Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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ABSTRACT Extremity injuries contribute a significant amount to the overall disability of combat-injured soldiers. Tracking patient outcomes allows military health care providers to gain a better understanding of the disability associ- ated with various injury patterns. Only recently have orthopedic surgeons begun to collect functional outcome mea- sures, and perhaps even more importantly, have begun to collect patient-reported outcomes. There is a growing body of evidence demonstrating the importance of a multidisciplinary approach to optimize outcomes in patients following severe extremity trauma. Tracking the outcomes of these interventions longitudinally will ultimately provide the mili- tary surgeon with an evidence-based plan to treat severe combat-related extremity injuries, leading to optimal care for future combat injured patients. “However beautiful the strategy, you should occasionally look at the results.”—Winston Churchill INTRODUCTION Extremity injuries contribute a signi ficant amount to the overall disability of combat-injured soldiers. For soldiers undergoing a physical evaluation board for un fitting condi- tions caused by a battle field injury, 3 out of the top 5 and 6 out of the top 10 are orthopedic/extremity conditions. 1 Fur-
thermore, 57% of combat-injured soldiers had un fitting con- ditions that were only orthopedic. Of soldiers medically evacuated with a head, thorax, or abdominal injury with a concomitant orthopedic injury, the orthopedic injury was the primary un fitting condition in over 75% of the patients. 1 In a follow-up study consisting of a cohort of these patients whose primary un fitting condition was osteoarthritis, it was directly attributable to combat injury in 92% of cases and occurred in as little as 19 ± 10 months following the injury. 2 This necessitates direct attention to examining lessons learned related to orthopedic injury so that every effort is made to optimize the functional recovery of soldiers injured in future con flicts. As the nation transitions to an interwar period, it provides an ideal time to re flect on the advances in the treat- ment of severe extremity injuries to identify “lessons learned” that will ultimately result in improving the military health care capability for the next con flict. IMPORTANCE OF TRACKING OUTCOMES Patient outcomes help military health care providers under- stand disability. Although the desired outcome is to return a patient to his or her maximal level of function, historically, orthopedic outcomes focus on factors such as radiographic union, alignment, development of arthritis, and the presence of postoperative complications such as infection. Only recently have orthopedic surgeons begun to collect functional outcome measures, and perhaps even more importantly, have begun to collect patient-reported outcomes. The extreme value of collecting relevant outcomes assess- ments was identi fied early during the conflicts and at the same time, the inherent dif ficulties with doing so were real- ized to include additional time and infrastructure require- ments. However, there is still a signi ficant need for more relevant surgical outcome assessments to assist in guiding dif ficult decision-making, such as the decision to amputate or attempt limb salvage in the severe extremity injury. 3 How- ever, as we have entered a low volume combat casualty flow
era, it can provide an opportunity to evaluate the outcomes achieved from the con flicts more thoroughly in an attempt for us, as providers, to continue to learn and improve. When examined closely, patients do not do as well as ini- tially perceived by their physicians. For example, Lebrun et al recently reported long-term outcomes of patients with a rela- tively simple fracture (patella) treated operatively. 4 Even at
6.5 years following surgery, patients still had signi ficant
functional de ficits despite the fracture being healed. Exten- sion power and Biodex dynamometric testing revealed de fi- cits of a quarter to one-third of the uninjured contralateral extremity. In addition, over half of the patients required an additional surgery due to symptomatic hardware. 4 This study highlights the fact that even with a simple fracture pattern that goes on to radiographic union following surgery, patients can still have signi ficant long-term functional deficits as a result of their injury. Now, consider the effects seen with more severe extremity trauma, such as those resulting from combat. In a large pro- spective observational study, the Lower Extremity Assess- ment Project (LEAP) Study Group showed the long-term consequences of severe lower extremity trauma in a civilian population. At 7 years following injury, just over one-third The Center for the Intrepid, Department of Orthopaedics and Rehabilita- tion, Brooke Army Medical Center, 3851 Rogers Brooke Drive, Fort Sam Houston, TX 78234. The views expressed in this article are those of the author(s) and do not re flect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-15-00511 MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 26
(34.5%) of patients had a physical Sickness Impact Pro file
(SIP) subscore typical of the general population of similar age and gender. 5 Furthermore, out of those who worked before their injury, only 58% returned to work 7 years later. Even worse, of those who return to work, patients are limited in their performance 20 to 25% of the time. 6 These data are similar to what has been seen in the military population following severe combat extremity injuries. In a retrospective cohort study of 324 Service Members who underwent amputation or limb sal- vage following a combat-related extremity injury, Doukas et al reported that at an average follow-up of 38.6 months only 43.7% had returned to work and 19.9% had pain interfering with daily activities. 7 These data demonstrate that similar challenges are seen long-term in patients, whether civilian or military, with severe lower extremity injuries. THE NEED FOR A MULTIDISCIPLINARY APPROACH
In assessing outcomes of patients that sustained high-energy lower extremity trauma, O ’Toole et al showed that surgeons and patients rarely agree on outcomes, as infrequently as ≤25%, which highlights the complexity of synthesizing out- comes based research. 8 Perhaps, surgeons should not just focus on treating the injury, but treating the individual patient as well. As Cannada and Jones highlighted in their review of the LEAP Study Group ’s findings, a patient’s per- sonality is not signi ficantly influenced by changes in the patient ’s life circumstances, i.e., the significant trauma they just experienced. 9 However, as eluded to by Levin et al, fail- ure to recognize the difference between treating an illness and a disease may be one explanation for the vast differ- ences in outcomes seen following injury. 10 Knowing this, could it be possible to predict which patients are going to do worse and intervene early to optimize their outcome? A vitally important lesson learned is establishing realistic expectations for pain management, speci fically noting that patients with severe lower extremity injuries may heal their bone and soft tissue injuries, but pain will frequently per- sist.
11 –13
In most cases, the bone heals, and, in some cases, there are complications. However, there remains a large degree of uncertainty as to why some patients do so much better than others, when the bone healed in good alignment and there were no postoperative complications. It has been shown that “negative mood,” specifically anxiety, plays an important role in the persistence of acute pain and both pain and depression correlates with patient satisfaction in those who have sustained severe lower extremity trauma. 14,15 When evaluating predictors of disability and pain following musculoskeletal injuries, Vranceanu et al found that cata- strophic thinking at 1 to 2 months postinjury was the sole signi ficant predictor of pain at rest, pain with activity, and disability at 5 to 8 months. 16 The physician must understand and recognize the impact that these factors can play in a patient
’s rehabilitation process to optimize their outcome. However, one of the most important advances in pain management during the recent con flicts can easily be summed up in the phrase “multimodal pain management.” In addition to the use of various intravenous and oral pain medications, the bene
fits of advanced regional anesthetics, delivered through continuous peripheral nerve catheters, were quickly realized. In many patients with severe extremity injuries or amputations, these were placed before transport back to the United States. These peripheral nerve catheters can provide the analgesia needed to make smooth transitions between the often, frequent, interval debridement and irrigations until the de finitive surgery can be safely performed, while minimizing the need for intravenous or oral narcotic pain medication. 12 As mentioned by Pasquina and Shero, rehabilitation needs to start in the acute care setting. The Amputee Patient Care Program, which encourages collaboration among vari- ous services, to include pain management, encouraged this to happen. 13 These studies highlight the fact that some patients may need more than just an orthopedic surgeon, following their fracture to union, to maximize their outcome. Archer et al found that 85% of patients reported a need for at least one vocational, behavioral health, or other support service fol- lowing severe lower extremity trauma, and 32% had an unmet need over the course of the first year. 17 The highest need unmet was for behavioral health and vocational ser- vices. Patients with a perceived unmet need have worse out- comes. 17
’ needs based on holistic care models, e.g., the Armed Forces Amputee Patient Care Program and newer interdisciplinary programs for combat injured undergoing limb salvage. 11,13,18 –22
Quality data come from the LEAP Study Group, speci fi- cally informing orthopedic surgeons on outcomes related to high-energy musculoskeletal trauma. 5,23
When comparing amputation to limb salvage, the authors found no difference in SIP scores at 2 and 7 years. The SIP assesses patients ’ dysfunction through everyday behavior capturing the physi- cal, mental, and social aspects of health-related function. Another important finding from the LEAP Study Group’s research was the identi fication of several predictors of poor outcome, regardless of group (amputation vs. limb salvage) to include a poor social support network and low self- ef ficacy. 5,23 This reinforces the importance of an individu- alized interdisciplinary approach to treating patients with severe extremity injuries. This is especially important when counseling patients on possible courses of action as sur- geons cannot rely on current lower-extremity injury sever- ity scoring systems because they have been shown not to be predictive of functional recovery of patients who undergo reconstruction. 24 The best available data from the military are from the Mil- itary Extremity Trauma Amputation/Limb Salvage study, which found better functional outcomes in patients with amputation compared to limb salvage. 7 However, when inter- preting these results it is important to look more closely MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 27 Improving Outcomes Following Extremity Trauma at the data before concluding that amputation is superior. Patients were included in the Military Extremity Trauma Amputation/Limb Salvage study if their injury occurred between 2003 and 2007. 7 During this period, there was a patient-centric rehabilitation program for amputees (The Armed Forces Amputee Patient Care Program), but, until late 2008, there was no such similar program for patients with limb salvage. In another retrospective comparison, service members with early amputation improved in several areas to include psychiatric diagnoses, but it is also important to note that they had more outpatient visits for psychiatry, occupa- tional therapy) and physical therapy. 25 Before acceptance of these results as de finitive evidence the following question must be answered, “Did amputees do better compared to those service members who underwent limb salvage because they received more attention and more support? ” In answering this question, it is helpful to further de fine the clinical problem and answer the questions, “How many patients fail limb salvage and why? ” Stinner et al initially reported that 15% of amputations occurred more than 90 days following injury, with many of those occurring more than a year after injury. 26 A comprehensive analysis by Krueger et al determined that during the first 10 years of conflicts in Afghanistan and Iraq, approximately 10% of all ampu- tations were performed more than 90 days following injury. 27
account time to attempt limb salvage. When evaluating outcomes of combat-related type III open tibia fractures, Huh et al found that those undergoing late amputation had several common characteristics: (a) more flaps, (b) higher rates of infection (both deep soft tissue and osteomyelitis), and (c) more reoperations. 28 This is similar to data reported by the LEAP Study Group, who noted that patients undergo- ing limb salvage for a mangled foot and ankle were likely to have a longer time to full weight bearing and more rehospitalizations. In addition, those that went on to an ankle arthrodesis (fusion) or required a free flap for soft tissue cov- erage were likely to have worse outcomes. 29 Optimizing the management of these severe injuries to minimize the post- operative complications that more commonly lead to poor outcomes should be a focus of future research efforts. SUMMARY
Ultimately, the surgeon should be armed with an evidence- based plan to treat severe combat-related extremity injuries and patients must be given the individualized tools to suc- ceed. For some, the tools to succeed may simply be follow- ing their fracture to union with periodic clinic visits to be reassured that they are on the right path. For others, it may consist of custom orthotics and/or intense physical therapy. 5 And, yet, for others, it may be a wide range of vocational, behavioral health, and other social support services to opti- mize their individual outcome. 9 Military treatment facilities have recognized the importance of this and have established well rounded integrated rehabilitation programs that are pushing beyond the boundaries of traditional rehabilitation, which is resulting in improved outcomes for injured service- men and women. 3,11
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