Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation

Prevalence of chronic pain after severe lower limb injury (SLLI): A systematic review and meta-analysis

BACKGROUND

Globally, severe lower limb injuries (SLLIs) are the predominant cause of long-term injury related disability and poor functional outcomes. Chronic pain is a major source of this morbidity, but the magnitude of the contribution is not clearly understood. The aim of this systematic review and meta-analysis was to determine the prevalence of chronic pain following SLLIs in civilian and military patients.

METHOD

This systematic review was prospectively registered with The International Prospective Register of Systematic Reviews (PROSPERO) with study ID CRD42022313615. A systematic literature search (Medline, Embase, Ovid, and Web of Science) was performed to identify original studies that reported chronic pain outcomes for adults who underwent surgical treatment for SLLIs in a civilian or military setting. Risk of bias in included studies was assessed using the ROBINS-E tool, and quality assessment was reported at study level using the Newcastle-Ottawa Scale, and at outcome-level using the GRADE framework. Absolute (proportional) and relative (odds ratio) outcome measures were calculated and pooled using a random effects model.

RESULTS

Forty-three studies reporting the outcomes of 5601 patients were included. Estimated overall prevalence of pain was 63 % (CI 55-70 %). The prevalence of chronic pain in amputees (64 % (CI 55-73 %)) was similar to those who underwent limb salvage (56 % (CI 44-67 %)). The prevalence of chronic pain in civilian populations was 70 % (CI 63-77 %) compared to military populations (51 % (CI 35-66 %)). In amputees, the prevalence of residual limb pain was similar to phantom limb pain (OR 1.06 [0.64-1.78], p = 0.81, I2 = 92 %).

CONCLUSION

Most people who sustain a SLLI will suffer from chronic pain. Healthcare systems must continue to research interventions that can reduce the incidence and severity of long-term pain and ensure adequate resources are allocated for this common and debilitating complication.

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel

ABSTRACT

Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review

BACKGROUND

It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees.

METHODS

A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included.

RESULTS

Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR.

CONCLUSION

The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.

Targeted Muscle Reinnervation at the Time of Amputation Decreases Recurrent Symptomatic Neuroma Formation

BACKGROUND

Targeted muscle reinnervation (TMR) is an effective technique for the prevention and management of phantom limb pain (PLP) and residual limb pain (RLP) among amputees. The purpose of this study was to evaluate symptomatic neuroma recurrence and neuropathic pain outcomes between cohorts undergoing TMR at the time of amputation (ie, acute) versus TMR following symptomatic neuroma formation (ie, delayed).

METHODS

A cross-sectional, retrospective chart review was conducted using patients undergoing TMR between 2015 and 2020. Symptomatic neuroma recurrence and surgical complications were collected. A subanalysis was conducted for patients who completed Patient-Reported Outcome Measurement Information System (PROMIS) pain intensity, interference, and behavior scales and an 11-point numeric rating scale (NRS) form.

RESULTS

A total of 105 limbs from 103 patients were identified, with 73 acute TMR limbs and 32 delayed TMR limbs. Nineteen percent of the delayed TMR group had symptomatic neuromas recur in the distribution of original TMR compared with 1% of the acute TMR group ( P < 0.05). Pain surveys were completed at final follow-up by 85% of patients in the acute TMR group and 69% of patients in the delayed TMR group. Of this subanalysis, acute TMR patients reported significantly lower PLP PROMIS pain interference ( P < 0.05), RLP PROMIS pain intensity ( P < 0.05), and RLP PROMIS pain interference ( P < 0.05) scores in comparison to the delayed group.

CONCLUSIONS

Patients who underwent acute TMR reported improved pain scores and a decreased rate of neuroma formation compared with TMR performed in a delayed fashion. These results highlight the promising role of TMR in the prevention of neuropathic pain and neuroma formation at the time of amputation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Sex and gender differences in quality of life and related domains for individuals with adult acquired lower-limb amputation: a scoping review

PURPOSE

To understand what is known about sex and gender differences in quality of life (QoL) and related domains for individuals with an adult acquired lower limb amputation (LLA).

METHODS

A computer-assisted literature search of four online databases was completed. Articles were included if they incorporated sex or gender as part of their data analysis with a focus on QoL-related domains. Data were analyzed using descriptive numerical analysis and thematic analysis.

RESULTS

One hundred and eleven articles were included in this review. Women were under-represented across studies, with most of the participants being men. No articles described the inclusion of trans or non-binary persons. Differences by sex or gender were reported by 66 articles. Articles reporting on gender seldom provided descriptions of how gender was defined. Overall, women/females seemed to have worse outcomes in terms of prosthesis-related outcomes, mental health, and return to occupations.

CONCLUSION

Articles included in this review were not clear with how gender was defined. In order for more targeted interventions that account for sex and gender differences, studies need to be more forthcoming about how they use and define gender. Future research should seek to include gender non-conforming participants to identify additional needs.Implications for rehabilitationSex and gender are important constructs that influence outcomes following lower limb amputation.Rehabilitation professionals should consider sex and gender-specific outcomes when tailoring programs to ensure ethical clinical care.

Prevention is better than cure: Surgical methods for neuropathic pain prevention following amputation - A systematic review

BACKGROUND

Pain after amputation can be known as residual limb pain (RLP) or phantom limb pain (PLP); however, both can be disabling in daily life with reported incidences of 8% for finger amputations and up to 85% for major limb amputations. The current treatment is focused on reducing the pain after neuropathic pain occurs. However, surgical techniques to prevent neuropathic pain after amputation are available and effective, but they are underutilized. The purpose of the review is to investigate the effects of techniques during amputation to prevent neuropathic pain.

METHODS

A systematic review was performed in multiple databases (Embase, Medline, Web of Science, Scopus, Cochrane, and Google Scholar) and following the PRISMA guidelines. Studies that reported surgical techniques to prevent neuropathic pain during limb amputation were included.

RESULTS

Of the 6188 selected studies, 13 eligible articles were selected. Five articles reported techniques for finger amputation: neurovascular island flap, centro-central union (CCU), and epineural ligatures, and flaps. For finger amputations, the use of prevention techniques resulted in a decrease of incidences from 8% to 0-3% with CCU being the most beneficial. For major limb amputations, the incidences for RLP were decreased to 0 to 55% with TMR and RPNI and compared to 64-91% for the control group. Eight articles reported techniques for amputations on major limbs: targeted muscle reinnervation (TMR), targeted nerve implantation, concomitant nerve coaptation, and regenerative peripheral nerve interface (RPNI).

CONCLUSIONS

Based on the current literature, we state that during finger and major limb amputation, the techniques to prevent neuropathic pain and PLP should be performed.

Patient-reported Outcome Measures following Traumatic Lower Extremity Amputation: A Systematic Review and Meta-analysis

BACKGROUND

Outcomes after traumatic major lower extremity amputation (MLEA) have focused on surgical complications, despite the life-altering impact on patients. With advances in the surgical management of MLEA, a heightened need for consistent reporting of patient-centered outcomes (PCO) remains. This meta-analysis assesses articles for the prevalence and methods of PCO reporting among traumatic MLEA studies.

METHODS

An electronic database search was completed using Ovid MEDLINE for studies published between 2000 and 2020. Studies were included that reported any outcome of traumatic MLEA. Weighted means of outcomes were calculated when data were available. The prevalence of PCO was assessed in the categories of physical function, quality of life (QOL), psychosocial, and pain. Trends in PCO reporting were analyzed using Pearson's chi-squared test and analysis of variance when appropriate.

RESULTS

In total, 7001 studies were screened, yielding 156 articles for inclusion. PCO were evaluated in 94 (60.3%) studies; 83 (53.2%) reported physical function and mobility outcomes, 33 (21.2%) reported QOL and satisfaction measures, 38 (24.4%) reported psychosocial data, and 43 (27.6%) reported pain outcomes. There was no change in prevalence of PCO reporting when comparing 5-year intervals between 2000 and 2020 (P = 0.557).

CONCLUSIONS

Optimization of function and QOL following traumatic MLEA has become a cornerstone of surgical success; however, only 60% of studies report PCO, with no trend over the last two decades suggesting improvement. As healthcare progresses toward patient-centered care, this inconsistent means of reporting PCO calls for improved inclusion and standardization of instruments to assess function, QOL, and other patient-focused measures.

Traditional Neuroma Management

With the development of newer techniques for symptomatic neuroma treatment, such as regenerative peripheral nerve interface and targeted muscle reinnervation, transposition and coverage techniques often have been referred to as "passive techniques." In spite of its negative connotation, these passive techniques yield positive results in a majority of patients treated. The experienced surgeon has more options than ever before in the prevention and management of problematic neuromas. Critical appraisal of the current literature reveals no single, optimal standard of care. Instead, surgeons have a plethora of useful techniques that can be implemented on a case-by-case basis to optimize outcomes.

More than half of persons with lower limb amputation suffer from chronic back pain or residual limb pain: a systematic review with meta-analysis

Purpose: The aim of this study is to systematically review and critically assess the methodological quality of literature regarding prevalence, characteristics and factors influencing pain, other than phantom limb pain (PLP) in persons with lower limb amputation (LLA).Materials and methods: A systematic review was performed (PROSPERO CRD42019138018). Literature was searched using PubMed, EMBASE, PsycINFO, and PEDro. Studies were included if describing pain other than PLP at least three months after amputation. For residual limb pain (RLP) and back pain, a meta-regression was performed.Results: Fifty-one studies were included in which predominantly young males with a unilateral traumatic amputation using a prosthesis were investigated. Pooled prevalence of RLP was 0.51 (95% CI 0.40-0.62) with a positive association with presence of back pain (p = 0.044) in the univariate meta-regression. Pooled prevalence of back pain was 0.55 (95% CI 0.45-0.64), with a positive association of time since amputation (p < 0.001) and co-occurrence of RLP (p = 0.050).Conclusions: Back pain and RLP are common after LLA. The prevalence of back pain was positively associated with the presence of RLP, and vice versa. Future studies should give more attention to other chronic pain types, to persons with a diabetic or vascular cause of amputation, and to pain-related interference.Implications for RehabilitationBoth back pain and residual limb pain occur in more than 50% of persons with lower limb amputation (LLA), and both pain types are positively associated.Clinicians should be aware that chronic pain is common after LLA and can have a significant impact on the functioning of persons with LLA.Future research on this topic should give more attention to other chronic pain types, to persons with a diabetic or vascular cause of amputation, and to pain-related interference.

Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation

Background

Various surgical treatments have been advocated for stump pain and phantom limb pain after limb amputation but the most effective is unknown. We report a case of intractable stump pain and phantom limb pain of the upper limb, which was successfully treated by end-to-end coaptation of the cutaneous nerves after multimodal treatment failures.

Case description

A 39-year-old man was referred to our department with a history of severe stump neuroma-related pain and phantom limb pain of his right upper limb. He had undergone multiple treatments over 26 years including medication, nerve blocks, and repeated surgeries. None had been successful for relief of pain. The clinical assessment showed a point of marked tenderness around the medial stump of the upper arm. Ultrasound-guided peripheral infiltration of local anaesthetic around the medial stump produced significant relief of his pain. Exploration around the medial limb stump revealed two stump neuromas of the medial cutaneous nerves of the forearm. Both stump neuromas were resected, and their stumps were coapted to each other. After 4 years, he was completely relieved of his pain and without any sensory deficit.

Conclusion

Successful nerve coaptations for painful stump neuromas of the upper limb are reported rarely. This case suggests this method can be helpful. The patient burden was minimal because it involved the resection and coaptation of the two neuromas. This method should be encouraged for cases of intractable stump-related pain in the upper limb.

How to cite this article

Kadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020;15(1):50-53.

Low back pain in persons with lower extremity amputation: a systematic review of the literature

BACKGROUND CONTEXT

Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life.

PURPOSE

The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs.

RESULTS

Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES.

CONCLUSIONS

Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

Long-term symptoms and function after war-related lower limb amputation: A national cross-sectional study

OBJECTIVE

The aim of this study was to document long-term symptoms and functional results following war-related knee disarticulation, trans-femoral amputation, and hip disarticulation.

METHODS

An observational cross-sectional study was conducted in a 7-day recreational camp in Iran. One thousand patients with unilateral hip disarticulation, trans-femoral amputation and knee disarticulation due to war-related injuries were invited to undergo a thorough physical examination. Among the invited persons, 58.7% (587 subjects) responded to our invitations. A complete examination related to phantom pain, phantom sensation, stump pain, back pain, and sound limb joints pain with a self-constructed questionnaire was performed. In addition, Amputee Mobility Predictor (AMP) instrument with a prosthesis was completed to assess the function of patients.

RESULTS

The mean duration of time since amputation was 22 years. The most common symptoms reported by participants were phantom sensation (82%), back pain (69%), and phantom pain (63%). In addition, total scores of AMP with a prosthesis in persons with knee disarticulation and trans-femoral amputations were 20.8 and 28, respectively. The knee disarticulation was associated with higher scores of AMP with a prosthesis compared to transfemoral amputation (p < 0.01).

CONCLUSION

The results of this study showed that patients with lower limb amputation suffer from significant clinical and functional problems. The findings may be useful to adopt new strategies in planning rehabilitation programs to improve quality of life and health status of patients with war-related lower limb amputation.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Ageing, limb-loss and military veterans: a systematic review of the literature

The impact of losing a limb in military service extends well beyond initial recovery and rehabilitation, with long-term consequences and challenges requiring health-care commitments across the lifecourse. This paper presents a systematic review of the current state of knowledge regarding the long-term impact of ageing and limb-loss in military veterans. Key databases were systematically searched including: ASSIA, CINAHL, Cochrane Library, Medline, Web of Science, PsycArticles/PsychInfo, ProQuest Psychology and ProQuest Sociology Journals, and SPORTSDiscus. Empirical studies which focused on the long-term impact of limb-loss and/or health-care requirements in veterans were included. The search process revealed 30 papers relevant for inclusion. These papers focused broadly on four themes: (a) long-term health outcomes, prosthetics use and quality of life; (b) long-term psycho-social adaptation and coping with limb-loss; (c) disability and identity; and (d) estimating the long-term costs of care and prosthetic provision. Findings present a compelling case for ensuring the long-term care needs and costs of rehabilitation for older limbless veterans are met. A dearth of information on the lived experience of limb-loss and the needs of veterans’ families calls for further research to address these important issues.

Evaluation of disabilities and activities of daily living of war-related bilateral lower extremity amputees

BACKGROUND

Long-term consequences and the activities of daily living of bilateral lower limb amputation are not well documented.

OBJECTIVES

The aims of our study were to identify the long-term effects of bilateral lower extremity amputations on daily activities and understand how these amputees cope with their mobility assistive devices.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 291 veterans with war bilateral lower limb amputations accepted to participate in a cross-sectional study.

RESULTS

The average of follow-up was 25.4 years. A total of 152 amputees (54%) were involved in sports averagely 6.7 h per week. Bilateral amputees walk 10 m by the average of 15 ± 33 s, and they could walk continuously with their prosthesis 315 ± 295 m. They wore their prosthesis 6.8 ± 1.7 days per week and 7.9 ± 8.1 h per day. Of these, 6.7% of bilateral lower limb amputees needed help to wear their prosthesis; 88.3% of amputees used assistant device for walking. According to this survey, 73 (42%) prostheses in right limb were appropriate, 95 (54.6%) needed to be replaced, and 6 (3.4) needed to be fixed. On the left side, it was 76 (42%), 92 (52.0%), and 9 (5.1%), respectively. A total of 203 (74.9%) amputees reported limitations in at least one domain of the activities of daily living. The most common single item that affected the patients was ascending and descending stairs by the score of 66% of normal population.

CONCLUSION

Veterans with bilateral lower limb amputations suffering from vast categories of daily problems.

CLINICAL RELEVANCE

This study and its results confirm that bilateral lower limb amputees have major progressive disabilities in daily activities and their social performance. This should attract the attention of amputees' administrative organizations, social workers, health-care providers and caregiver providers.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees

BACKGROUND

Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation.

METHODS

The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered.

RESULTS

The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %).

CONCLUSION

The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Traction Neurectomy for Treatment of Painful Residual Limb Neuroma in Lower Extremity Amputees

OBJECTIVES

To describe the outcomes of traction neurectomy as a surgical treatment for symptomatic neuroma of the residual lower extremity and to identify clinical and/or demographic factors associated with an increased likelihood of persistent or recurrent pain after surgery.

DESIGN

Retrospective Cohort Study.

SETTING

Amputee clinic at a Level I Trauma Center.

PATIENTS

Inclusion required a history of transfemoral or transtibial amputation and a history of symptomatic neuroma(s) at the residual limb treated with traction neurectomy. Twelve months of clinical follow-up or the recurrence of neuroma-type pains was required for inclusion. Thirty-eight patients (63 nerves) comprised the study group.

INTERVENTION

Traction neurectomy for treatment of symptomatic neuroma.

MAIN OUTCOME MEASURES

The primary outcome was the presence or absence of persistent or recurrent neuroma-type pain at last follow-up. The secondary outcome was reoperation for persistent or recurrent symptomatic neuroma.

RESULTS

Sixteen of 38 patients (42%) had recurrent or persistent neuroma-type pain at a mean follow-up of 37 months (range, 11-91 months), and 8/38 (21%) have undergone subsequent surgical treatment. Among the demographic and clinical features examined, only male gender was found to be a statistically significant predictor of persistent or recurrent neuroma-type pain.

CONCLUSIONS

Traction neurectomy results in a high rate of persistent or recurrent neuroma-type and that surgeons should be cautious when considering it for the treatment of symptomatic neuroma of the residual lower extremity. Furthermore, efforts to identify better surgical and nonsurgical treatments for this problem are justified.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review

BACKGROUND

Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment.

METHOD

Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)).

RESULTS

25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%).

CONCLUSIONS

Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Long-term clinical outcomes of war-related bilateral lower extremities amputations

In a cross-sectional study, 291 out of 500 veterans with war-related bilateral lower limb amputations from Iran-Iraq war (1980-1988) accepted to participate in our study. Information related to amputees and amputated limbs were gathered and a Persian version of the Medical Outcomes Study Short Form 36 (SF-36) was filled. To evaluate the effect of amputation level on health related quality of life, we classified patients to seven types according to the functional remainder of major joints (ankles, knees, hips). 97% of patients were male and the average age at the time of injury was 20 years. The major cause of war injury was shells in 50. 54% of amputees were involved in sport activities. The most common amputation level was transtibial (48%).The major stump complaint was muscle spasm. History of being hospitalized for a psychiatric disorder was reported in 5.6%. The average SF-36 score in type 2 to type 6 were 68, 60, 60, 56, and 62, respectively. Except Energy/Fatigue domain, all the other domains were different from normal population. There was not any significant statistical correlation between amputation type and any domain of the SF-36. Type 6 amputees showed an increase in physical health domains compared with former types.

Does targeted nerve implantation reduce neuroma pain in amputees?

BACKGROUND

Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.

QUESTIONS/PURPOSES

We asked: Does TNI (1) prevent primary neuroma-related pain in the setting of acute traumatic amputation and (2) reduce established neuroma pain in upper- and lower-extremity amputees?

METHODS

We retrospectively reviewed two groups of patients treated by one surgeon: (1) 12 patients who underwent primary TNI for neuroma prevention at the time of acute amputation and (2) 23 patients with established neuromas who underwent neuroma excision with secondary TNI. The primary outcome was the presence or absence of palpation-induced neuroma pain at last followup, based on a review of medical records. The patients presented here represent 71% of those who underwent primary TNI (12 of 17) and 79% of those who underwent neuroma excision with secondary TNI (23 of 29 patients) during the period in question; the others were lost to followup. Minimum followup was 8 months (mean, 22 months; range, 8-60 months) for the primary TNI group and 4 months (mean, 22 months; range, 4-72 months) for the secondary TNI group.

RESULTS

At last followup, 11 of 12 patients (92%) after primary TNI and 20 of 23 patients (87%) after secondary TNI were free of palpation-induced neuroma pain.

CONCLUSIONS

TNI performed either primarily at the time of acute amputation or secondarily for the treatment of established symptomatic neuroma is associated with a low frequency of neuroma-related pain. By providing a distal target for regenerating axons, TNI may offer an effective strategy for the prevention and treatment of neuroma pain in amputees.

Reoperation after combat-related major lower extremity amputations

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.

Long-term clinical outcomes of war-related hip disarticulation and transpelvic amputation

BACKGROUND

The Iran-Iraq war (1980 to 1988) was one of the longest wars of the twentieth century. Few studies are available in the current literature evaluating the long-term results of proximal lower-extremity war-related amputations. The purpose of the present cross-sectional study was to evaluate the current health-related quality of life and clinical musculoskeletal function of Iranian veterans with hip or hemipelvic amputation.

METHODS

Seventy-six patients from a cohort of eighty-four veterans with hip disarticulation and transpelvic amputation participated in this study. A Persian version of Medical Outcomes Study Short Form-36 (SF-36) was completed for all of the veterans.

RESULTS

The average duration of follow-up was 26.6 ± 3.7 years. The average age (and standard deviation) of the veterans was 44.1 ± 7.0 years. The average scores for the physical and mental health dimensions of the SF-36 were 45.85 ± 21.56 and 57.98 ± 25.19, respectively. These data indicate that the amputees were doing better in the mental domain than in the physical domain. Forty-five patients with a primary amputation (97.8%) and ten with a secondary amputation (33.3%) complained of pain in the amputation stump.

CONCLUSIONS

Veterans with proximal lower-extremity amputation will need life-long care. Supervision starts with stump management and the application of appropriate surgical techniques at the time of the injury and continues with periodic examination throughout life.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis

INTRODUCTION

Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject.

METHODS

An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500m and proportion of time that prosthesis is worn.

RESULTS

As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500m than those with an AKA or bilateral amputation (p=0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA.

CONCLUSION

This study describes the impact of LLA of different levels on patients' lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.

Operative complications of combat-related transtibial amputations: a comparison of the modified burgess and modified Ertl tibiofibular synostosis techniques

BACKGROUND

The complications of bone-bridging amputations remain ill defined. The purpose of this study was to compare the early and intermediate-term complications leading to reoperation between the modified Burgess and modified Ertl tibiofibular synostosis in combat-related transtibial amputations.

METHODS

We conducted a retrospective review of consecutive, contemporaneous cohorts of thirty-seven modified Ertl bone-bridge and 100 modified Burgess combat-related transtibial amputations. The primary outcome measure was the need for reoperation following definitive closure.

RESULTS

At a mean follow-up of two years (range, nine to forty-eight months), there was a 53% overall reoperation rate. The overall complications included infection (34%), neuroma excision (18%), heterotopic ossification excision (15%), myodesis failure (4%), and scar revision (7%). A significantly higher rate of overall complications (p = 0.008) was noted in the bone-bridge group. Additionally, there was an increased rate of noninfectious complications in the bone-bridge group (p = 0.02). A positive selection bias was also noted for performing bone-bridge amputations late (p = 0.0002) and outside the zone of injury (p < 0.0001). Bone-bridge-specific complications occurred in 32% of the modified Ertl group. Delayed union or nonunion of the synostosis (11%) and implant-related complications (27%) predominated. Three bone bridges were ultimately removed.

CONCLUSIONS

Reoperations were needed at a significantly greater rate overall and for noninfectious complications following bone-bridge synostosis compared with modified Burgess transtibial amputations. Additionally, despite the positive selection bias favoring the bridge synostosis cohort, infection rates were not lower in that group. Detailed patient counseling and careful patient selection are indicated prior to performing modified Ertl amputations, particularly in the absence of convincing evidence regarding objective functional benefits from the procedure.

Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations

Deliberate attention to the management of soft tissue is imperative when performing an amputation. Identification and proper management of the nerves accompanied by the performance of a stable myodesis and ensuring robust soft-tissue coverage are measures that will improve patient outcomes. Limb length should be preserved when practicable; however, length preservation at the expense of creating a nonhealing or painful residual limb with poor soft-tissue coverage is contraindicated. While a large proportion of individuals with a trauma-related amputation remain severely disabled, a chronically painful residual limb is not inevitable and late revision amputations to improve soft-tissue coverage, stabilize the soft tissues (revision myodesis), or remove symptomatic neuromas can dramatically improve patient outcomes. Psychosocial issues may dramatically affect the outcomes after trauma-related amputations. A multidisciplinary team should be consulted or created to address the multiple complex physical, mental, and psychosocial issues facing patients with a recent amputation.

[Penetrating injury of the lungs and multiple injuries of lower extremities caused by aircraft bombs splinters]

INTRODUCTION

Injuries caused by aircraft bombs cause severe damages to the human body. They are characterized by massive destruction of injured tissues and organs, primary contamination by polymorph bacterial flora and modified reactivity of the body. Upon being wounded by aircraft bombs projectiles a victim simultaneously sustains severe damages of many organs and organ systems due to the fact that a large number of projectiles at the same time injure the chest, stomach, head and extremities.

CASE REPORT

We presented a patient, 41 years of age, injured by aircraft bomb with hemo-pneumothorax and destruction of the bone and soft tissue structures of the foot, as well as the treatment result of such heavy injuries. After receiving thoracocentesis and short reanimation, the patient underwent surgical procedure. The team performed thoracotomy, primary treatment of the wound and atypical resection of the left lung. Thoracic drains were placed. The wounds on the lower leg and feet were treated primarily. Due to massive destruction of bone tissue of the right foot by cluster bomb splinters, and impossibility of reconstruction of the foot, guillotine amputation of the right lower leg was performed. Twelve days after the wounding caused by cluster bomb splinters, soft tissue of the left lower leg was covered by Tirsch free transplant and the defect in the area of the left foot was covered by dorsalis pedis flap. The transplant and flap were accepted and the donor sites were epithelized. Twenty-six days following the wounding reamputation was performed and amputation stump of the right lower leg was closed. The patient was given a lower leg prosthesis with which he could move.

CONCLUSION

Upon being wounded by aircraft bomb splinters, the injured person sustains severe wounds of multiple organs and organ systems due to simultaneous injuries caused by a large number of projectiles. It is necessary to take care of the vital organs first because they directly threaten the life of the wounded patient. Despite adequate surgical treatment of war wounds of the feet, because of massive defect of bone and soft tissue, amputation may be the only rational solution of the treatment. The resection of the lung may be succesfull method for the severe destruction of the lung.