Singleton James A G, Walker N M, Gibb I E, Bull A M J, Clasper J C
The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK.
J R Army Med Corps. 2014 Jun;160(2):187-90. doi: 10.1136/jramc-2013-000210. Epub 2013 Dec 18.
Analysis of recent UK Armed Forces combat casualty data has highlighted a significant number of through joint traumatic amputations (TAs), most commonly through knee (through knee amputations (TKAs)). Previously, a consensus statement on lower limb amputation from the UK Defence Medical Services reported better outcomes in some patients with TKAs when compared with those with above knee amputations. This study sought to define the proportion of recent combat casualties sustaining severe lower extremity trauma with acute osseous and soft tissue injury anatomy amenable to definitive TKA.
The UK Joint Theatre Trauma Registry and post mortem CT (PM-CT) databases were used to identify all UK Armed Forces personnel (survivors and fatalities) sustaining a major extremity TA (through/proximal to wrist or ankle joint) between August 2008 and August 2010. Through knee and all below knee TAs were grouped as 'potential TKAs' (pTKAs), that is, possible candidates for definitive TKA.
146 Cases (75 survivors and 71 fatalities) sustaining 271 TAs (130 in survivors, 141 in fatalities) were identified. The through-joint TA rate was 47/271 (17.3%); 34/47 through-joint injuries (72.3%) were TKAs. Overall, 63/130 TAs in survivors and 66/140 TAs in fatalities merited analysis as the pTKA group. Detailed anatomical data on pre-debridement osseous and soft tissue injury levels were only consistently available for fatalities through PM-CT findings. Further analysis of the soft tissue injury profile revealed that a definitive TKA in the pTKA group (all BKAs as well as TKAs) would have been proximal to the zone of injury (ZOI) in only 3/66 cases.
Traumatic TKAs following explosive blast are more common than previously reported. The majority of lower limb TAs are skeletally amenable to a definitive TKA. Maximising residual stump length carries the risks of definitive level amputation within the original ZOI but this study demonstrates that the proximal extent of the soft tissue injury may frequently make this unavoidable. Further work is required to determine the relative merits of definitive below, through and above knee amputations in the short, medium and long term to ensure survivors are subject to minimal complications while maintaining capacity to achieve optimal functional outcomes.
对英国武装部队近期战斗伤亡数据的分析凸显出大量的贯通性关节创伤性截肢（TA），最常见的是通过膝关节（膝关节贯通性截肢（TKA））。此前，英国国防医疗服务部门关于下肢截肢的一份共识声明报告称，与膝上截肢患者相比，一些TKA患者的预后更好。本研究旨在确定近期因严重下肢创伤导致急性骨与软组织损伤且解剖结构适合进行确定性TKA的战斗伤亡人员的比例。
利用英国联合战区创伤登记处和尸检CT（PM-CT）数据库，识别2008年8月至2010年8月期间所有遭受主要肢体TA（通过/靠近腕关节或踝关节）的英国武装部队人员（幸存者和死亡者）。膝关节贯通性截肢和所有膝关节以下截肢被归为“潜在TKA”（pTKA），即可能适合进行确定性TKA的候选者。
共识别出146例（75名幸存者和71名死亡者）遭受271次TA（幸存者130次，死亡者141次）的病例。贯通性关节TA发生率为47/271（17.3%）；47例贯通性关节损伤中有34例（72.3%）为TKA。总体而言，幸存者中的63/130次TA和死亡者中的66/140次TA作为pTKA组值得分析。仅通过PM-CT结果才能始终如一地获得清创前骨与软组织损伤水平的详细解剖数据。对软组织损伤情况的进一步分析显示，pTKA组（所有膝关节以下截肢以及TKA）中只有3/66例的确定性TKA会在损伤区域（ZOI）近端。
爆炸冲击后的创伤性TKA比先前报道的更为常见。大多数下肢TA在骨骼结构上适合进行确定性TKA。最大化残肢长度存在在原始ZOI内进行确定性截肢平面截肢的风险，但本研究表明软组织损伤的近端范围可能常常使这一情况不可避免。需要进一步开展工作以确定短期、中期和长期内确定性膝关节以下、膝关节贯通性和膝关节以上截肢的相对优点，以确保幸存者并发症最少，同时保持获得最佳功能结果的能力。
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