The Journal of Bone and Joint Surgery (American). 2005;87:1801-1809.
doi:10.2106/JBJS.E.00032
© 2005 The Journal of Bone and Joint Surgery, Inc.
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Long-Term Persistence of Disability Following Severe Lower-Limb Trauma

Results 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 and 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{at}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

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.

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.


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