Session XI - Reconstruction
Sun., 10/10/04 Reconstruction, Paper #68, 10:19 am
Disability Persists Long Term following Severe Lower Limb Trauma: Results of a 7 Year Follow-up
Purpose: Recent studies have shown little difference in functional outcome of amputation as compared with reconstruction of a severe lower extremity injury. These results, however, were based on 2-year follow-up data. For many patients, recovery is still not complete by 2 years. The resolution of fracture nonunions may improve the long-term function of patients undergoing reconstruction, whereas continued fit modification and increasing comfort and confidence in the prosthesis could improve the long-term function of the amputee. Both groups are at risk of developing complications and secondary conditions. The purpose of this study was to examine outcomes at 7-years following amputation or reconstruction and to examine the factors that correlate with variations in outcome both within and across treatment groups.
Methods: A cohort of 569 patients, age 18 to 69, who were treated at eight level-I trauma centers for a severe leg injury were contacted 7 years after injury and asked to participate in a telephone interview. These patients had previously participated in follow-up assessments at 3, 6, 12, and 24 months after their injury. Eligible for participation in the study were patients with one or more of the following injuries to the lower extremity: Gustilo grade IIIB and IIIC fractures, selected grade IIIA fractures, dysvascular limbs, major soft tissue injuries to the tibia, and severe foot injuries. A total of 129 patients underwent amputation prior to discharge from the acute hospitalization (including 32 patients with traumatic amputations). After initial discharge, 28 additional patients underwent amputation. Seven-year (84 month) outcomes of principal interest were the physical and psychosocial sub-scores on the Sickness Impact Profile (SIP), a self-reported measure of disability, and time to first return to work (for the 423 patients who were working before the injury). Multiple regression techniques were used to examine differences in SIP outcomes adjusting for differences in injury severity, complications, and patient characteristics. A Cox proportional hazards model was used to examine differences in time to first return to work.
Results: Of the 569 patients previously enrolled in the study, 413 (72.6%) completed the follow-up interview at 84 months. As shown below, mean SIP scores (over all patients) were slightly worse at 84 months compared with 24 months, and there was little improvement in the percentage of return to work.
|
3 Mos. | 6 Mos. | 12 Mos. | 24 Mos. | 84 Mos. |
|
24.1 (13.8) | 16.4 (11.4) | 12.1(11.0) | 9.7 (9.8) | 14.1 (14.4) |
|
14.1 (14.4) | 10.9 (13.3) | 10.2(14.2) | 9.3 (13.9) | 12.7 (17.8) |
| Percentage return to work | 12% |
28% |
42% |
51% |
58% |
At 84 months, nearly 50% of all patients had SIP scores of 10 or more, which is indicative of significant disability. Of those who had returned to work within 84 months, 68% first returned to work with some limitation in the amount or type of work they were able to do. One quarter (26%) returned to a different type of job due to residual limitations associated with their injury. After controlling for important injury and patient characteristics, there were no statistically significant differences in outcomes by treatment group, with two exceptions. Patients with severe soft tissue injuries who underwent reconstruction and patients who underwent a through-the-knee amputation had significantly worse scores on the physical sub-score of the SIP. Factors that did make a difference in 84-month outcomes included: age, sex, race, education, poverty status, smoking status, self-efficacy, social support, job tenure, job involvement, and involvement with the legal system for obtaining disability payments. In particular, patients who at baseline reported low self-efficacy, weak social support, and high levels of depression, anxiety, and pain were significantly more likely to have poor outcomes at 84 months.
Conclusion/Significance: These results suggest little improvement in function beyond the 2-year follow-up. The slight decline in SIP scores is likely due to the aging of the study population (SIP scores tend to decline with age). The results confirm our conclusions based on 2-year data; patients with severe leg injuries can be advised that reconstruction typically results in long-term outcomes equivalent to amputation. The results further confirm our findings of worse outcomes for two important subgroups of patients those who undergo a through-the-knee amputation and those who undergo reconstruction procedures due to a dysvascular injury. Outcomes for all groups were, on average, poor. Our analysis of the correlates of outcomes results strongly suggests that major improvements in functional outcome require interventions in the early post-acute phase of recovery that directly address the psychosocial needs of the patients and assist them in self-managing the multi-factorial consequences of their injury.