Post on 26-Jul-2020
transcript
Upper Extremity Injuries and Correlates with Amputation Outcome
following Combat Trauma
John J Carroll, MD Peter C Rhee, DO
Jessica C Rivera, MD
US Army Institute of Surgical Research And
San Antonio Military Medical Center Department of Orthopaedic Surgery
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The author have no disclosures to report related to this work. The authors acknowledge the Department of Defense Trauma Registry (DoDTR) for providing data for this study. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
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Introduction
• UE amputations 14% of OIF/OEF combat amputations
• Predictors of UE amputations less explored compared to LE
• Vascular status not predictive
Tennent D, et al. Characterization and outcomes of upper extremity amputations. Injury, 2014; 45(6): 965-9. Prichayudh S, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg, 2009; 33(4): 857-63 MacKenzie EJ, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma, 2000; 14(7): 455-66.
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Question
Are there acute injury predictors of amputation for the combat related upper extremity injury?
Hypothesis: Vascular and nerve injury most predictive of limb retention.
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Methods
DoDTR search for neurovascular injuries to UE between 2002 and 2007
Cross reference amputation search through 201
Annotate tissue injured: Nerve, Vessel, Bone, Muscle
Chi-Square and Logistic regression to test associate between tissues injured and amputation outcome
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Results
397 subjects with UE injures • 87 traumatic amputations excluded
310 subjects analyzed • 72 non-traumatic amputations • 238 retained limbs
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Frequencies of Injuries in Subjects with and without Amputation
Amputa'on
N=72
NoAmputa'on
N=238
Frequency of injury χ2 P value Cramer’s V
Nerve Injury 62.5% 80.3% 0.002 -0.18
Vascular
Injury56.90% 34.03% <0.001 0.198
Fracture 68.10% 42.9% <0.001 0.2129
Muscle Loss 69.44% 32.80% <0.001 0.3145
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Frequencies of Injuries in Subjects with and without Amputation
Amputa'on
N=72
NoAmputa'on
N=238
Frequency of injury χ2 P value Cramer’s V
Nerve Injury 62.5% 80.3% 0.002 -0.18
Vascular
Injury56.90% 34.03% <0.001 0.198
Fracture 68.10% 42.9% <0.001 0.2129
Muscle Loss 69.44% 32.80% <0.001 0.3145
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Odds: Amputation Day 1-14
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Injury
Severity
8.70**
(3.97-19.06)
8.27**
(3.73-18.34)
7.21**
(3.23-16.10)
5.96**
(2.64-13.47)
6.16**
(2.63-14.60)
5.91**
(2.44-14.31)
Nerve
Injury
0.79
(0.41-1.51)
0.90
(0.46-1.76)
0.86
(0.43-1.71)
0.65
(0.31-1.37)
0.24*
(0.09-0.65)
Vascular
Injury
2.27*
(1.23-4.18)
2.57*
(1.36-4.85)
2.59*
(1.32-5.12)
1.13
(0.47-2.69)
Fracture 3.45**
(1.76-6.77)
3.80**
(1.85-7.78)
1.67
(0.70-4.01)
Muscle
Loss
5.89**
(2.94-11.80)
2.28
(0.93-5.62)
Total
Injuries
2.15**
(1.31-3.52)
BIC 281.38 286.56§ 285.26ǂ 276.77ǂ 254.28ǂ 250.58ǂ*p < 0.01; **p<0.001; § BIC support for saved model; ǂ BIC support for current model
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Odds: Amputation Day 1-14
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Injury
Severity
8.70**
(3.97-19.06)
8.27**
(3.73-18.34)
7.21**
(3.23-16.10)
5.96**
(2.64-13.47)
6.16**
(2.63-14.60)
5.91**
(2.44-14.31)
Nerve
Injury
0.79
(0.41-1.51)
0.90
(0.46-1.76)
0.86
(0.43-1.71)
0.65
(0.31-1.37)
0.24*
(0.09-0.65)
Vascular
Injury
2.27*
(1.23-4.18)
2.57*
(1.36-4.85)
2.59*
(1.32-5.12)
1.13
(0.47-2.69)
Fracture 3.45**
(1.76-6.77)
3.80**
(1.85-7.78)
1.67
(0.70-4.01)
Muscle
Loss
5.89**
(2.94-11.80)
2.28
(0.93-5.62)
Total
Injuries
2.15**
(1.31-3.52)
BIC 281.38 286.56§ 285.26ǂ 276.77ǂ 254.28ǂ 250.58ǂ*p < 0.01; **p<0.001; § BIC support for saved model; ǂ BIC support for current model
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Odds: day 15 or greater Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Injury
Severity
4.27
(0.87-21.02)
4.39
(0.87-22.10)
4.99
(0.98-25.41)
4.40
(0.85-22.79)
3.56
(0.66-19.25)
3.02
(0.52-17.41)
Nerve
Injury
1.17
(0.23-6.02)
0.77
(0.13-4.46)
0.73
(0.12-4.43)
0.63
(0.10-3.97)
0.17
(0.02-1.66)
Vascular
Injury
0.36
(0.06-2.10)
0.38
(0.06-2.26)
0.44
(0.07-2.58)
0.08
(0.01-1.07)
Fracture 1.97
(0.47-8.32)
2.5
(0.56-11.32)
0.83
(0.13-5.45)
Muscle
Loss
8.03*
(1.57-41.14)
2.7
(0.39-18.70)
Total
Injuries
2.82
(0.97-8.19)
BIC 83.84 89.28§ 93.31§ 97.91§ 95.61ǂ 97.53§*p<0.05; § BIC support for saved model; ǂ BIC support for current model
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Odds: day 15 or greater Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Injury
Severity
4.27
(0.87-21.02)
4.39
(0.87-22.10)
4.99
(0.98-25.41)
4.40
(0.85-22.79)
3.56
(0.66-19.25)
3.02
(0.52-17.41)
Nerve
Injury
1.17
(0.23-6.02)
0.77
(0.13-4.46)
0.73
(0.12-4.43)
0.63
(0.10-3.97)
0.17
(0.02-1.66)
Vascular
Injury
0.36
(0.06-2.10)
0.38
(0.06-2.26)
0.44
(0.07-2.58)
0.08
(0.01-1.07)
Fracture 1.97
(0.47-8.32)
2.5
(0.56-11.32)
0.83
(0.13-5.45)
Muscle
Loss
8.03*
(1.57-41.14)
2.7
(0.39-18.70)
Total
Injuries
2.82
(0.97-8.19)
BIC 83.84 89.28§ 93.31§ 97.91§ 95.61ǂ 97.53§*p<0.05; § BIC support for saved model; ǂ BIC support for current model
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Discussion
• 25% frequency of muscle conditions following extremity injury
• High percent disability despite “successful” healing of limb
• Muscle disability increases with time
0 365 730 1095 1460 1825 2190
010203040506070
NR
TPI (days)
% D
isab
ility
Initial Final (With Initial Rating)Initial Final (With no Initial Rating)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
010203040506070
NR
Subject
% D
isab
ility
A
B
Corona BT, Rivera JC, Owens JG, Wenke JC, Rathbone CR. Volumetric muscle loss leads to permanent disability following extremity trauma. J Rehabil Res Dev, 2015; 52(7): 785-92. Rivera JC, Corona BT. Muscle-related disability following combat injury increases with time. US Army Med Dep J, 2016; Jan-Mar: 30-34.
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Conclusion
• Nerve and vascular injury only weakly associated with limb loss
• Muscle injury most predictive after acute period has past
• Low “late” amputation rate may indicate differences in decision toward attempted reconstruction
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Questions?