Renan C. Castillo

Long-term persistence of disability following severe lower-limb trauma : Results of a seven-year follow-up

BACKGROUND A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. METHODS Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. RESULTS On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. CONCLUSIONS The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery.

Impact of Smoking on Fracture Healing and Risk of Complications in Limb-threatening Open Tibia Fractures

Objectives: Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders. Setting: Eight Level I trauma centers. Patients: Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105). Outcome Measure: Time to fracture healing, diagnosis of infection, and osteomyelitis. Methods: Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics Results: After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection. Conclusion: Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Psychological Distress Associated with Severe Lower-Limb Injury

BACKGROUND Little is known about the psychological morbidity associated with limb-threatening injuries. It was hypothesized that a substantial proportion of patients who sustain a severe lower-limb injury will report serious psychological distress. METHODS Adult patients who were admitted to one of eight level-I trauma centers for treatment of an injury threatening the lower limb were enrolled during their initial hospitalization. Patients were recontacted at three, six, twelve, and twenty-four months after the injury and asked to complete the Brief Symptom Inventory (BSI), a fifty-three-item, self-reported measure of psychological distress. Patients who screen positive on the BSI are considered likely to have a psychological disorder and should receive a mental health evaluation. Longitudinal regression techniques were used to model positive case status (i.e., likely to have a psychological disorder) as a function of patient, injury, and treatment characteristics. RESULTS Of the 569 patients enrolled, 545 (96%) completed at least one BSI and 385 (68%) completed all four. Forty-eight percent of the patients screened positive for a likely psychological disorder at three months after the injury, and this percentage remained high (42%) at twenty-four months. Two years after the injury, almost one-fifth of the patients reported severe phobic anxiety and/or depression. While these two subscales reflected the highest prevalence of severe psychological distress, none of the BSI subscales reflected the prevalence expected from a normal sample (i.e., 2% to 3%). Factors associated with a likely psychological disorder included poorer physical function, younger age, non-white race, poverty, a likely drinking problem, neuroticism, a poor sense of self-efficacy, and limited social support. Relatively few patients reported receiving any mental health services following the injury (12% at three months and 22% at twenty-four months). CONCLUSIONS Severe lower-limb injury is associated with considerable psychological distress. More attention to the psychological as well as the physical health of patients who sustain a limb-threatening injury may be needed to ensure an optimal recovery following these devastating injuries.

Health-care costs associated with amputation or reconstruction of a limb-threatening injury

BACKGROUND Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. METHODS Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. RESULTS When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups (

Functional Outcomes Following Trauma-Related Lower-Extremity Amputation

81,316 for patients treated with reconstruction and

Complications Following Limb-threatening Lower Extremity Trauma

91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction (

Prevalence of chronic pain seven years following limb threatening lower extremity trauma.

509,275 and

The relationship between time to surgical débridement and incidence of infection after open high-energy lower extremity trauma

163,282, respectively). CONCLUSIONS These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures.

BACKGROUND The principal aims of this study were to examine functional outcomes following trauma-related lower-extremity amputation and to compare outcomes according to the amputation levels. We hypothesized that above-the-knee amputations would result in less favorable outcomes than would through-the-knee or below-the-knee amputations. A secondary aim was to examine the factors, in addition to amputation level, that influence outcome, including the type of soft-tissue coverage, selected patient characteristics, and the technological sophistication of the prosthetic device. METHODS A cohort of 161 patients who had undergone an above-the-ankle amputation at a trauma center within three months following the injury was followed prospectively at three, six, twelve, and twenty-four months after the injury. The Sickness Impact Profile, a self-reported measure of functional status, was used as the principal measure of outcome. Secondary outcomes included pain; degree of independence in transfers, walking, and climbing stairs; self-selected walking speed; and the physicians satisfaction with the clinical, functional, and cosmetic recovery of the limb. Longitudinal multivariate regression techniques were used to determine whether outcomes differed according to the level of amputation after we controlled for covariates. RESULTS There was no significant difference in the scores on the Sickness Impact Profile between the patients treated with above-the-knee and those treated with below-the-knee amputation. However, patients with a below-the-knee amputation performed better than did patients with an above-the-knee amputation on the timed test for walking speed (p = 0.04). Patients with a through-the-knee amputation had worse regression-adjusted Sickness Impact Profile scores (p = 0.05) and slower self-selected walking speeds (p = 0.004) than did patients with either a below-the-knee or an above-the-knee amputation. Differences according to the level of amputation were most pronounced for physical function. In general, physicians were less satisfied with the clinical, cosmetic, and functional recovery of the patients with a through-the-knee amputation. Except for problems encountered with insufficient gastrocnemius coverage of the stump in many patients with a through-the-knee amputation, neither the soft-tissue coverage nor the technological sophistication of the prosthesis correlated with outcome. CONCLUSIONS Severe disability accompanies above-the-ankle lower-extremity amputation following trauma, regardless of the level of amputation. Clinicians should critically evaluate the need for a through-the-knee amputation in patients with a traumatic injury. The results of this study also underscore the need for controlled studies that examine the relationship between the type and fit of prosthetic devices and functional outcomes.

Determinants of Patient Satisfaction After Severe Lower-Extremity Injuries

Objective: Our objective is to report the nature and incidence of major complications after severe lower extremity trauma. Design: Multicenter, prospective, observational study. Setting: Eight level-1 trauma centers. Patients/Participants: Five hundred forty-five patients were followed for 2 years. Intervention: Amputation or reconstruction. Main Outcome Measurements: The type and number of complications associated with these injuries were recorded at baseline, 3-, 6-, 12-, and 24-month intervals. Results: One hundred forty-nine underwent amputation during the initial hospitalization. The revision amputation rate was 5.4%. Among the amputation group, a complication was noted most frequently at 3 months (24.8%), and the most commonly seen complication was wound infection (34.2%). Wound complications including dehiscence (13.4%) were seen more commonly in the amputation group. Three hundred seventy-one limb reconstructions were performed with 25 patients (3.9%) requiring late amputation. The most frequently reported complication was at 6 months for the salvage group (37.7%), and the most commonly seen complication was wound infection (23.2%). Not surprisingly, osteomyelitis (8.6%) and nonunions (31%) were seen more commonly in the salvage group. Complications of wound infection, osteomyelitis, nonunion, malunion, and prominent hardware resulted in rehospitalization in at least one-third of patients. However, patients who underwent reconstruction were more likely to be hospitalized for these complications. Conclusions: Patients with severe lower extremity injuries can expect a significant number of complications, most notably wound infection, nonunion, wound necrosis, and osteomyelitis. A large portion of these will require additional inpatient or operative treatment. Patients electing for reconstruction can expect a higher risk of complications.