Andrew J. Sheean

Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients☆

INTRODUCTION Following severe lower extremity trauma, patients who undergo limb reconstruction and amputations both endure frequent complications and mental health sequelae. The purpose of this study is to assess the extent to which late amputation following a period of limb salvage impacts the evolution of the clinical variables that can affect the patients perception of his or her limb: ongoing limb associated complications and mental health conditions. PATIENTS AND METHODS A case series of US service members who sustained a late major extremity amputation from September 2001 through July 2011 were analysed. Pre- and post-amputation complications, mental health conditions, and reason(s) for desiring amputation were recorded. RESULTS Forty-four amputees with detailed demographic, injury and treatment data were identified. The most common reasons for desiring a late amputation were pain and being dissatisfied with the function of the salvage limb. An average of 3.2 (range 1-10) complications were reported per amputee prior to undergoing late amputation and an average of 1.8 (range 0-5) complications reported afterwards. The most common complication prior to and after late amputation was soft tissue infection (24 (17%) and 9 (22%), respectively). Twenty-nine (64%) late amputees were diagnosed with a mental health condition prior to undergoing their amputation and 27 (61%) late amputees were diagnosed with mental conditions after late amputation. Only three of the 15 patients who did not have a mental health condition documented prior to their late amputation remained free of a documented mental health condition after the amputation. DISCUSSION Ongoing complications and mental health conditions can affect how a patient perceives and copes with his or her limb following severe trauma. Patient dissatisfaction following limb reconstruction can influence the decision to undergo a late amputation. Patients with a severe, combat related lower extremity injury that are undergoing limb salvage may not have a reduction in their overall complication rate, a resolution of specific complications or an improvement of their mental health after undergoing late amputation. CONCLUSION Surgeons caring for limb salvage patients should counsel appropriately when managing expectations for a patient who desires a late amputation.

Evaluation of the Mangled Extremity Severity Score in Combat-Related Type III Open Tibia Fracture

Objectives: The purpose of this study was to determine the extent to which the Mangled Extremity Severity Score (MESS) predicted outcomes for soldiers sustaining combat-related Gustilo–Anderson type III open tibia fractures. Design: Retrospective cohort study. Setting: Tertiary trauma center. Patients: Service Members with combat-related type III open tibia fractures occurring between 2003 and 2007 treated definitively in a US military medical center. Intervention: Amputation or limb salvage. Main Outcome Measurements: MESS, amputation or limb salvage. Results: Complete data were available for 155 patients treated for type III open tibia fractures. One hundred ten patients had salvaged limbs, and 45 patients had lower extremity amputations. The mean MESS values for amputees and patients treated with limb salvage were 5.8 and 5.3 (P = 0.057), respectively. The sensitivity and specificity of a MESS ≥7 predicting amputation was 35% and 87.8%, respectively. A MESS value of ≥7 was found to have a positive predictive value on 50%. Thirty-three percent of patients treated with amputation had an associated vascular injury versus 12.7% of patients treated with limb salvage (P < 0.0026). Conclusions: There was no significant difference between MESS values of amputees and those treated with limb salvage. Moreover, these data demonstrate that the MESS is neither sensitive nor accurate in predicting amputation.

Soft tissue and wound management of blast injuries

The management of blast-related soft tissue wounds requires a comprehensive surgical approach that acknowledges extensive zones of injury and the likelihood of massive contamination. The experiences of military surgeons during the last decade of war have significantly enhanced current understandings of the optimal means of mitigating infectious complications, the timing of soft tissue coverage attempts, and the reconstructive options available for definitive wound management. Early administration of antibiotics in the setting of soft tissue wounds and associated open fractures is the single most important aspect of open fracture care. Both civilian and military reports have elucidated the incidence of invasive fungal infection in the setting of high-energy injuries with significant wound burdens, and novel treatment protocols have emerged. The type of reconstruction is predicated upon the zone of injury and location of the soft tissue defect. Multiple reports of military cohorts have suggested the equivalency of various techniques and types of soft tissue coverage. Longer-term follow-up will inform future perspectives on the durability of these surgical approaches.

Return to Duty and Disability After Combat Related Hindfoot Injury

Objectives: To characterize the return-to-duty (RTD) rates and disability outcomes for soldiers who sustained combat-related hindfoot injuries that were treated with either reconstruction or transtibial amputation (TTA). Design: Retrospective cohort series. Setting: Tertiary trauma center. Patients/Participants: All patients treated for combat-related hindfoot injuries between May 2005 and July 2011. Intervention: TTA or hindfoot reconstruction/ankle fusion. Main Outcome Measurements: Age, RTD rate, combined disability, and associated disabling conditions. Results: One hundred twenty-two patients underwent treatment for combat-related hindfoot injuries. Fifty-seven patients were treated with amputation, and 65 patients were treated with hindfoot reconstruction or ankle fusion. The overall RTD rate was 20%. Amputees had a RTD rate of 12%, which was lower than those who had a fusion or hindfoot repair [26% (P < 0.06)]. The disability ratings of amputees were significantly higher than those patients undergoing either ankle fusion or primary hindfoot repair [75% and 62%, respectively (P < 0.006)]. Discussion: While RTD rates were higher for hindfoot reconstruction or ankle fusion compared with TTA, psychiatric conditions were more common among these patients. Although there were clear differences between both groups, the relationship between true functional outcomes and disability ratings remains unclear and both treatment groups seem to do poorly in terms of returning to active duty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Shoulder instability: State of the Art

The mobility of the glenohumeral joint in multiple anatomic planes is not without consequence as recurrent instability is common, particularly among young, active individuals. Throughout midranges of shoulder motion, stability is conferred primarily by the compression-cavity effect of the rotator cuff as muscular contractions maintain the humeral head centred in the glenoid cavity. At extremes of shoulder motion (flexion and abduction), derangements of capsule-ligamentous complex, glenoid and glenoid labrum drive a pathophysiological cascade that manifests clinically as recurrent anterior, unidirectional instability. In the setting of bone loss <25% of the inferior glenoid diameter, arthroscopic Bankart repair using proper technique yields reliable clinical results. Additionally, much is now known about the extent to which attritional glenoid bone loss, related commonly to repeated dislocation events, affects the predicted success of certain treatment approaches. The preponderance of existing literature supports performing a bone grafting procedure for cases in which the osseous defect comprises >25% of the glenoid width, with the Latarjet procedure being favoured among recent authors. A growing body of evidence has elucidated the consequence of humeral head defects (the Hill-Sachs lesion) as a predictor of recurrent instability. Thus, the concept of ‘bipolar bone loss’ has emerged as a critical concept in the surgical treatment of recurrent shoulder instability. Surgeons should adopt a treatment paradigm that focuses on the relationship between both osseous defects—glenoid and humeral head—and incorporates a surgical tactic to appropriately address each lesion.

Return to duty following combat-related multi-ligamentous knee injury

INTRODUCTION This retrospective cohort study characterized injury patterns, treatment practices, and identified the return to duty (RTD) rate following combat-related multi-ligament knee injuries (MLKI). PATIENTS AND METHODS We evaluated injury characteristics and treatment methods of 46 military service members who had sustained a MLKI during combat activity. The primary clinical outcome measure was ability to return to active military duty. Secondary outcomes included subjective pain score, knee motion, knee instability, and use of ambulatory assistive device. RESULTS The RTD rate was 41% (19/46). High-energy mechanism, neurovascular injury, compartment syndrome, traumatic knee arthrotomy, and intra-articular femur fracture (Orthopedic Trauma Association Classification (OTA) 33-B/C) were all more prevalent in subjects who were unable to return to duty (p<0.05). Acute external fixator application and poor knee range of motion (ROM) were also associated with military separation (p=0.041 and p=0.016, respectively). The most common ligament injury pattern (n=9; 20%) was combined disruption of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial collateral ligament (MCL). However, number of ligaments injured was not associated with RTD status. CONCLUSION MLKIs sustained in a combat setting have a high incidence of associated lower extremity injuries. Certain associated injuries, such as intra-articular femur fracture, knee arthrotomy, neurovascular injury, and compartment syndrome may be more important than the severity of the knee ligamentous injury in determining RTD outcome.

Massive Rotator Cuff Lesion: Arthroscopic Repair

The treatment of massive rotator cuff tears is challenging, and a number of different surgical tactics have been proposed. Advancements in shoulder arthroscopy allow for enhanced visualization of rotator cuff tear morphology and a thorough assessment of tissue quality and mobility. A number of arthroscopic techniques have been described to visualize relevant pathology, mobilize contracted or less compliant tissues, and promote durable, tension-free repairs. In cases of truly irreparable rotator cuff tears, superior capsular reconstruction has emerged as a viable alternative to open tendon transfers and arthroplasty procedures.

Complications After Instability Surgery

Shoulder stabilization surgery is a challenging proposition, and a comprehensive understanding of the complications associated with arthroscopic and open procedures is critical for the treating surgeon. While stiffness, infection, iatrogenic nerve injury, and glenohumeral chondrolysis have been reported with relatively low frequencies, recurrent instability following stabilization procedures occurs at comparatively higher rates. Successful treatment is predicated on a treatment approach that addresses all capsuloligamentous and osseous pathologies.

Iatrogenic Hip Instability Treated With Periacetabular Osteotomy

Hip dislocation following hip arthroscopy is a devastating complication. Previous reports of arthroscopy–related iatrogenic instability have focused on strategies aimed at restoring the stabilizing effects of the hip joint capsuloligamentous complex. Less has been written about treatment options for patients in whom deficient acetabular coverage of the femoral head is implicated in the functionally unstable hip joint. Given this relative paucity of information, an optimal treatment approach has yet to be elucidated for these patients. Periacetabular osteotomy has been described as a treatment for iatrogenic hip instability related to surgical hip dislocation; however, to our knowledge, this is the first case of a patient with hip arthroscopy–related iatrogenic instability manifesting as recurrent, frank dislocations treated with periacetabular osteotomy.

Assessment of Disability Related to Femoroacetabular Impingement Syndrome by Use of the Patient-Reported Outcome Measure Information System (PROMIS) and Objective Measures of Physical Performance

Background: The National Institutes of Health (NIH)–sponsored Patient-Reported Outcomes Measurement System (PROMIS) has been described as a valuable tool for characterizing outcomes among patients with specific musculoskeletal conditions. Additionally, previously proposed objective measures of physical performance among patients with nonarthritic hip abnormalities are costly and not practically incorporated into routine clinical practice. Purpose: (1) To determine the ability of the PROMIS to differentiate between patients with femoroacetabular impingement (FAI) and asymptomatic controls, (2) to determine the effect of FAI on subjects’ completion of timed physical performance measures, and (3) to determine whether associations exist between established patient-reported outcome (PRO) measures and subjects’ completion of physical performance measures. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Twenty-two asymptomatic controls (CON group) and 20 patients with FAI completed multiple activities to assess physical ability: self-selected walking velocity (SSWV), timed stair ascent (TSA), four-square step test (FSST), and sit-to-stand five times test (STS5). All subjects also underwent a battery of PRO questionnaires: Visual Analog Scale for Pain (VAS), Modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-33), Hip Disability and Osteoarthritis Outcome Score (HOOS), and PROMIS. Descriptive analyses were performed and comparisons between groups were made by use of paired t tests with Bonferroni-Holm correction. Spearman’s rank correlation coefficients were used to determine associations between physical performance measures and PRO. The magnitude of differences between groups for each measured variable was calculated by use of Cohen’s d. Results: Significant differences between CON and FAI groups were observed for all hip-specific PRO measures (CON vs FAI for all; HOOS 99.2 vs 42.8, P < .001, iHOT-33 99.0 vs 26.6, P < .001, mHHS 99.6 vs 62.2, P < .001). Similarly, PROMIS scores were significantly different between groups for 8 of 9 tested domains. Patients with FAI demonstrated significant decrements in performance of all tested physical measures compared with asymptomatic controls (CON vs FAI, SSWV: 1.51 vs 1.32 m/s, P = .002; TSA: 3.05 vs 5.92 s, P = .017; FSST: 4.83 vs 8.89 s, P = .006; STS5: CON 5.53 vs FAI 10.75 s, P = .005.) Deficits in activities involving hip flexion—TSA, STS5—were strongly associated (r < –0.7, P < .001) with increased reports of disability. Conclusion: FAI has a negative effect on patient-reported and objectively measured function. Hip-specific and general measures such as PROMIS, FSST, TSA, and STS5 are responsive to FAI-associated debility and may be used to objectively assess surgical or rehabilitative outcomes.