Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
J Bone Joint Surg Am. 2019 Aug 21;101(16):1470-1478. doi: 10.2106/JBJS.18.00970.
Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference.
This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18).
Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation.
Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在最近的全球反恐战争中，近一半的四肢创伤都是严重的上肢损伤。很少有长期结果研究涉及严重的与战斗相关的上肢损伤。本研究的目的是描述全球反恐战争退伍军人中与截肢相比，保肢治疗严重上肢损伤的长期功能结果。假设保肢治疗会导致更好的手臂和手部功能评分、整体功能状态和生活质量，而疼痛干扰相似。
这项回顾性队列研究利用军事四肢创伤截肢/保肢（METALS）研究的数据，对 155 名接受截肢或保肢治疗的上肢严重损伤患者进行了亚组分析。参与者在受伤后 40 个月通过电话接受访谈，评估社会支持、个人习惯以及功能、活动、抑郁、疼痛和创伤后应激障碍的患者报告结果测量工具。对上肢严重损伤患者进行了结局评估，并与伴有严重下肢损伤的患者进行了比较。由于双侧上肢损伤患者数量较少（n = 18），因此对保肢与截肢治疗结局进行比较的分析仅限于 137 名单侧上肢损伤患者。
总体而言，上肢损伤患者报告了中度至高度的身体和心理社会残疾。短肌肉骨骼功能评估（SMFA）评分在各领域均较高；19.4%的患者筛查出创伤后应激障碍（PTSD），12.3%的患者筛查出抑郁。尽管如此，63.6%的参与者仍在工作、现役或上学，38.7%的参与者参与剧烈的娱乐活动。接受保肢治疗和截肢治疗的患者之间没有观察到结局的显著差异。
严重的、与战斗相关的上肢损伤导致自我报告的功能和心理社会健康状况下降。我们的研究结果表明，保肢治疗和截肢治疗的长期结果是等效的。解决或预防 PTSD、抑郁、慢性疼痛和相关的健康习惯可能会减轻该人群的残疾负担。
治疗性 III 级。请参阅作者说明，以获取完整的证据水平描述。
