Johnny G. Owens

Clinical application of an acellular biologic scaffold for surgical repair of a large, traumatic quadriceps femoris muscle defect.

Many battlefield injuries involve penetrating soft tissue trauma often accompanied by skeletal muscle defects, known as volumetric muscle loss. This article presents the first known case of a surgical technique involving an innovative tissue engineering approach for the repair of a large volumetric muscle loss. A 19-year-old Marine presented with large volumentric muscle loss of the right thigh as a result of an explosion. The patient reported muscle weakness with right knee extension, secondary to volumentric muscle loss, primarily involving the vastus medialis muscle. This persisted 3 years postinjury, despite extensive physical therapy. With all existing management options exhausted, restoration of a portion of the lost vastus medialis muscle was attempted by surgical implantation of a multi-layered scaffold composed of extracellular matrix derived from porcine intestinal submucossa. The patient had no complications, was discharged home on postoperative day 5, and resumed physical therapy after 4 weeks. Four months postoperatively, the patient demonstrated marked gains in isokinetic performance. Computer tomography indicated new tissue at the implant site. This approach offers a treatment option to a heretofore untreatable injury and will allow us to improve future surgical treatments for volumetric muscle loss.

Comparative effect of orthosis design on functional performance.

BACKGROUND High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace. METHODS Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it. RESULTS Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation. CONCLUSIONS Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.

Volumetric muscle loss: persistent functional deficits beyond frank loss of tissue.

Open fracture is a common occurrence in civilian and military populations. Though great strides have been made in limb salvage efforts, persistent muscle strength deficits can contribute to a diminished limb function after the bone has healed. Over the past decade, a growing effort to establish therapies directed at de novo muscle regeneration has produced several therapeutic approaches. As this effort progresses and as therapies reach clinical testing, many questions remain regarding the pathophysiology of the volumetric loss of skeletal muscle. The current study demonstrates, in a rat “open fracture” model, that the volumetric loss of skeletal muscle results in persistent functional deficits that are dependent on muscle length and joint angle. Moreover, the injured muscle has an increased stiffness during passive stretch and a reduced functional excursion. A case study of a patient with an open type III tibia fracture resulting in volumetric muscle loss in the anterior and posterior compartment is also presented. Eighteen months after injury and tibia healing, persistent functional deficits are apparent with many of the same qualities demonstrated in the animal model. Muscle architectural adaptations likely underlie the altered intrinsic functional characteristics of the remaining musculature. Published 2014. This article is a U.S. Government work and is in the public domain in the USA. J Orthop Res 33:40–46, 2015.

Return to Running and Sports Participation After Limb Salvage

BACKGROUND The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage. METHODS We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining. RESULTS The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon. CONCLUSION Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage.

Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma

BackgroundPatients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.Questions/purposes(1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation?MethodsWe prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation.ResultsBy 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks.ConclusionsWe found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.Level of EvidenceLevel II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Volumetric muscle loss leads to permanent disability following extremity trauma.

Extremity injuries comprise the majority of battlefield injuries and contribute the most to long-term disability of servicemembers. The purpose of this study was to better define the contribution of muscle deficits and volumetric muscle loss (VML) to the designation of long-term disability in order to better understand their effect on outcomes for limb-salvage patients. Medically retired servicemembers who sustained a combat-related type III open tibia fracture (Orthopedic cohort) were reviewed for results of their medical evaluation leading to discharge from military service. A cohort of battlefield-injured servicemembers (including those with nonorthopedic injuries) who were medically retired because of various injuries (General cohort) was also examined. Muscle conditions accounted for 65% of the disability of patients in the Orthopedic cohort. Among the General cohort, 92% of the muscle conditions were identified as VML. VML is a condition that contributes significantly to long-term disability, and the development of therapies addressing VML has the potential to fill a significant void in orthopedic care.

Return to duty after integrated orthotic and rehabilitation initiative.

Objectives: To determine the return to active duty rate of military service members undergoing lower extremity limb salvage while using a novel custom orthosis and specialized rehabilitation compared with those receiving a novel custom orthosis alone. Design: Retrospective cohort study. Setting: Military level I trauma center and tertiary referral center for limb salvage. Patients/Participants: All active duty service members enrolled in our institutions Return to Run Clinical Pathway were analyzed retrospectively. Service members were enrolled if they sustained injuries with residual disability below the knee. Injuries typically involved substantial motor and/or nerve deficit, and the overwhelming majority was secondary to high-energy injuries. Intervention: Service members were fitted with a customized orthosis, an Intrepid Dynamic Exoskeletal Orthosis (IDEO), for use during rehabilitation. Service members were divided into 2 groups: those who had participated in the Return to Run Clinical Pathway with an IDEO (group 1) and those who only were fitted with an IDEO only (group 2). Main Outcome Measure: Return to military active duty rate. Results: One hundred forty-six service members met the inclusion criteria. Group 1 consisted of 115 service members and group 2 consisted of 31 service members. Of those in group 1, 59 (51.3%) returned to active duty compared with 4 (12.9%) in group 2 (P = 0.0001). Mechanisms of injury were significant factors for return to duty (RTD), and those sustaining explosive mechanisms of injury or gunshot wounds had significantly lower RTD rates across both groups. Conclusions: Active duty service members participating in an integrated orthotic and rehabilitation initiative after a lower extremity injury have a higher rate of RTD than previous reports, and it is significantly higher than the orthotic device alone. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study.

Introduction: Quadriceps strength after arthroscopic knee procedures is frequently diminished several years postoperation. Blood flow restriction (BFR) training uses partial venous occlusion while performing submaximal exercise to induce muscle hypertrophy and strength improvements. The purpose of this study was to evaluate BFR as a postoperative therapeutic intervention after knee arthroscopy. Methods: A randomized controlled pilot study comparing physical therapy with and without BFR after knee arthroscopy was conducted. Patients underwent 12 sessions of supervised physical therapy. Subjects followed the same postoperative protocol with the addition of 3 additional BFR exercises. Outcome measures included thigh girth, physical function measures, Knee Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR12), and strength testing. Bilateral duplex ultrasonography was used to evaluate for deep venous thrombosis preintervention and postintervention. Results: Seventeen patients completed the study. Significant increases in thigh girth were observed in the BFR group at 6-cm and 16-cm proximal to the patella (P = 0.0111 and 0.0001). All physical outcome measures significantly improved in the BFR group, and the timed stair ascent improvements were greater than conventional therapy (P = 0.0281). The VR-12 and KOOS subscales significantly improved in the BFR group, and greater improvement was seen in VR-12 mental component score (P = 0.0149). The BFR group displayed approximately 2-fold greater improvements in extension and flexion strength compared with conventional therapy (74.59% vs 33.5%, P = 0.034). No adverse events were observed during the study. Conclusions: This study suggests that BFR is an effective intervention after knee arthroscopy. Further investigation is warranted to elucidate the benefits of this intervention in populations with greater initial impairment.

Management of posttraumatic osteoarthritis with an integrated orthotic and rehabilitation initiative.

&NA; Posttraumatic osteoarthritis affects approximately 5.6 million Americans annually. Those affected are typically younger and more active than persons with primary osteoarthritis. Arthrodesis is the typical management option for persons with end‐stage ankle and subtalar posttraumatic arthritis. Arthroplasty is typically reserved for elderly persons. The functional limitations resulting from any of these strategies make treatment of this young population challenging. Combat wounds frequently lead to severe lower extremity injuries. We present a series of patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint after combat trauma. They were treated at our institution with an integrated orthotic and rehabilitation initiative called the Return To Run clinical pathway. This clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint.

Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury

Purpose of ReviewThe purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation.Recent FindingsMLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested.SummaryConsideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.