 2024; 7:e306. [PMID: 38840707 PMCID: PMC11149746 DOI: 10.1097/oi9.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/17/2023] [Accepted: 12/01/2023] [Indexed: 06/07/2024]
Abstract
Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.
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2
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Farrelly E, Tarapore R, Lindsey S, Wieland MD. Management of the Mangled Extremity. Surg Clin North Am 2024; 104:385-404. [PMID: 38453309 DOI: 10.1016/j.suc.2023.10.006] [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: 03/09/2024]
Abstract
Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.
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Affiliation(s)
- Erin Farrelly
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA.
| | - Rae Tarapore
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Sierra Lindsey
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Mark D Wieland
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
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3
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Smith TP, Cognetti DJ, Cook A, Lynch TB, Alderete JF, Lybeck DO, Dowd TC. Similar rates of reoperation for neuroma after transtibial amputations with and without targeted muscle reinnervation. OTA Int 2024; 7:e297. [PMID: 38433988 PMCID: PMC10906631 DOI: 10.1097/oi9.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 09/13/2023] [Accepted: 10/14/2023] [Indexed: 03/05/2024]
Abstract
Objective To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR). Design Retrospective cohort study. Setting Level I trauma hospital and tertiary military medical center. Patients/Participants Adult patients undergoing transtibial amputations with and without TMR. Intervention Transtibial amputation with targeted muscle reinnervation. Main Outcome Measurements Reoperation for symptomatic neuroma. Results During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97). Conclusions Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Alyssa Cook
- San Antonio Military Medical Center, San Antonio, TX
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4
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Fabre I, Thompson D, Gwilym B, Jones K, Pinzur M, Geertzen JHB, Twine C, Bosanquet D. Surgical Techniques of, and Outcomes after, Distal Muscle Stabilization in Transfemoral Amputation: A Systematic Review and Narrative Synthesis. Ann Vasc Surg 2024; 98:182-193. [PMID: 37802139 DOI: 10.1016/j.avsg.2023.07.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Distal muscle stabilization, such as myodesis (suturing muscles to bone) or myoplasty (suturing agonistic-antagonistic muscles together), can aid residual limb stabilization, provide a good soft-tissue covering, and increase rehabilitation potential. However, surgical practice varies due to scant clinical data. The aim of this review is to summarize and evaluate the literature regarding techniques and associated outcomes of distal muscle stabilization in transfemoral amputation (TFA). METHODS A systematic review and narrative synthesis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Resources, including observational studies, nonobservational scientific papers, conference proceedings, and textbooks, detailing techniques of TFA distal muscle stabilization were identified from standard medical repositories and library search. A supplementary search of YouTube and Google was undertaken to identify additional resources. Quality assessment was undertaken using Risk Of Bias In Nonrandomized Studies-of Interventions; Authority, Accuracy, Coverage, Objectivity, Date, Significance; and modified-Discern tools. RESULTS Forty seven resources were identified, including 17 journal articles, 17 textbooks, 5 educational websites/eBooks, 5 videos, 2 online presentations, and 1 webpage. Thirty seven described myodesis, 11 described myoplasty, and 6 described closure without distal muscle stabilization. Eight observational studies presented outcome data for 302 TFAs. No studies comparing closure with or without distal muscle stabilization were identified. All papers describing myodesis secured the adductors to the femur, and most also secured the quadriceps and/or hamstrings to this complex. Number of femoral drill holes varied from 1 to 6. Early wound complications occurred in 17% of amputations, whereas myodesis failure occurred in 9.5%. Prosthetic fitting rates were 73% and, where reported, 100% of patients maintained neutral femoral alignment. CONCLUSIONS Distal muscle stabilization, particularly myodesis, is a commonly described technique for TFA, although operative techniques are heterogenous. There is a paucity of outcome data, and no studies comparing it to closures without distal muscle stabilization. However, these low-quality data suggest wound healing rates are equivalent to TFA without distal muscle stabilization while demonstrating improvement to patients' rehabilitation potential.
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Affiliation(s)
| | | | | | | | | | - Jan H B Geertzen
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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5
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Keleş AD, Türksoy RT, Yucesoy CA. The use of nonnormalized surface EMG and feature inputs for LSTM-based powered ankle prosthesis control algorithm development. Front Neurosci 2023; 17:1158280. [PMID: 37465585 PMCID: PMC10351874 DOI: 10.3389/fnins.2023.1158280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/14/2023] [Indexed: 07/20/2023] Open
Abstract
Advancements in instrumentation support improved powered ankle prostheses hardware development. However, control algorithms have limitations regarding number and type of sensors utilized and achieving autonomous adaptation, which is key to a natural ambulation. Surface electromyogram (sEMG) sensors are promising. With a minimized number of sEMG inputs an economic control algorithm can be developed, whereas limiting the use of lower leg muscles will provide a practical algorithm for both ankle disarticulation and transtibial amputation. To determine appropriate sensor combinations, a systematic assessment of the predictive success of variations of multiple sEMG inputs in estimating ankle position and moment has to conducted. More importantly, tackling the use of nonnormalized sEMG data in such algorithm development to overcome processing complexities in real-time is essential, but lacking. We used healthy population level walking data to (1) develop sagittal ankle position and moment predicting algorithms using nonnormalized sEMG, and (2) rank all muscle combinations based on success to determine economic and practical algorithms. Eight lower extremity muscles were studied as sEMG inputs to a long-short-term memory (LSTM) neural network architecture: tibialis anterior (TA), soleus (SO), medial gastrocnemius (MG), peroneus longus (PL), rectus femoris (RF), vastus medialis (VM), biceps femoris (BF) and gluteus maximus (GMax). Five features extracted from nonnormalized sEMG amplitudes were used: integrated EMG (IEMG), mean absolute value (MAV), Willison amplitude (WAMP), root mean square (RMS) and waveform length (WL). Muscle and feature combination variations were ranked using Pearson's correlation coefficient (r > 0.90 indicates successful correlations), the root-mean-square error and one-dimensional statistical parametric mapping between the original data and LSTM response. The results showed that IEMG+WL yields the best feature combination performance. The best performing variation was MG + RF + VM (rposition = 0.9099 and rmoment = 0.9707) whereas, PL (rposition = 0.9001, rmoment = 0.9703) and GMax+VM (rposition = 0.9010, rmoment = 0.9718) were distinguished as the economic and practical variations, respectively. The study established for the first time the use of nonnormalized sEMG in control algorithm development for level walking.
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Affiliation(s)
- Ahmet Doğukan Keleş
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Türkiye
- Institute for Modelling and Simulation of Biomechanical Systems, University of Stuttgart, Stuttgart, Germany
| | - Ramazan Tarık Türksoy
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Türkiye
- Huawei Turkey R&D Center, Istanbul, Türkiye
| | - Can A. Yucesoy
- Institute of Biomedical Engineering, Boğaziçi University, Istanbul, Türkiye
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6
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Lansford JL, McCarthy CF, Souza JM, Saberski ER, Potter BK. Preventing biological waste: Effective use of viable tissue in traumatized lower extremities. OTA Int 2023; 6:e242. [PMID: 37448566 PMCID: PMC10337847 DOI: 10.1097/oi9.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/17/2022] [Indexed: 07/15/2023]
Abstract
Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are "spare parts" that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function. Level of Evidence 5.
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Affiliation(s)
| | | | - Jason M. Souza
- Ohio State University College of Medicine, Columbus, OH; and
| | - Ean R. Saberski
- Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University of Health Sciences, Bethesda, MD
| | - Benjamin K. Potter
- Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University of Health Sciences, Bethesda, MD
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7
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Li Z, Koban KC, Schenck TL, Giunta RE, Li Q, Sun Y. Artificial Intelligence in Dermatology Image Analysis: Current Developments and Future Trends. J Clin Med 2022; 11:jcm11226826. [PMID: 36431301 PMCID: PMC9693628 DOI: 10.3390/jcm11226826] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Thanks to the rapid development of computer-based systems and deep-learning-based algorithms, artificial intelligence (AI) has long been integrated into the healthcare field. AI is also particularly helpful in image recognition, surgical assistance and basic research. Due to the unique nature of dermatology, AI-aided dermatological diagnosis based on image recognition has become a modern focus and future trend. Key scientific concepts of review: The use of 3D imaging systems allows clinicians to screen and label skin pigmented lesions and distributed disorders, which can provide an objective assessment and image documentation of lesion sites. Dermatoscopes combined with intelligent software help the dermatologist to easily correlate each close-up image with the corresponding marked lesion in the 3D body map. In addition, AI in the field of prosthetics can assist in the rehabilitation of patients and help to restore limb function after amputation in patients with skin tumors. THE AIM OF THE STUDY For the benefit of patients, dermatologists have an obligation to explore the opportunities, risks and limitations of AI applications. This study focuses on the application of emerging AI in dermatology to aid clinical diagnosis and treatment, analyzes the current state of the field and summarizes its future trends and prospects so as to help dermatologists realize the impact of new technological innovations on traditional practices so that they can embrace and use AI-based medical approaches more quickly.
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Affiliation(s)
- Zhouxiao Li
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200023, China
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80339 Munich, Germany
| | | | - Thilo Ludwig Schenck
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80339 Munich, Germany
| | - Riccardo Enzo Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80339 Munich, Germany
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200023, China
- Correspondence: (Q.L.); (Y.S.)
| | - Yangbai Sun
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200023, China
- Correspondence: (Q.L.); (Y.S.)
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8
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Fleming A, Stafford N, Huang S, Hu X, Ferris DP, Huang H(H. Myoelectric control of robotic lower limb prostheses: a review of electromyography interfaces, control paradigms, challenges and future directions. J Neural Eng 2021; 18:10.1088/1741-2552/ac1176. [PMID: 34229307 PMCID: PMC8694273 DOI: 10.1088/1741-2552/ac1176] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022]
Abstract
Objective.Advanced robotic lower limb prostheses are mainly controlled autonomously. Although the existing control can assist cyclic movements during locomotion of amputee users, the function of these modern devices is still limited due to the lack of neuromuscular control (i.e. control based on human efferent neural signals from the central nervous system to peripheral muscles for movement production). Neuromuscular control signals can be recorded from muscles, called electromyographic (EMG) or myoelectric signals. In fact, using EMG signals for robotic lower limb prostheses control has been an emerging research topic in the field for the past decade to address novel prosthesis functionality and adaptability to different environments and task contexts. The objective of this paper is to review robotic lower limb Prosthesis control via EMG signals recorded from residual muscles in individuals with lower limb amputations.Approach.We performed a literature review on surgical techniques for enhanced EMG interfaces, EMG sensors, decoding algorithms, and control paradigms for robotic lower limb prostheses.Main results.This review highlights the promise of EMG control for enabling new functionalities in robotic lower limb prostheses, as well as the existing challenges, knowledge gaps, and opportunities on this research topic from human motor control and clinical practice perspectives.Significance.This review may guide the future collaborations among researchers in neuromechanics, neural engineering, assistive technologies, and amputee clinics in order to build and translate true bionic lower limbs to individuals with lower limb amputations for improved motor function.
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Affiliation(s)
- Aaron Fleming
- Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
- Equal contribution as the first author
| | - Nicole Stafford
- Department of Mechanical and Aerospace Engineering, University of Florida, Gainesville, FL 32611, United States of America
- Equal contribution as the first author
| | - Stephanie Huang
- Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Xiaogang Hu
- Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Daniel P Ferris
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611, United States of America
| | - He (Helen) Huang
- Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
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9
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Sahin AA, Khalil E. LOWER EXTREMITY PROBLEMS AND RELATED SURGICAL PROCEDURES BEFORE AND DURING THE COVID-19 PANDEMIC IN A TERTIARY HEALTHCARE INSTITUTION. SANAMED 2021. [DOI: 10.24125/sanamed.v16i2.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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10
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Hoyt BW, Gibson JA, Potter BK, Souza JM. Practice Patterns and Pain Outcomes for Targeted Muscle Reinnervation: An Informed Approach to Targeted Muscle Reinnervation Use in the Acute Amputation Setting. J Bone Joint Surg Am 2021; 103:681-687. [PMID: 33849050 DOI: 10.2106/jbjs.20.01005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures have been shown to improve patient-reported outcomes for the treatment of symptomatic neuromas after amputation; however, the specific indications and comparative outcomes of each are unclear. The primary research questions were what complement of nerves most frequently requires secondary pain intervention after conventional amputation, whether this information can guide the focused application of TMR and RPNI to the primary amputation setting, and how the outcomes compare in both settings. METHODS We performed a retrospective review of records for patients who had undergone lower-extremity TMR and/or RPNI at our institution. Eighty-seven procedures were performed: 59 for the secondary treatment of symptomatic neuroma pain after amputation and 28 for primary prophylaxis during amputation. We reviewed records for the amputation level, TMR and/or RPNI timing, pain scores, patient-reported resolution of nerve-related symptoms, and complications or revisions. We evaluated the relationship between the amputation level and the frequency with which each transected nerve required neurologic intervention for pain symptoms. RESULTS The mean pain score decreased after delayed TMR or RPNI procedures from 4.3 points to 1.7 points (p < 0.001), and the mean final pain score (and standard deviation) was 1.0 ± 1.9 points at the time of follow-up for acute procedures. Symptom resolution was achieved in 92% of patients. The sciatic nerve most commonly required intervention for symptomatic neuroma above the knee, and the tibial nerve and common or superficial peroneal nerve were most problematic following transtibial amputation. None of our patients required a revision pain treatment procedure after primary TMR targeting these commonly symptomatic nerves. Failure to address the tibial nerve during a delayed procedure was associated with an increased risk of unsuccessful TMR, resulting in a revision surgical procedure (odds ratio, 26 [95% confidence interval, 1.8 to 368]; p = 0.02). CONCLUSIONS There is a consistent pattern of symptomatic nerves that require secondary surgical intervention for the management of pain after amputation. TMR and RPNI were translated to the primary amputation setting by using this predictable pattern to devise a surgical strategy that prevents symptomatic neuroma pain. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin W Hoyt
- USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
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11
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Ding Z, Jarvis HL, Bennett AN, Baker R, Bull AMJ. Higher knee contact forces might underlie increased osteoarthritis rates in high functioning amputees: A pilot study. J Orthop Res 2021; 39:850-860. [PMID: 32427347 DOI: 10.1002/jor.24751] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/24/2020] [Accepted: 05/01/2020] [Indexed: 02/04/2023]
Abstract
High functioning military transtibial amputees (TTAs) with well-fitted state of the art prosthetics have gait that is indistinguishable from healthy individuals, yet they are more likely to develop knee osteoarthritis (OA) of their intact limbs. This contrasts with the information at the knees of the amputated limbs that have been shown to be at a significantly reduced risk of pain and OA. The hypothesis of this study is that biomechanics can explain the difference in knee OA risk. Eleven military unilateral TTAs and eleven matched healthy controls underwent gait analysis. Muscle forces and joint contact forces at the knee were quantified using musculoskeletal modeling, validated using electromyography measurements. Peak knee contact forces for the intact limbs on both the medial and lateral compartments were significantly greater than the healthy controls (P ≤ .006). Additionally, the intact limbs had greater peak semimembranosus (P = .001) and gastrocnemius (P ≤ .001) muscle forces compared to the controls. This study has for the first time provided robust evidence of increased force on the non-affected knees of high functioning TTAs that supports the mechanically based hypothesis to explain the documented higher risk of knee OA in this patient group. The results suggest several protentional strategies to mitigate knee OA of the intact limbs, which may include the improvements of the prosthetic foot control, socket design, and strengthening of the amputated muscles.
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Affiliation(s)
- Ziyun Ding
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Hannah L Jarvis
- Faculty of Science and Engineering, School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Headley Court, Epsom, United Kingdom.,National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Richard Baker
- School of Health Sciences, University of Salford, Salford, United Kingdom
| | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, United Kingdom
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12
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Bates TJ, Fergason JR, Pierrie SN. Technological Advances in Prosthesis Design and Rehabilitation Following Upper Extremity Limb Loss. Curr Rev Musculoskelet Med 2020; 13:485-493. [PMID: 32488625 PMCID: PMC7340716 DOI: 10.1007/s12178-020-09656-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The complexity of the human extremity, particularly the upper extremity and the hand, allows us to interact with the world. Prosthetists have struggled to recreate the intuitive motor control, light touch sensation, and proprioception of the innate limb in a manner that reflects the complexity of its native form and function. Nevertheless, recent advances in prosthesis technology, surgical innovations, and enhanced rehabilitation appear promising for patients with limb loss who hope to return to their pre-injury level of function. The purpose of this review is to illustrate recent technological advances that are moving us one step closer to the goal of multi-functional, self-identifiable, durable, and intuitive prostheses. RECENT FINDINGS Surgical advances such as targeted muscle reinnervation, regenerative peripheral nerve interfaces, agonist-antagonist myoneural interfaces, and targeted sensory reinnervation; development of technology designed to restore sensation, such as implanted sensors and haptic devices; and evolution of osseointegrated (bone-anchored) prostheses show great promise. Augmented and virtual reality platforms have the potential to enhance prosthesis design, pre-prosthetic training, incorporation, and use. Emerging technologies move surgeons, rehabilitation physicians, therapists, and prosthetists closer to the goal of creating highly functional prostheses with elevated sensory and motor control. Collaboration between medical teams, scientists, and industry stakeholders will be required to keep pace with patients who require durable, high-functioning prostheses.
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Affiliation(s)
- Taylor J Bates
- Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA-Ft Sam Houston, TX, 78234, USA
| | - John R Fergason
- Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, JBSA-Ft Sam Houston, TX, USA
| | - Sarah N Pierrie
- Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA-Ft Sam Houston, TX, 78234, USA.
- Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, JBSA-Ft Sam Houston, TX, USA.
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13
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14
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Barnes SC, Clasper JC, Bull AMJ, Jeffers JRT. Micromotion and Push-Out Evaluation of an Additive Manufactured Implant for Above-the-Knee Amputees. J Orthop Res 2019; 37:2104-2111. [PMID: 31166039 DOI: 10.1002/jor.24389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/28/2019] [Indexed: 02/04/2023]
Abstract
In comparison to through-knee amputees the outcomes for above-the-knee amputees are relatively poor; based on this novel techniques have been developed. Most current percutaneous implant-based solutions for transfemoral amputees make use of high stiffness intramedullary rods for skeletal fixation, which can have risks including infection, femoral fractures, and bone resorption due to stress shielding. This work details the cadaveric testing of a short, cortical bone stiffness-matched subcutaneous implant, produced using additive manufacture, to determine bone implant micromotion and push-out load. The results for the micromotions were all <20 μm and the mean push-out load was 2,099 Newtons. In comparison to a solid control, the stiffness-matched implant exhibited significantly higher micromotion distributions and no significant difference in terms of push-out load. These results suggest that, for the stiffness-matched implant at time zero, osseointegration would be facilitated and that the implant would be securely anchored. For these metrics, this provides justification for the use of a short-stem implant for transfemoral amputees in this subcutaneous application. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2104-2111, 2019.
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Affiliation(s)
- Spencer C Barnes
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, United Kingdom.,Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Jon C Clasper
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, United Kingdom.,Defence Medical Group South East, Frimley Park Hospital, Camberley, United Kingdom
| | - Anthony M J Bull
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, United Kingdom.,Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Jonathan R T Jeffers
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
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15
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Utilizing Precision Medicine to Estimate Timing for Surgical Closure of Traumatic Extremity Wounds. Ann Surg 2019; 270:535-543. [DOI: 10.1097/sla.0000000000003470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Potter BK. From Bench to Bedside: We Can (Still) Do Better-Moving Towards More Thoughtful, "Constructive" Amputations. Clin Orthop Relat Res 2019; 477:1793-1795. [PMID: 31335599 PMCID: PMC7000012 DOI: 10.1097/corr.0000000000000872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/09/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K Potter
- B. K. Potter, Directorate for Surgical Services, Walter Reed National Military Medical Center & the Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD USA
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17
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Abstract
BACKGROUND Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump. OBJECTIVES To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations. SEARCH METHODS In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments. MAIN RESULTS We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I2 = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I2 = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost. AUTHORS' CONCLUSIONS We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).
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Affiliation(s)
- Li Khim Kwah
- Singapore Institute of TechnologyHealth and Social Sciences Cluster10 Dover DriveSingaporeSingapore138683
| | - Matthew T Webb
- South Eastern Sydney Local Health DistrictDirectorate of Allied HealthDistrict Executive UnitLocked Mail Bag 21Taren PointNSWAustralia2229
| | - Lina Goh
- Bankstown‐Lidcombe HospitalDepartment of PhysiotherapyEldridge RdBankstownNSWAustralia2200
| | - Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchRoyal North Shore HospitalSt LeonardsNSWAustralia2065
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18
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Geertzen JHB, van der Schans SM, Jutte PC, Kraeima J, Otten E, Dekker R. Myodesis or myoplasty in trans-femoral amputations. What is the best option? An explorative study. Med Hypotheses 2019; 124:7-12. [PMID: 30798921 DOI: 10.1016/j.mehy.2019.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/14/2018] [Accepted: 01/10/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Jan H B Geertzen
- University of Groningen, University Medical Centre Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands.
| | - Sanne M van der Schans
- University of Groningen, University Medical Centre Groningen, Centre for Human Movement Sciences, Groningen, the Netherlands
| | - Paul C Jutte
- University of Groningen, University Medical Centre Groningen, Department of Orthopedics, Groningen, the Netherlands.
| | - Joep Kraeima
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, the Netherlands.
| | - Egbert Otten
- University of Groningen, University Medical Centre Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands.
| | - Rienk Dekker
- University of Groningen, University Medical Centre Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands.
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Noblet T, Lineham B, Wiper J, Harwood P. Amputation in Trauma—How to Achieve a Good Result from Lower Extremity Amputation Irrespective of the Level. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0159-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Indications and Decision Making in Lower Extremity Amputations: Has Anything Changed in the Era of Microvascular Soft Tissue and Bone Regeneration Techniques? CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0148-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Herrera-Moreno D, Carvajal-Ovalle D, Cueva-Nuñez MA, Acevedo C, Riveros-Munévar F, Camacho K, Fajardo-Tejada DM, Clavijo-Moreno MN, Lara-Correa DL, Vinaccia-Alpi S. Body image, perceived stress, and resilience in military amputees of the internal armed conflict in Colombia. Int J Psychol Res (Medellin) 2018; 11:56-62. [PMID: 32612779 PMCID: PMC7110278 DOI: 10.21500/20112084.3487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The objective of this study was to determine the levels and the relationship between body image satisfaction, perceived stress and resilience in soldier amputee victims of the internal armed conflict in Colombia. It was a quantitative, cross-sectional study of correlational scope, with the participation of 22 Colombian soldiers who were victims of the internal armed conflict and with some degree of amputation. For each soldier, the Multidimensional Body Self-relations Questionnaire (MBSRQ), Perceived Stress (EEP-14) and the Connor-Davidson Resilience Scale (CD-RISC 10) were applied. The results show high scores in behaviors aimed at maintaining physical fitness, self-assessed physical attractiveness and physical appearance, low scores in stress and scores with high trends in resilience, as well as a negative correlation between stress and conducts aimed to maintain physical fitness.
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Affiliation(s)
- Daniela Herrera-Moreno
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - Diego Carvajal-Ovalle
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - María Angélica Cueva-Nuñez
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - Camila Acevedo
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - Fernando Riveros-Munévar
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - Katherin Camacho
- Universidad de San Buenaventura, Bogotá, Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Bogotá Colombia
| | - Diana Milena Fajardo-Tejada
- Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva, Colombia. Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva Colombia
| | - Mauricio Noel Clavijo-Moreno
- Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva, Colombia. Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva Colombia
| | - Dary Luz Lara-Correa
- Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva, Colombia. Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva Colombia
| | - Stefano Vinaccia-Alpi
- Universidad del Sinú, Montería, Colombia. Universidad del Sinú Universidad del Sinú Montería Colombia
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Abstract
OBJECTIVES To determine what proportion of residual limbs formed heterotopic ossification (HO) in amputations sustained by US service members, the injury profile of these amputations, and what effect the number of limb amputations sustained has on resource utilization. DESIGN Retrospective review. SETTING A tertiary military medical center. PATIENTS Four-hundred seventy-one consecutive patients with 714 combat-related amputations were treated at our institution between September 2009 and August 2014. Four-hundred thirty-nine amputations had radiographic follow-up beyond 2 months of injury and met the criteria for study inclusion. MAIN OUTCOME MEASURE Formation and grade of HO. RESULTS HO was present in 399 of 439 (91%) residual limbs, including 211 of 216 (98%) transfemoral amputations. Dismounted improvised explosive device blast injury resulted in HO development in 346 of 372 (93%) residual limbs compared with 36 of 44 (82%) in mounted improvised explosive device blast injury [P = 0.014; odds ratio (OR) 2.96, 95% confidence interval (CI), 1.25-7.04]. As the number of amputations per patient increased, so too did blood product utilization [including packed red blood cells (P < 0.001), fresh frozen plasma (P < 0.001), and platelets (P < 0.001)]; the number of days on a ventilator (P < 0.001), in the intensive care unit (P < 0.001), and in the hospital (P = 0.007). CONCLUSIONS HO prevalence in the traumatic amputations of war wounded has increased compared with earlier studies, which is temporally associated with higher rates of increasingly severe injuries due to dismounted blast. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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23
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Lim PK, Sampathi B, Moroski NM, Scolaro JA. Acute femoral shortening for reconstruction of a complex lower extremity crush injury. Strategies Trauma Limb Reconstr 2018; 13:185-189. [PMID: 29796861 PMCID: PMC6249149 DOI: 10.1007/s11751-018-0311-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 05/20/2018] [Indexed: 11/25/2022] Open
Abstract
Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.
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Affiliation(s)
- Philip K. Lim
- Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Orange, CA 92868 USA
| | - Bharat Sampathi
- School of Medicine, University of California, Irvine, 252 Irvine Hall, Irvine, CA 92697 USA
| | - Nathan M. Moroski
- Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Orange, CA 92868 USA
| | - John A. Scolaro
- Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Orange, CA 92868 USA
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24
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Hansson E, Hagberg K, Cawson M, Brodtkorb TH. Patients with unilateral transfemoral amputation treated with a percutaneous osseointegrated prosthesis: a cost-effectiveness analysis. Bone Joint J 2018; 100-B:527-534. [PMID: 29629586 DOI: 10.1302/0301-620x.100b4.bjj-2017-0968.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aims The aim of this study was to compare the cost-effectiveness of treatment with an osseointegrated percutaneous (OI-) prosthesis and a socket-suspended (S-) prosthesis for patients with a transfemoral amputation. Patients and Methods A Markov model was developed to estimate the medical costs and changes in quality-adjusted life-years (QALYs) attributable to treatment of unilateral transfemoral amputation over a projected period of 20 years from a healthcare perspective. Data were collected alongside a prospective clinical study of 51 patients followed for two years. Results OI-prostheses had an incremental cost per QALY gained of €83 374 compared with S-prostheses. The clinical improvement seen with OI-prostheses was reflected in QALYs gained. Results were most sensitive to the utility value for both treatment arms. The impact of an annual decline in utility values of 1%, 2%, and 3%, for patients with S-prostheses resulted in a cost per QALY gained of €37 020, €24 662, and €18 952, respectively, over 20 years. Conclusion From a healthcare perspective, treatment with an OI-prosthesis results in improved quality of life at a relatively high cost compared with that for S-prosthesis. When patients treated with S-prostheses had a decline in quality of life over time, the cost per QALY gained by OI-prosthesis treatment was considerably reduced. Cite this article: Bone Joint J 2018;100-B:527-34.
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Affiliation(s)
- E Hansson
- Institute of Health and Care Sciences, Sahlgrenska Academy University of Gothenburg, Medicinaregatan 3, Gothenburg 413 90, Sweden and Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg 413 45, Sweden
| | - K Hagberg
- University of Gothenburg, Medicinaregatan 3, Gothenburg 413 90, Sweden and Advanced Reconstruction of Extremities and Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg 413 45, Sweden
| | - M Cawson
- RTI Health Solutions, The Pavilion, Towers Business Park, Wilmslow Road, Didsbury, Manchester M20 2LS, UK
| | - T H Brodtkorb
- RTI Health Solutions, Vällebergsv 9B, Ljungskile 459 30, Sweden
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25
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Wheatley BM, Cilwa KE, Dey D, Qureshi AT, Seavey JG, Tomasino AM, Sanders EM, Bova W, Boehm CA, Iwamoto M, Potter BK, Forsberg JA, Muschler GF, Davis TA. Palovarotene inhibits connective tissue progenitor cell proliferation in a rat model of combat-related heterotopic ossification. J Orthop Res 2018; 36:1135-1144. [PMID: 28960501 DOI: 10.1002/jor.23747] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/20/2017] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) develops in the extremities of wounded service members and is common in the setting of high-energy penetrating injuries and blast-related amputations. No safe and effective prophylaxis modality has been identified for this patient population. Palovarotene has been shown to reduce bone formation in traumatic and genetic models of HO. The purpose of this study was to determine the effects of Palovarotene on inflammation, progenitor cell proliferation, and gene expression following a blast-related amputation in a rodent model (n = 72 animals), as well as the ability of Raman spectroscopy to detect early HO before radiographic changes are present. Treatment with Palovarotene was found to dampen the systemic inflammatory response including the cytokines IL-6 (p = 0.01), TNF-α (p = 0.001), and IFN-γ (p = 0.03) as well as the local inflammatory response via a 76% reduction in the cellular infiltration at post-operative day (POD)-7 (p = 0.03). Palovarotene decreased osteogenic connective tissue progenitor (CTP-O) colonies by as much as 98% both in vitro (p = 0.04) and in vivo (p = 0.01). Palovarotene treated animals exhibited significantly decreased expression of osteo- and chondrogenic genes by POD-7, including BMP4 (p = 0.02). Finally, Raman spectroscopy was able to detect differences between the two groups by POD-1 (p < 0.001). These results indicate that Palovarotene inhibits traumatic HO formation through multiple inter-related mechanisms including anti-inflammatory, anti-proliferative, and gene expression modulation. Further, that Raman spectroscopy is able to detect markers of early HO formation before it becomes radiographically evident, which could facilitate earlier diagnosis and treatment. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1135-1144, 2018.
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Affiliation(s)
- Benjamin M Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, Maryland
| | - Katherine E Cilwa
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Ammar T Qureshi
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Jonathan G Seavey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, Maryland
| | - Allison M Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Erin M Sanders
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Wesley Bova
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
| | - Cynthia A Boehm
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
| | - Masahiro Iwamoto
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Benjamin K Potter
- Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, Maryland
| | - Jonathan A Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, Maryland
| | - George F Muschler
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio.,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, Maryland
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26
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Wade SM, Harrington C, Fleming M, Potter BK. A Combined Distal Tibial Turn-up Plasty and Intercalary Calcaneal Osteocutaneous Fillet Flap for Salvage of a Transtibial Amputation: A Case Report. JBJS Case Connect 2017; 7:e91. [PMID: 29286974 DOI: 10.2106/jbjs.cc.16.00255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE This case demonstrates the successful attempt at a combined distal tibial turn-up plasty and intercalary calcaneal osteocutaneous fillet flap to increase functional limb length in order to salvage a transtibial amputation following a high-energy blast injury. CONCLUSION A transtibial amputation is preferred over more proximal levels of amputation because of the decreased energy expenditure that is required for ambulation. In cases where there is not enough viable tibia to allow for a transtibial level of amputation, combining a calcaneal osteocutaneous fillet flap with a distal tibial turn-up plasty can be utilized to optimize residual limb length for a transtibial amputation.
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Affiliation(s)
- Sean M Wade
- Department of Orthopaedics, Uniformed Services University, Walter Reed National Military Medical Center, Bethesda, Maryland
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27
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Pet MA, Morrison SD, Mack JS, Sears ED, Wright T, Lussiez AD, Means KR, Higgins JP, Ko JH, Cederna PS, Kung TA. Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation. Injury 2016; 47:2783-2788. [PMID: 28029356 DOI: 10.1016/j.injury.2016.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/03/2016] [Accepted: 10/08/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND After major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation. METHODS At three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain. RESULTS Nine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p=0.08). CONCLUSIONS Patients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.
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Affiliation(s)
- Mitchell A Pet
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Shane D Morrison
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jacob S Mack
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Erika D Sears
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Thomas Wright
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Alisha D Lussiez
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Kenneth R Means
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Paul S Cederna
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Theodore A Kung
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States.
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28
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Kwah LK, Goh L, Harvey LA. Rigid dressings versus soft dressings for transtibial amputations. Hippokratia 2016. [DOI: 10.1002/14651858.cd012427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Li Khim Kwah
- University of Technology Sydney; Discipline of Physiotherapy, Graduate School of Health; PO Box 123, Ultimo Sydney NSW Australia 2007
| | - Lina Goh
- St George Hospital; Department of Physiotherapy; Gray Street Kogarah NSW Australia 2217
| | - Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health District; John Walsh Centre for Rehabilitation Research; Royal North Shore Hospital St Leonards NSW Australia 2065
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29
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Abstract
Traumatic and trauma-related amputations represent unfortunate sequelae of severe injury, but should not be viewed as a treatment failure and may represent the best reconstructive option for some patients. Lessons from recent military conflicts have guided the evolution of modern surgical techniques and rehabilitation management of this challenging patient population, and treatment at a specialty center may improve patient outcomes. Despite appropriate management, however, surgical complications remain common and revision surgery is often necessary. Bridge synostosis procedures remain controversial, and clinical equipoise remains regarding their functional benefits. Based on European experience over the last 3 decades, osseointegration has evolved into a viable clinical alternative for patients unable to achieve acceptable function using conventional sockets, and several devices are being developed or tested in the United States. Targeted muscle reinnervation and advanced pattern recognition may dramatically improve the functional potential of many upper extremity amputees, and the procedure may also relieve neuroma-related pain. Furthermore, exciting new research may eventually facilitate haptic feedback and restore useful sensation for amputees. Natural disasters and global terrorism events, in addition to conventional trauma resulting in limb loss, make a working knowledge of current amputation surgical techniques essential to the practicing orthopaedic trauma surgeon.
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Affiliation(s)
- Scott M Tintle
- *Division of Orthopaedics, Uniformed Services University-Walter Reed National Military Medical Center Department of Surgery, Bethesda, MD; †Orthopaedic Trauma Service, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and ‡Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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30
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Wanivenhaus F, Mauler F, Stelzer T, Tschopp A, Böni T, Berli MC. Revision Rate and Risk Factors After Lower Extremity Amputation in Diabetic or Dysvascular Patients. Orthopedics 2016; 39:e149-54. [PMID: 26726973 DOI: 10.3928/01477447-20151222-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/06/2015] [Indexed: 02/03/2023]
Abstract
This article reports the revision rate and possible risk factors for lower extremity amputations in patients with diabetes mellitus or peripheral arterial disease (PAD). Data were collected from 421 patients with diabetes mellitus or PAD who underwent amputations of the lower extremity at the authors' institution from 2002 to 2012. There was a 25.2% overall revision rate. Mean time from amputation to revision was 244 days (range, 2-2590 days). Patients with diabetes mellitus had a significantly higher rate of revision to a more proximal level compared with patients without diabetes mellitus (type 1: odds ratio [OR]=3.73; 95% confidence interval [CI], 1.21-11.52; P=.022; and type 2: OR=2.3; 95% CI, 1.07-4.95; P=.033). A significant increase in revision rates was observed from Fontaine stage 0 to IV (stage 0: 17.9%; stage IV, 34.7%; P=.03). Risk factors for revision were diabetic nephropathy (OR=2.26; 95% CI, 1.4-3.63; P=.001) and polyneuropathy (OR=1.68; 95% CI, 1.03-2.73; P=.037). Patients who underwent revision amputation had a significantly younger mean age than patients who did not undergo revision amputation (65.23 years [range, 40-92 years] vs 68.52 years [range, 32-96 years]; P=.013). Anticipated amputation in this patient population requires a multidisciplinary approach with optimization of the patient's health. In the authors' clinical practice, the determination of the appropriate amputation level is performed individually for each patient, considering the risk factors identified in this study and the patient's expected mobilization potential, social background, and acceptance of a more proximal primary amputation level.
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Abstract
Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India. A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%-63%, posttraumatic stress disorder 3.3%-56.3%, and phantom limb phenomenon 14%-92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.
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Affiliation(s)
- Anamika Sahu
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Siddharth Sarkar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
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Gordon W, Kuhn K, Staeheli G, Dromsky D. Challenges in definitive fracture management of blast injuries. Curr Rev Musculoskelet Med 2015; 8:290-7. [PMID: 26104316 PMCID: PMC4596208 DOI: 10.1007/s12178-015-9286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The United States military remains engaged in the longest armed conflict in this nation's history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.
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Affiliation(s)
- Wade Gordon
- />Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Kevin Kuhn
- />Naval Medical Center San Diego, San Diego, CA USA
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Retrograde intramedullary fixation of long bone fractures through ipsilateral traumatic amputation sites. J Orthop Trauma 2015; 29:e203-7. [PMID: 25272202 DOI: 10.1097/bot.0000000000000248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The technique of retrograde intramedullary fixation of fractures through open traumatic amputations has not been previously described. We performed a retrospective case series at a tertiary-care military hospital setting. Ten patients met inclusion criteria. All were male, and all were injured through improvised explosive device. Outcome measures included the incidence of fracture nonunion, osteomyelitis or acute infection, heterotopic ossification (HO), as well as successful prosthesis fitting and ambulation. Average time to fixation after injury and amputation closure was 11.7 and 12.2 days, respectively. Follow-up averaged 20.2 months. The radiographic union rate was 100%, and time to osseous union averaged 7.5 months. One patient had an amputation site infection requiring revision, but none of the nails was removed for infectious reasons. HO occurred in 7 patients, and 2 patients required revision for symptomatic HO. All patients were successfully fitted with prostheses and able to ambulate. To our knowledge, this is the only series in the literature to specifically describe retrograde intramedullary fixation of long bone fractures through the zone of traumatic amputation sites. The infectious risk is relatively low, whereas the union rate (100%) and successful prosthesis fitting are high. For patients with similar injuries, retrograde intramedullary fixation through the zone of amputation is a viable treatment option.
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Matthes I, Beirau M, Ekkernkamp A, Matthes G. [Amputation and prosthesis attachment of the lower extremities]. Unfallchirurg 2015; 118:535-46; quiz 547-8. [PMID: 26013390 DOI: 10.1007/s00113-015-0015-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately 61,000 amputations are performed in Germany per year. In most cases the lower limbs are affected. The reasons for amputations are arteriosclerosis, diabetes mellitus, severe infections, tumors and complex trauma to the extremities. A decision must be made concerning whether a salvage procedure or amputation is appropriate, specially after trauma. In cases where the need for amputation is clear, the site of amputation needs to be planned in advance with the aim of creating a stump which allows sufficient prosthetic attachment. Adjuvant pain therapy is mandatory, especially in order to avoid subsequent phantom pain. The type of prosthetic restoration is influenced by the grade of mobility and personal requirements of patients. Moreover, aftercare and adjusted rehabilitation are recommended.
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Affiliation(s)
- I Matthes
- Klinik für Unfallchirurgie und Orthopädie, Unfallkrankenhaus Berlin, Warener Str.7, 12683, Berlin, Deutschland,
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Bauer JM, Callan AK, Jahangir AA. Length-Preserving Intramedullary Femoral Fixation for Traumatic Leg Amputation. JBJS Case Connect 2015; 5:e38. [PMID: 29252607 DOI: 10.2106/jbjs.cc.n.00169] [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 present the case of a twenty-one-year-old woman with a traumatic left leg amputation, substantial proximal skin degloving, and an ipsilateral femoral fracture treated with revision amputation distal to the fracture site and retrograde femoral nailing through the amputation site. CONCLUSION A short retrograde femoral nail is a surgical option to fix a femoral shaft fracture proximal to a traumatic amputation in order to preserve limb length for effective prosthetic fit and ambulation.
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Affiliation(s)
- Jennifer M Bauer
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - Alexandra K Callan
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - Alex A Jahangir
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
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Polfer EM, Hope DN, Elster EA, Qureshi AT, Davis TA, Golden D, Potter BK, Forsberg JA. The development of a rat model to investigate the formation of blast-related post-traumatic heterotopic ossification. Bone Joint J 2015; 97-B:572-6. [DOI: 10.1302/0301-620x.97b4.34866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Currently, there is no animal model in which to evaluate the underlying physiological processes leading to the heterotopic ossification (HO) which forms in most combat-related and blast wounds. We sought to reproduce the ossification that forms under these circumstances in a rat by emulating patterns of injury seen in patients with severe injuries resulting from blasts. We investigated whether exposure to blast overpressure increased the prevalence of HO after transfemoral amputation performed within the zone of injury. We exposed rats to a blast overpressure alone (BOP-CTL), crush injury and femoral fracture followed by amputation through the zone of injury (AMP-CTL) or a combination of these (BOP-AMP). The presence of HO was evaluated using radiographs, micro-CT and histology. HO developed in none of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats. Exposure to blast overpressure increased the prevalence of HO. This model may thus be used to elucidate cellular and molecular pathways of HO, the effect of varying intensities of blast overpressure, and to evaluate new means of prophylaxis and treatment of heterotopic ossification. Cite this article: Bone Joint J 2015;97-B:572–6
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Affiliation(s)
- E. M. Polfer
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - D. N. Hope
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - E. A. Elster
- Uniformed Services University of the Health
Sciences, 4301 Jones Bridge Rd, Bethesda, Maryland
20814, USA
| | - A. T. Qureshi
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - T. A. Davis
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - D. Golden
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - B. K. Potter
- Walter Reed National Military Medical
Center, 8901 Wisconsin Ave, Bethesda, Maryland
20889, USA
| | - J. A. Forsberg
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
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Chattopadhyay A, McGoldrick R, Umansky E, Chang J. Principles of tendon reconstruction following complex trauma of the upper limb. Semin Plast Surg 2015; 29:30-9. [PMID: 25685101 DOI: 10.1055/s-0035-1544168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reconstruction of tendons following complex trauma to the upper limb presents unique clinical and research challenges. In this article, the authors review the principles guiding preoperative assessment, surgical reconstruction, and postoperative rehabilitation and management of the upper extremity. Tissue engineering approaches to address tissue shortages for tendon reconstruction are also discussed.
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Affiliation(s)
- Arhana Chattopadhyay
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, California ; Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Rory McGoldrick
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, California ; Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Elise Umansky
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, California ; Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, California ; Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Hoyt BW, Pavey GJ, Pasquina PF, Potter BK. Rehabilitation of Lower Extremity Trauma: a Review of Principles and Military Perspective on Future Directions. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-014-0004-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res 2014; 472:2984-90. [PMID: 24562875 PMCID: PMC4160494 DOI: 10.1007/s11999-014-3528-7] [Citation(s) in RCA: 240] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. QUESTIONS/PURPOSES We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. METHODS We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. RESULTS Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient's pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. CONCLUSIONS None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation.
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Affiliation(s)
- Jason M. Souza
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
| | - Jennifer E. Cheesborough
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
| | - Jason H. Ko
- Division of Plastic Surgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA USA
| | - Mickey S. Cho
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX USA
| | - Todd A. Kuiken
- Center for Bionic Medicine, Rehabilitation Institute of Chicago, Chicago, IL USA
| | - Gregory A. Dumanian
- Division of Plastic Surgery, Northwestern Feinberg School of Medicine and Neural Engineering Center for Artificial Limbs, 675 N St Clair, Suite 19-250, Chicago, IL 60610 USA
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Polfer EM, Hoyt BW, Senchak LT, Murphey MD, Forsberg JA, Potter BK. Fluid collections in amputations are not indicative or predictive of infection. Clin Orthop Relat Res 2014; 472:2978-83. [PMID: 24691841 PMCID: PMC4160471 DOI: 10.1007/s11999-014-3586-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the acute postoperative period, fluid collections are common in lower extremity amputations. Whether these fluid collections increase the risk of infection is unknown. QUESTIONS/PURPOSES The purposes of this study were to determine (1) the percentage of patients who develop postoperative fluid collections in posttraumatic amputations and the natural course of the collection; (2) whether patients who develop these collections are at increased risk for infection; and to ask (3) are there objective clinical or radiologic signs that are associated with likelihood of infection when a fluid collection is present? METHODS We performed a review of all 300 patients injured in combat operations who sustained at least one major lower extremity amputation (at or proximal to the tibiotalar joint) and were treated definitively at our institution between March 2005 and April 2009. We segregated the groups based on whether cross-sectional imaging was performed less than 3 months (early group) after closure, greater than 3 months (late group) after closure, or not at all (control group, baseline frequency of infection). Our primary study cohort where those patients with a fluid collection in the first three months. The clinical course was reviewed and the primary outcome was a return to the operating room for irrigation and débridement with positive cultures. For those patients with cross-sectional imaging, we also collected objective clinical parameters within 24 hours of the scan (white blood cell count, maximum temperature, presence of bacteremia, tachycardia, oxygen desaturation), extremity examination (presence of erythema, warmth, and/or drainage), and characteristics of the fluid collections seen (size of the fluid collection, enhancement, complexity (simple versus loculated), surrounding edema, skin changes, tract formation, presence of air, and changes within the bone itself). The presence of a fluid collection on imaging was analyzed to determine whether it was associated with infection. We further analyzed clinical parameters, objective physical examination findings at the extremity, and characteristics of the fluid collection to determine if there were other parameters associated with infection. RESULTS Over half (55%) of the limbs demonstrated fluid collection in the early postoperative period and the prevalence decreased in the late group (11%; p = 0.001). There was no association between the presence of a fluid collection and infection. However, there was an association between objective clinical signs at the extremity (erythema and/or drainage) and infection (p < 0.001) in our primary study cohort. CONCLUSIONS Fluid collections are common in combat-related amputations in the immediate postoperative period and become smaller and less frequent over time. In the absence of extremity erythema and wound drainage, imaging of a residual limb to evaluate for the presence of a fluid collection appears to be of little clinical use.
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Affiliation(s)
- Elizabeth M. Polfer
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Benjamin W. Hoyt
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Lien T. Senchak
- />Department of Radiology, Walter Reed National Military Medical Center, Bethesda, MD USA
- />The American Institute for Radiologic Pathology, Silver Spring, MD USA
| | - Mark D. Murphey
- />Department of Radiology, Walter Reed National Military Medical Center, Bethesda, MD USA
- />The American Institute for Radiologic Pathology, Silver Spring, MD USA
- />Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Jonathan A. Forsberg
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Benjamin K. Potter
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
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Kingsbury T, Thesing N, Collins JD, Carney J, Wyatt M. Do patients with bone bridge amputations have improved gait compared with patients with traditional amputations? Clin Orthop Relat Res 2014; 472:3036-43. [PMID: 24818734 PMCID: PMC4160467 DOI: 10.1007/s11999-014-3617-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Two surgical techniques for performing a transtibial amputation include a traditional approach and a bone bridge approach. To date, there is no conclusive evidence of superiority of either technique in terms of temporal-spatial, kinetic, and mechanical work parameters. QUESTIONS/PURPOSES We sought to compare instrumented three-dimensional gait parameters and mechanical work measurements of patients who had undergone a traditional or bone bridge amputation at the transtibial level. Residual limb length and its effect on those functional outcomes was a secondary interest irrespective of amputation type. METHODS This retrospective comparative study included 14 active-duty military men with a mean age of 25 years (range, 20-28 years). Comparisons were made between seven patients with traditional and seven patients with bone bridge amputations at the transtibial level. The patients walked at self-selected and fast paces while three-dimensional gait analysis data were collected and comparisons were made between patients with the two amputation types as well as by length of the residual limb. RESULTS With the numbers available, we observed no differences between the two surgical groups at either speed for the temporal-spatial parameters or mechanical work metrics. However, the bone bridge group did demonstrate greater rolloff vertical ground reaction force during the fast walking condition with a median 1.02% of body weight compared with 0.94% (p = 0.046), which suggests a more stable platform in terminal stance. When the two groups were combined into one to test the effect of residual limb length, the linear regression resulted in an R(2) value of 0.419 (p = 0.012), in which patients with longer residual limbs had improved F3 force values during self-selected walking. CONCLUSIONS Overall, limited functional differences were found between the two groups in this small pilot study, so a superior surgical technique could not be determined; whereas our limited sample size prevents a firm conclusion of no difference, our data can be considered hypothesis-generating for future, larger studies. Although some evidence indicated that patients with a bone bridge have improved loading at higher speeds, a regression of all patients walking at self-selected speed indicates that as residual limb length increases, loading increases regardless of amputation type. Thus, our data suggest it is important to preserve residual limb length to allow for improved loading in terminal stance.
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Pascale BA, Potter BK. Residual Limb Complications and Management Strategies. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2014. [DOI: 10.1007/s40141-014-0063-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Forsberg JA, Potter BK, Polfer EM, Safford SD, Elster EA. Do inflammatory markers portend heterotopic ossification and wound failure in combat wounds? Clin Orthop Relat Res 2014; 472:2845-54. [PMID: 24879568 PMCID: PMC4117913 DOI: 10.1007/s11999-014-3694-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 05/09/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND After a decade of war in Iraq and Afghanistan, we have observed an increase in combat-related injury survival and a paradoxical increase in injury severity, mainly because of the effects of blasts. These severe injuries have a devastating effect on each patient's immune system resulting in massive upregulation of the systemic inflammatory response. By examining inflammatory mediators, preliminary data suggest that it may be possible to correlate complications such as wound failure and heterotopic ossification (HO) with distinct systemic and local inflammatory profiles, but this is a relatively new topic. QUESTIONS/PURPOSES We asked whether systemic or local markers of inflammation could be used as an objective means, independent of demographic and subjective factors, to estimate the likelihood of (1) HO and/or (2) wound failure (defined as wounds requiring surgical débridement after definitive closure, or wounds that were not closed or covered within 21 days of injury) in patients sustaining combat wounds. METHODS Two hundred combat wounded active-duty service members who sustained high-energy extremity injuries were prospectively enrolled between 2008 and 2012. Of these 200 patients, 189 had adequate followups to determine the presence or absence of HO, and 191 had adequate followups to determine the presence or absence of wound failure. In addition to injury-specific and demographic data, we quantified 24 cytokines and chemokines during each débridement. Patients were followed clinically for 6 weeks, and radiographs were obtained 3 months after definitive wound closure. Associations were investigated between these markers and wound failure or HO, while controlling for known confounders. RESULTS The presence of an amputation (p < 0.001; odds ratio [OR], 6.1; 95% CI. 1.63-27.2), Injury Severity Score (p = 0.002; OR, 33.2; 95% CI, 4.2-413), wound surface area (p = 0.001; OR, 1.01; 95% CI, 1.002-1.009), serum interleukin (IL)-3 (p = 0.002; OR, 2.41; 95% CI, 1.5-4.5), serum IL-12p70 (p = 0.01; OR, 0.49; 95% CI, 0.27-0.81), effluent IL-3 (p = 0.02; OR, 1.75; 95% CI, 1.2-2.9), and effluent IL-13 (p = 0.006; OR, 0.67; 95% CI, 0.50-0.87) were independently associated with HO formation. Injury Severity Score (p = 0.05; OR, 18; 95% CI, 5.1-87), wound surface area (p = 0.05; OR, 28.7; 95% CI, 1.5-1250), serum procalcitonin ([ProCT] (p = 0.03; OR, 1596; 95% CI, 5.1-1,758,613) and effluent IL-6 (p = 0.02; OR, 83; 95% CI, 2.5-5820) were independently associated with wound failure. CONCLUSIONS We identified associations between patients' systemic and local inflammatory responses and wound-specific complications such as HO and wound failure. However, future efforts to model these data must account for their complex, time dependent, and nonlinear nature. LEVEL OF EVIDENCE Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jonathan A. Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA ,Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden ,Surgical Critical Care Initiative (SC2I), Bethesda, MD USA
| | - Benjamin K. Potter
- Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA ,Surgical Critical Care Initiative (SC2I), Bethesda, MD USA
| | - Elizabeth M. Polfer
- Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA
| | - Shawn D. Safford
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA ,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA ,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD USA ,Surgical Critical Care Initiative (SC2I), Bethesda, MD USA
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Ipaktchi K, Seidl A, Banegas R, Hak D, Mauffrey C. Pirogoff amputation for a bilateral traumatic lower-extremity amputee: indication and technique. Orthopedics 2014; 37:397-401. [PMID: 24972429 DOI: 10.3928/01477447-20140528-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although only a small portion of all lower-extremity amputations in the United States are of traumatic origin, almost half of all living amputees have sustained traumatic amputations. This particular epidemiology is explained by the younger age, and thus longer life expectancy, of traumatic amputees. In this group especially, restoration and lifelong maintenance of ambulation and mobility is essential. The authors present the case of a bilateral traumatic lower-leg amputee whose management included a Pirogoff amputation. Although this amputation technique is not widely used, the authors believe it greatly facilitated stump and soft tissue management in this case and allowed for improved mobility. The indication for and technique of Pirogoff amputation are described, and a brief overview of amputation techniques in the foot is provided.
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Mathieu L, Marty A, Ramaki A, Najib A, Ahmadzai W, Fugazzotto DJ, Rigal S, Shirzai N. Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul. Eur J Trauma Emerg Surg 2014; 40:387-93. [PMID: 26816076 DOI: 10.1007/s00068-013-0334-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 09/19/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed. METHODS This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation. RESULTS Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1-28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4-45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up. CONCLUSION This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.
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Affiliation(s)
- L Mathieu
- Department of Orthopaedic and Trauma Surgery, Desgenettes Military Hospital, Lyon, France.
| | - A Marty
- Department of Orthopaedic and Trauma Surgery, Legouest Military Hospital, Metz, France
| | - A Ramaki
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - A Najib
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - W Ahmadzai
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - D J Fugazzotto
- Afghan National Security Forces, Health System Development, ISAF Joint Command, Kabul, Afghanistan
| | - S Rigal
- Department of Orthopaedic and Trauma Surgery, Percy Military Hospital, Clamart, France
- Department of Surgery, French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France
| | - N Shirzai
- National Military Hospital, Kabul, Afghanistan
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Abstract
OBJECTIVE Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients. DESIGN Retrospective review of a consecutive series of patients. SETTING Tertiary Military Medical Center. PATIENTS/PARTICIPANTS Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009. INTERVENTION We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients. MAIN OUTCOME MEASUREMENTS The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status. RESULTS At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4). CONCLUSIONS In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.
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Bevevino AJ, Lehman RA, Tintle SM, Kang DG, Dworak TC, Potter BK. Incidence and morbidity of concomitant spine fractures in combat-related amputees. Spine J 2014; 14:646-50. [PMID: 24071037 DOI: 10.1016/j.spinee.2013.06.098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/28/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT High-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown. PURPOSE This study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF. STUDY DESIGN/SETTING Retrospective case control. PATIENT SAMPLE Two hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis. OUTCOME MEASURES Physiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up. METHODS Data from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes. RESULTS A total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005). CONCLUSIONS The incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.
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Affiliation(s)
- Adam J Bevevino
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA.
| | - Ronald A Lehman
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Scott M Tintle
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Daniel G Kang
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Theodora C Dworak
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Benjamin K Potter
- Department of Orthopedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Aderibigbe K, Fletcher JW, Barta RJ, Hill BW, Cole PA. Staged calcaneus osteocutaneous filet flap for salvage of transtibial amputation. Foot Ankle Int 2014; 35:71-9. [PMID: 24142949 DOI: 10.1177/1071100713509802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kamaldeen Aderibigbe
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, Saint Paul, MN, USA
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Lisboa FA, Forsberg JA, Brown TS, Gage FA, Potter BK, Elster EA. Bilateral lower-extremity amputation wounds are associated with distinct local and systemic cytokine response. Surgery 2013; 154:282-90. [PMID: 23889954 DOI: 10.1016/j.surg.2013.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 04/12/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Approximately 25% of U.S. military members sustaining extremity amputations in recent military conflicts have bilateral lower-extremity amputations (BLA). We investigated among combat-related extremity wounds whether BLA exhibit different bacterial burden, inflammatory response, and local complications. METHODS A total of 75 patients with combat-related extremity wounds (19 BLA) were evaluated for age, tobacco use, body mass index, Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and delayed primary closure time. Blood, wound exudates, and muscle biopsies were obtained and analyzed for cytokine and quantitative bacteriology, excluding patients using nonsteroidal anti-inflammatory medications and corticosteroids, due to potential effects on their inflammatory profile. RESULTS BLA was not associated with differences in age, tobacco use, body mass index, and delayed primary closure time, but these patients had increased Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and rates of critical colonization. Proinflammatory cytokines including tumor necrosis factor-α (exudate), interleukin (IL)-1 (exudate) and IL-6 (serum) were increased in BLA patients. They also had serum and exudate increased IL-8 and decreased IL-13 and granulocyte-macrophage colony-stimulating factor. Both wound dehiscence (WD) and heterotopic ossification (HO) were more common in BLA patients. CONCLUSION BLA patients were more likely to exhibit critical bacterial colonization, a distinct inflammatory response, and develop WD and HO. Modulating this response represents an attractive target in an effort to prevent complications such as WD and HO.
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Affiliation(s)
- Felipe A Lisboa
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD, USA
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