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Stahel PF, Kaufman AM. Contemporary management of open extremity fractures: What you need to know. J Trauma Acute Care Surg 2024; 97:11-22. [PMID: 38374531 DOI: 10.1097/ta.0000000000004288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
ABSTRACT Open extremity fractures are high-risk injuries prone to significant complications, including soft tissue loss, bone defects, infection, infected nonunion, and the necessity for limb amputation. Large-scale multicenter prospective studies from the Lower Extremity Assessment Project and the Major Extremity Trauma Research Consortium have provided novel scientific insights pertinent to the timeliness and appropriateness of specific treatment modalities aimed at improving outcomes of patients with open extremity injuries. These include the imperative for early administration of intravenous antibiotics within 3 hours of injury, preferably within 1 hour of hospital admission. Unlike the proven value of early antibiotics, the time to initial surgical debridement does not appear to affect infection rates and patient outcomes. Recent evidence-based consensus guidelines from the American Academy of Orthopedic Surgeons provide scientific guidance for preventing surgical site infections in patients with open extremity fractures and support the decision making of limb salvage versus amputation in critical open extremity injuries. Patient survival represents the overarching priority in the management of any trauma patient with associated orthopedic injuries. Therefore, the timing and modality of managing open fractures must take into account the patient's physiology, response to resuscitation, and overall injury burden. The present review was designed to provide a state-of-the-art overview on the recommended diagnostic workup and management strategies for patients with open extremity fractures, based on the current scientific evidence.
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Affiliation(s)
- Philip F Stahel
- From the Department of Surgery (P.F.S.), Brody School of Medicine, East Carolina University, Greenville, North Carolina; College of Osteopathic Medicine (P.F.S.), Rocky Vista University, Parker, Colorado; and Mission Health, HCA Healthcare (P.F.S., A.M.K.), North Carolina Division, Asheville, North Carolina
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Rizos J, Hebert-Seropian S, Buckley R. Do we try to salvage too many traumatic limb injuries with reconstruction and flaps when we should be doing more amputations? Injury 2024; 55:111489. [PMID: 38460479 DOI: 10.1016/j.injury.2024.111489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Affiliation(s)
- Julian Rizos
- Foothills Medical Center, Department of Surgery, Calgary, AB T2N 5A1, Canada
| | | | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW, Calgary, AB T2N 5A1, Canada.
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Fram BR, Bosse MJ, Odum SM, Reider L, Gary JL, Gordon WT, Teague D, Alkhoury D, MacKenzie EJ, Seymour RB, Karunakar MA. Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study. J Bone Joint Surg Am 2024; 106:776-781. [PMID: 38512987 DOI: 10.2106/jbjs.23.00878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brianna R Fram
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J Bosse
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Susan M Odum
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Wade T Gordon
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | | | - Dana Alkhoury
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ellen J MacKenzie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rachel B Seymour
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
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Goldman SM, Eskridge SL, Franco SR, Souza JM, Tintle SM, Dowd TC, Alderete J, Potter BK, Dearth CL. A Data-Driven Method to Discriminate Limb Salvage from Other Combat-Related Extremity Trauma. J Clin Med 2023; 12:6357. [PMID: 37835001 PMCID: PMC10573244 DOI: 10.3390/jcm12196357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. METHODS Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. RESULTS The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. CONCLUSIONS This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.
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Affiliation(s)
- Stephen M. Goldman
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Susan L. Eskridge
- Leidos, Reston, VA 20190, USA
- Naval Health Research Center, San Diego, CA 92152, USA
| | - Sarah R. Franco
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Jason M. Souza
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Scott M. Tintle
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Thomas C. Dowd
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Houston, TX 78234, USA
| | - Joseph Alderete
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Houston, TX 78234, USA
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Christopher L. Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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The Major Extremity Trauma Research Consortium: Development and Impact of an Orthopaedic Trauma Research Program. J Am Acad Orthop Surg 2023; 31:945-956. [PMID: 37671450 DOI: 10.5435/jaaos-d-23-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 09/07/2023] Open
Abstract
The Major Extremity Trauma Research Consortium (METRC) is a unique and ongoing military-civilian collaboration that resulted in the largest orthopaedic trauma research enterprise to date. The Consortium was established in September 2009 with funding from the Department of Defense. It employs a centralized data coordinating center and has grown into a network of nearly 400 investigators at 70 clinical centers. METRC conducts large multicenter clinical research studies selected and designed to improve outcomes among severely injured military and civilian patients with extremity trauma. Over the past decade, the consortium has implemented 35 such studies distributed among 19 principal investigators, enrolled more than 23,000 patients, published 61 articles, and received more than $150 million in funding from the Department of Defense, Patient Centered Outcomes Research Institute, and National Institutes of Health. This unique multidisciplinary research platform is a powerful community capable of addressing the challenging issues related to the evaluation, treatment, and recovery after severe extremity trauma. This body of work received the 2023 Elizabeth Winston Lanier Kappa Delta Award. An overview of the METRC development, organization, and research focus areas is presented.
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Harrington CJ, Wade SM, Hoyt BW, Tintle SM, Potter BK, Souza JM. A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage. J Orthop Trauma 2023; 37:361-365. [PMID: 36750445 DOI: 10.1097/bot.0000000000002582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma. DESIGN Retrospective review. SETTING Level II trauma center. PATIENTS 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014. INTERVENTION We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS Early and late amputation rates, time to amputation, reason for amputation. RESULTS 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. CONCLUSIONS This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Colin J Harrington
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Sean M Wade
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin W Hoyt
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | - Benjamin K Potter
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
- Uniformed Services University-Walter Reed Department of Surgery, 4301 Jones Bridge Road, Bethesda, MD; and
| | - Jason M Souza
- Departments of Plastic and Reconstructive Surgery and Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43212
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Patzkowski JC, Dunn JC. Editorial Comment: Selected Proceedings From the Society of Military Orthopaedic Surgeons 2021 Annual Meeting. Clin Orthop Relat Res 2022; 480:2108-2110. [PMID: 36173767 PMCID: PMC9555938 DOI: 10.1097/corr.0000000000002435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/08/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Jeanne C. Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, San Antonio, TX, USA
- Assistant Professor of Surgery, Texas Tech University, El Paso, TX, USA
| | - John C. Dunn
- Assistant Professor of Surgery, Texas Tech University, El Paso, TX, USA
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Humbyrd CJ. Virtue Ethics in a Value-driven World: Seeking the Story. Clin Orthop Relat Res 2022; 480:241-243. [PMID: 34978537 PMCID: PMC8747678 DOI: 10.1097/corr.0000000000002100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Casey Jo Humbyrd
- Chief, Penn Orthopaedics Foot and Ankle Service, The Hospitals of the University of Pennsylvania, Philadelphia, PA, USA
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