Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma

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Abstract

Introduction

Individuals with delayed below-knee amputation have previously reported superior clinical outcomes compared with lower limb reconstruction. The UK military have since introduced a passive-dynamic ankle-foot orthosis (PDAFO) into its rehabilitation care pathway to improve limb salvage outcomes. The aims were to determine if wearing a PDAFO improves medium-term clinical outcomes and what influence does multidisciplinary team (MDT) rehabilitation have after PDAFO fitting? Also, what longitudinal changes in clinical outcomes occur with MDT rehabilitation and how do these results compare with patients with previous lower extremity trauma discharged prior to PDAFO availability?

Methods

We retrospectively evaluated levels of mobility, activities of daily living, anxiety, depression and pain in a heterogeneous group of 23 injured UK servicemen 34±11 months after PDAFO provision. We also retrospectively analysed 16 patients across four time points (pre-PDAFO provision, first, second and final inpatient admissions post-PDAFO provision) using identical outcome measures, plus the 6 min walk test.

Results

Outcomes were compared with previous below-knee limb salvage and amputees. Before PDAFO, 74% were able to walk and 4% were able to run independently. At follow-up, this increased to 91% and 57%, respectively. Mean depression and anxiety scores remained stable over time (p>0.05). After 3 weeks, all patients could walk independently (pre-PDAFO=31%). Mean 6 min walk distance significantly increased from 440±75 m (pre-PDAFO) to 533±68 m at last admission (p=0.003). The ability to run increased from 6% to 44% after one admission.

Conclusions

All functional and most psychosocial outcomes in PDAFO users were superior to previous limb salvage and comparable to previous below-knee amputees. The PDAFO facilitated favourable short-term and medium-term changes in all clinical outcome measurements.

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Most cited references 22

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An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.

Lawrence Webb, Helen Jones, Rogier Sanders … (2002)

Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated. We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization. At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively). Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation. Copyright 2002 Massachusetts Medical Society

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Reference values for the 6-min walk test in healthy subjects 20-50 years old.

Margherita Neri, Panagiota Tzani, Giovanna Pisi … (2006)

In 102 healthy Caucasians, 20-50 years old, we investigated the effect of anthropometrics on the 6-min walk test (6MWT), in order to provide reference values for walk distance (6MWD), oxygen saturation (SpO2), pulse rate (PR), respiratory rate (RR), breathlessness perception (VAS) and for the walking distance and body weight product (DW). The mean 6MWD and DW values were 593 +/- 57 and 638+/-44 m (P < 0.01) and 35,030 +/- 5306 and 48,882 +/- 6555 kg m (P < 0.01), respectively for women and for men. While walking, SpO2 remained unaltered and subjects reached 67 +/- 10% of their maximal predicted heart rate and a RR mean value of 19 +/- 4 bpm. VAS ratings were significantly higher in females as compared to males (24 +/- 15 vs. 18 +/- 5 mm, P < 0.05), however, when corrected for PR change while walking, they were not different. The equation by stepwise multiple regression analysis included height, age and gender for the 6MWD and accounted for 42% of the total variance. This study confirms the relevant effect of anthropometrics on walking capacity and suggests that when rating dyspnea, the change in heart rate during walking should be considered.

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Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up.

Rogier Sanders, Lawrence Webb, Michael J Bosse … (2005)

A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery.

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Author and article information

Journal

Journal ID (nlm-ta): J R Army Med Corps

Journal ID (iso-abbrev): J R Army Med Corps

Journal ID (hwp): jramc

Journal ID (publisher-id): jramc

Title: Journal of the Royal Army Medical Corps

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0035-8665

ISSN (Electronic): 2052-0468

Publication date (Print): October 2019

Publication date (Electronic): 9 November 2018

Volume: 165

Issue: 5

Pages: 330-337

Affiliations

[1 ] departmentAcademic Department of Military Rehabilitation , Defence Medical Rehabilitation Centre (DMRC) Headley Court , Surrey, UK

[2 ] departmentBlatchford , Defence Medical Rehabilitation Centre (DMRC) Headley Court , Surrey, UK

[3 ] departmentCentre for Blast Injury Studies (CBIS) , Imperial College London , London, UK

[4 ] departmentNational Heart and Lung Institute, Faculty of Medicine , Imperial College London , London, UK

Author notes

[Correspondence to ] Peter Ladlow, Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey KT18 6JW, UK; peter.ladlow100@ 123456mod.gov.uk

Article

Publisher ID: jramc-2018-001082

DOI: 10.1136/jramc-2018-001082

PMC ID: 6839716

PubMed ID: 30415216

SO-VID: 1f23f8fa-52f4-4c28-ba31-1ae04f100659

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 25 September 2018

Date revision received : 12 October 2018

Date accepted : 13 October 2018

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Keywords: rehabilitation,orthosis,outcomes,function,lower-limb,trauma

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Keywords: rehabilitation, orthosis, outcomes, function, lower-limb, trauma

Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma

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Abstract

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Most cited references 22

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.

Reference values for the 6-min walk test in healthy subjects 20-50 years old.

Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up.

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