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Wade SM, Harrington CJ, Hoyt BW, Melendez-Munoz AM, Potter BK, Souza JM. Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness. Mil Med 2023; 188:e584-e590. [PMID: 34591089 DOI: 10.1093/milmed/usab403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. MATERIALS AND METHODS We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. RESULTS Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. CONCLUSION Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.
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Affiliation(s)
- Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Jason M Souza
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Fries CA, Tuder D, Gorantla VS, Chan RK, Davis MR. Military VCA in the World. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00294-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Factors Associated with Primary and Secondary Amputation following Limb-Threatening Upper Extremity Trauma. Plast Reconstr Surg 2020; 145:987-999. [DOI: 10.1097/prs.0000000000006644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sposato L, Yancosek K, Lospinoso J, Cancio J. Psychosocial reactions to upper extremity limb salvage: A cross-sectional study. J Hand Ther 2019; 31:494-501. [PMID: 28802537 DOI: 10.1016/j.jht.2017.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 05/18/2017] [Accepted: 05/25/2017] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Descriptive cross-sectional survey study. INTRODUCTION Limb salvage spares an extremity at risk for amputation after a major traumatic injury. Psychosocial recovery for individuals with lower extremity limb salvage has been discussed in the literature. However, to date, psychosocial reactions for individuals with upper extremity (UE) limb salvage have not been examined. PURPOSE OF THE STUDY To determine which factors may influence psychosocial adaptation to UE limb salvage. METHODS Participants (n = 30; 28 males) were adults (mean, 30.13; range, 18-61) who sustained an UE limb salvage from a traumatic event. Adaptation was measured using a modified version of the Reactions to Impairment and Disability Inventory. RESULTS A linear mixed-effects regression found that worse psychosocial adaptation was associated with having less than a college degree, being less than 6 months post-injury, being older than 23 years, and having more pain. Dominant hand injuries were found to influence poor adaptation on the denial Reactions to Impairment and Disability Inventory subscale only. DISCUSSION The results of this study indicate that there is potential for nonadaptive reactions and psychological distress with certain variables in UE limb salvage. Therapists may use these results to anticipate which clients may be at risk for poor psychosocial outcomes. CONCLUSIONS This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. However, future research is indicated to better understand the unique psychosocial challenges and needs of these individuals. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | - Kathleen Yancosek
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, San Antonio, TX, USA
| | - Josh Lospinoso
- Portia Statistical Consulting, LLC, San Antonio, TX, USA
| | - Jill Cancio
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, San Antonio, TX, USA; Extremity Trauma and Amputation Center of Excellence (EACE), Joint Base San Antonio - Fort Sam Houston, San Antonio, TX, USA
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Mitchell SL, Hayda R, Chen AT, Carlini AR, Ficke JR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma. J Bone Joint Surg Am 2019; 101:1470-1478. [PMID: 31436655 PMCID: PMC7406140 DOI: 10.2106/jbjs.18.00970] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stuart L. Mitchell
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Roman Hayda
- Department of Orthopaedic Surgery, Brown University Warren Alpert School of Medicine, Providence, Rhode Island
| | - Andrew T. Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James R. Ficke
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen J. MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Melcer T, Walker J, Sechriest VF, Bhatnagar V, Richard E, Perez K, Galarneau M. A Retrospective Comparison of Five‐Year Health Outcomes Following Upper Limb Amputation and Serious Upper Limb Injury in the Iraq and Afghanistan Conflicts. PM R 2019; 11:577-589. [DOI: 10.1002/pmrj.12047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/17/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Ted Melcer
- Department of Medical Modeling, Simulation, and Mission SupportNaval Health Research Center, 140 Sylvester Road San Diego CA 92106‐3521
| | - Jay Walker
- Department of Medical Modeling, Simulation, and Mission Support Naval Health Research Center, Leidos San Diego CA
| | - Vernon Franklin Sechriest
- Department of Orthopedic Surgery, Minneapolis Veterans Affairs Hospital, Minneapolis VA Health Care System Minneapolis MN
| | - Vibha Bhatnagar
- VA San Diego Healthcare System San Diego CA
- Department for Family and Preventive MedicineUniversity of California San DiegoLa JollaCA
| | - Erin Richard
- VA San Diego Healthcare System San Diego CA
- Department for Family and Preventive MedicineUniversity of California San DiegoLa JollaCA
| | - Katheryne Perez
- Department of Medical Modeling, Simulation, and Mission Support Naval Health Research Center, Leidos San Diego CA
| | - Michael Galarneau
- Department of Medical Modeling, Simulation, and Mission SupportNaval Health Research Center San Diego CA
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A Porcine Orthotopic Forelimb Vascularized Composite Allotransplantation Model. Plast Reconstr Surg 2016; 138:461e-471e. [DOI: 10.1097/prs.0000000000002451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Krueger CA, Rivera JC, Tennent DJ, Sheean AJ, Stinner DJ, Wenke JC. Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients. Injury 2015; 46:1527-32. [PMID: 26003681 DOI: 10.1016/j.injury.2015.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/10/2015] [Accepted: 05/02/2015] [Indexed: 02/02/2023]
Abstract
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 patient's 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.
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Affiliation(s)
- Chad A Krueger
- San Antonio Military Medical Center, Fort Sam Houston, TX, United States.
| | - Jessica C Rivera
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - David J Tennent
- San Antonio Military Medical Center, Fort Sam Houston, TX, United States
| | - Andrew J Sheean
- San Antonio Military Medical Center, Fort Sam Houston, TX, United States
| | - Daniel J Stinner
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
| | - Joseph C Wenke
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
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Shin EH, Sabino JM, Nanos GP, Valerio IL. Ballistic trauma: lessons learned from iraq and afghanistan. Semin Plast Surg 2015; 29:10-9. [PMID: 25685099 DOI: 10.1055/s-0035-1544173] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.
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Affiliation(s)
- Emily H Shin
- Department of Orthopaedic Surgery, Division of Hand Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland ; The Curtis National Hand Center at MedStar Union Memorial, Baltimore, Maryland
| | - Jennifer M Sabino
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - George P Nanos
- Department of Orthopaedic Surgery, Division of Hand Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ian L Valerio
- Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland ; Department of Plastic and Reconstructive Surgery, Division of Burn, Wound, and Trauma, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Guda T, Labella C, Chan R, Hale R. Quality of bone healing: Perspectives and assessment techniques. Wound Repair Regen 2014; 22 Suppl 1:39-49. [DOI: 10.1111/wrr.12167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 01/28/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Teja Guda
- Dental Trauma Research Detachment; US Army Institute of Surgical Research; Fort Sam Houston
- Wake Forest Institute for Regenerative Medicine; Winston-Salem North Carolina
- Biomedical Engineering; University of Texas at San Antonio; San Antonio Texas
| | - Carl Labella
- Dental Trauma Research Detachment; US Army Institute of Surgical Research; Fort Sam Houston
| | - Rodney Chan
- Dental Trauma Research Detachment; US Army Institute of Surgical Research; Fort Sam Houston
| | - Robert Hale
- Dental Trauma Research Detachment; US Army Institute of Surgical Research; Fort Sam Houston
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