Scientific Articles   |    
Long-Term Persistence of Disability Following Severe Lower-Limb TraumaResults of a Seven-Year Follow-up
Ellen J. MacKenzie, PhD1; Michael J. Bosse, MD2; Andrew N. Pollak, MD3; Lawrence X. Webb, MD4; Marc F. Swiontkowski, MD5; James F. Kellam, MD2; Douglas G. Smith, MD6; Roy W. Sanders, MD7; Alan L. Jones, MD3; Adam J. Starr, MD8; Mark P. McAndrew, MD9; Brendan M. Patterson, MD10; Andrew R. Burgess, MD11; Renan C. Castillo, MS1
1 Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205. E-mail address: emackenz@jhsph.edu
2 Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232
3 The R. Adams Cowley Shock Trauma Center, University of Maryland at Baltimore, 22 South Green Street, Baltimore, MD 21201
4 Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157
5 Department of Orthopaedic Surgery, University of Minnesota Medical School, 420 Delaware Street S.E., Box 492, Minneapolis, MN 55455
6 Department of Orthopaedics and Sports Medicine, University of Washington, 1959 N.E. Pacific Street, Box 356500, Seattle, WA 98195-6500
7 Orthopaedic Trauma Service, 4 Columbia Drive, Suite 710, Tampa, FL 33606
8 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
9 Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University, P.O. Box 19679, Springfield, IL 62794
10 Department of Orthopaedic Surgery, Cleveland MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109
11 Department of Orthopaedic Surgery, Orlando Regional Medical Center, 83 West Columbia, Orlando, FL 32806
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received National Institutes of Health-National Institute of Arthritis and Musculoskeletal and Skin Diseases Grant ROI-AR42659. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Aug 01;87(8):1801-1809. doi: 10.2106/JBJS.E.00032
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Background: 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.

Methods: 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.

Results: 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 =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.

Conclusions: 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.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    Massachusetts - The University of Massachusetts Medical School
    Georgia - Choice Care Occupational Medicine & Orthopaedics
    Ohio - OhioHealth Research and Innovation Institute (OHRI)