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Background Key factors limiting patients with lower extremity amputations to achieve maximal functional capabilities are falls and fear of falling. A task-specific fall prevention training program has successfully reduced prospectively recorded trip-related falls that occur in the community by the elderly. However, this program has not been tested in amputees. Questions/purposes In a cohort of unilateral transtibial amputees, we aimed to assess effectiveness of a falls prevention training program by (1) quantifying improvements in trunk control; (2) measuring responses to a standardized perturbation; and (3) demonstrating retention at 3 and 6 months after training. Second, we collected patient-reported outcomes for balance confidence and falls control. Methods Fourteen male military service members (26 ± 3 years) with unilateral transtibial amputations and who had been walking without an assistive device for a median of 10 months (range, 2–106 months) were recruited to participate in this prospective cohort study. The training program used a microprocessor-controlled treadmill designed to deliver task-specific postural perturbations that simulated a trip. The training consisted of six 30-minute sessions delivered over a 2-week period, during which task difficulty, including perturbation magnitude, increased as the patient’s ability progressed. Training effectiveness was assessed using a perturbation test in an immersive virtual environment. The key outcome variables were peak trunk flexion and velocity, because trunk kinematics at the recovery step have been shown to be a determinant of fall likelihood. The patient-reported outcomes were also collected using questionnaires. The effectiveness of the rehabilitation program was also assessed by collecting data before perturbation training and comparing the key outcome parameters with those measured immediately after perturbation training (0 months) as well as both 3 and 6 months posttraining. Results Mean trunk flexion angle and velocity significantly improved after participating in the training program. The prosthetic limb trunk flexion angle improved from pretraining (42°; 95% confidence interval [CI], 38°–47°) to after training (31°; 95% CI, 25°–37°; p < 0.001). Likewise, the trunk flexion velocity improved from pretraining (187°/sec; 95% CI, 166°–209°) to after training (143°/sec; 95% CI, 119°–167°; p < 0.004). The results display a significant side-to-side difference for peak trunk flexion angle (p = 0.01) with perturbations of the prosthetic limb resulting in higher peak angles. Prosthetic limb trips also exhibited significantly greater peak trunk flexion velocity compared with trips of the prosthetic limb (p = 0.005). These changes were maintained up to 6 months after the training. The peak trunk flexion angle of the subjects when the prosthetic limb was perturbed had a mean of 31° (95% CI, 25°–37°) at 0 month, 32° (95% CI, 28°–37°) at 3 months, and 30° (95% CI, 25°–34°) at 6 months. Likewise, the peak trunk flexion velocity for the prosthetic limb was a mean of 143°/sec (95% CI, 118°–167°) at 0 months, 143°/sec (95% CI, 126°–159°) at 3 months, and 132° (95% CI, 115°–149°) at 6 months. The peak trunk flexion angle when the nonprosthetic limb was perturbed had a mean of 22° (95% CI, 18°–24°) at 0 months, a mean of 26° (95% CI, 20°–32°) at 3 months, and a mean of 23° (95% CI, 19°–28°) at 6 months. The peak trunk flexion velocity for the nonprosthetic limb had a mean of 85°/sec (95% CI, 71°–98°) at 0 months, a mean of 96° (95% CI, 68°–124°) at 3 months, and 87°/sec (95% CI, 68°–105°) at 6 months. There were no significant changes in the peak trunk flexion angle (p = 0.16) or peak trunk flexion velocity (p = 0.35) over time after the training ended. The skill retention was present when either the prosthetic or nonprosthetic limb was perturbed. There were side-to-side differences in the trunk flexion angle (p = 0.038) and trunk flexion velocity (p = 0.004). Perturbations of the prosthetic side resulted in larger trunk flexion and higher trunk flexion velocities. Subjects prospectively reported decreased stumbles, semicontrolled falls, and uncontrolled falls. Conclusions These results indicate that task-specific fall prevention training is an effective rehabilitation method to reduce falls in persons with lower extremity transtibial amputations. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Turning gait is an integral part of daily ambulation and likely poses a greater challenge for patients with transtibial amputation compared with walking a straight pathway. A torsion adapter is a prosthetic component that can increase transverse plane compliance of the prosthesis and decrease the torque applied to the residual limb, but whether this will improve patients’ mobility, pain, and fatigue remains unknown. Questions/purposes Does prescription of a torsion adapter translate to improvements in (1) functional mobility and (2) self-perceived pain and fatigue in moderately active patients with lower limb amputation? Methods Ten unilateral transtibial amputees wore a torsion or rigid adapter in random order. Functional mobility was assessed through a field measurement using an activity monitor and through a laboratory measurement using a 6-minute walk test that included turns. The residual limb pain grade assessed self-perceived pain and the Multidimensional Fatigue Inventory assessed fatigue. Results We found relatively small functional differences for amputees wearing a torsion adapter versus a rigid adapter. Amputees wearing a torsion adapter tended to take more low- and medium-intensity steps per day (331 ± 365 and 437 ± 511 difference in steps; effect size = 0.44 and 0.17; confidence interval [CI], 70–592 and 71–802; p = 0.019 and 0.024, respectively). They also experienced less pain interference with activities (1.9 ± 1.7 change in score; effect size = 0.83; CI, 0.3–3.4; p = 0.026) when wearing a torsion adapter. However, these patients took a similar number of total steps per day, walked a comparable distance in 6 minutes, and reported similar residual limb pain and fatigue. Conclusions For a moderately active group of amputees, the torsion adapter did not translate to substantial improvements in functional mobility and self-perceived pain and fatigue. The small increases in low- and medium-intensity activities with less pain interference when wearing a torsion adapter provides evidence to support prescribing this device for amputees with difficulty navigating the household and community environments. Level of Evidence Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Motor imagery (MI) is the mental representation of an action without any concomitant movement. MI has been used frequently after peripheral injuries to decrease pain and facilitate rehabilitation. However, little is known about the effects of MI on muscle activation underlying the motor recovery. This study aimed to assess the therapeutic effects of MI on the activation of lower limb muscles, as well as on the time course of functional recovery and pain after surgery of the anterior cruciate ligament (ACL). Twelve patients with a torn ACL were randomly assigned to a MI or control group, who both received a series of physiotherapy. Electromyographic activity of the quadriceps, pain, anthropometrical data, and lower limb motor ability were measured throughout a 12-session therapy. The data provided evidence that MI elicited greater muscle activation, even though imagery practice did not result in pain decrease. Muscle activation increase might originate from a redistribution of the central neuronal activity, as there was no anthropometric change in lower limb muscles after imagery practice. This study confirmed the effectiveness of integrating MI in a rehabilitation process by facilitating muscular properties recovery following motor impairment. MI may thus be considered a reliable adjunct therapy to help injured patients to recover motor functions after reconstructive surgery of ACL.

Background Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated. Questions/purposes We asked: Does TNI (1) prevent primary neuroma-related pain in the setting of acute traumatic amputation and (2) reduce established neuroma pain in upper- and lower-extremity amputees? Methods We retrospectively reviewed two groups of patients treated by one surgeon: (1) 12 patients who underwent primary TNI for neuroma prevention at the time of acute amputation and (2) 23 patients with established neuromas who underwent neuroma excision with secondary TNI. The primary outcome was the presence or absence of palpation-induced neuroma pain at last followup, based on a review of medical records. The patients presented here represent 71% of those who underwent primary TNI (12 of 17) and 79% of those who underwent neuroma excision with secondary TNI (23 of 29 patients) during the period in question; the others were lost to followup. Minimum followup was 8 months (mean, 22 months; range, 8–60 months) for the primary TNI group and 4 months (mean, 22 months; range, 4–72 months) for the secondary TNI group. Results At last followup, 11 of 12 patients (92%) after primary TNI and 20 of 23 patients (87%) after secondary TNI were free of palpation-induced neuroma pain. Conclusions TNI performed either primarily at the time of acute amputation or secondarily for the treatment of established symptomatic neuroma is associated with a low frequency of neuroma-related pain. By providing a distal target for regenerating axons, TNI may offer an effective strategy for the prevention and treatment of neuroma pain in amputees. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background To study costs and outcome for serious hand and arm injuries during the first year after the trauma. Methods In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. Results The majority of the 45 included patients (median 42 years 16–64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. Conclusions Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.

High-energy lower extremity injury presents with difficult clinical decisions because successful limb salvage is the best scenario for complex traumas, but early amputation may be necessary to limit complications. Artificial Intelligence is a tool rising in popularity to help make clinical judgements. The aim of this study is to determine whether ChatGPT-4 can produce accurate recommendations for limb salvage or amputation given various patient scenarios. Various lower leg trauma scenarios were given to the appropriate use criteria for limb salvage made by AAOS or ChatGPT-4. A recommendation score for limb salvage and early amputation were collected. Tests to determine statistical significance between AAOS and ChatGPT-4 were performed. A total of 196 patient scenario combinations were utilized. The mean error for limb salvage and early amputation were −0.3 and −0.2 respectively. AAOS and ChatGPT had significant positive correlations when predicting limb salvage and early amputation scores. The effect size of limb salvage and early amputation was −0.094 and −0.14, respectively. ChatGPT-4 generally under-estimates appropriateness scores for both limb salvage and early amputation treatment options, but produces similar scores. ChatGPT-4 may be used to aid physicians in choosing between limb salvage and early amputation, though with caution. •The choice between limb salvage and early amputation involves complex clinical decisions and various factors.•There was a statistically significant difference between AAOS and ChatGPT in providing appropriateness scores for limb salvage.•There was no difference in recommendations between AAOS guidelines and ChatGPT when examining early amputation.•The use of ChatGPT-4 in clinical decisions should be cautious due to its dynamic behavior and limitations in accuracy and reliability.

The tourniquet has been considered as a recognized cause of limb ischemia/reperfusion injury in orthopedic surgery resulting in a transient neutrophil, monocyte activation, and enhanced neutrophil transendothelial migration with potential remote tissue injury. This study investigated the effect of unilateral tourniquet application within a safe time limit on pulmonary function and the roles of lipid peroxidation and systemic inflammatory response. Thirty patients undergoing unilateral lower extremity surgery with or without tourniquet were equally divided into a control group with no tourniquet (Group C) and a tourniquet (Group T). Arterial partial pressure of oxygen (PaO2), arterial-alveolar oxygen tension ratio (a/A ratio), alveolar-arterial oxygen difference (A-aDO2) and respiratory index, plasma malondialdehyde, serum interleukin (IL) -6 and IL-8 levels were measured immediately before and 1 hour after tourniquet inflation/operation beginning, 0.5, 2, 6, and 24 hours after tourniquet deflation/operation ending. The results represented no significant changes in Group C with regard to either blood gas variables or levels of circulating mediators, while blood gas variable changes of greater A-aDO2 and respiratory index and lower PaO2 and a/A ratio were shown at 6 hours following tourniquet deflation. The levels of malondialdehyde, IL-6, and IL-8 were increased over baseline values from 2 to 24 hours following tourniquet deflation in Group T. We concluded that tourniquet application within a safe time limit may cause pulmonary gas exchange impairment several hours after tourniquet deflation, where lipid peroxidation and systemic inflammatory response may be involved.

Background Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown. Questions/purposes (1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation? Methods We prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation. Results By 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks. Conclusions We found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation. Level of Evidence Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Purpose Crush injuries result from the physical compression of muscles and may lead to crush syndrome. Early fluid resuscitation and surgical intervention is key. Few studies have reported the outcomes of crush injuries in the non-disaster setting. This retrospective study aims to characterise such cases. Methods Patients with lower limb crush injuries were identified from an internal database. Non-crush injuries and patients under the age of 18 were excluded. Types of injuries, management, and complications were extracted. Results 27 patients were included. The right leg (n = 10) was the most frequently injured site. Mechanisms included being run over by vehicles (n = 10) and being crushed by, between, or inside vehicles (n = 8). Fractures were the most common acute injuries (n = 16), while other injuries included rhabdomyolysis, compartment syndrome and degloving. Fluid resuscitation was required in 17 patients. 58 surgeries were performed on 18 patients, with wound debridement and amputations being common. Complications such as acute kidney injury, hyperkalaemia, and sepsis were noted during hospitalisation. Individuals with injuries to the leg or thigh experienced a greater burden of injury and incidence of in-hospital complications compared to those with isolated injuries to the foot. Conclusion Crush injuries in the non-disaster setting show distinct mechanisms and injury patterns. Those with crush injuries to the leg or thigh more closely resemble a patient cohort seen in the disaster setting compared to those with isolated foot injuries.

Forklift trucks can cause serious lower limb trauma with long-lasting sequelae to patients. The aim of this study was to analyse a case series of patients with forklift-related injuries over 7 years at a level 1 major trauma centre in the UK and present their patient-reported outcome measures (PROMs) with long-term follow-up. To the best of the authors' knowledge, this is the largest case series study in the UK describing forklift injuries. Retrospective case note analysis of 19 patients over 7 years. Data including demographics, injury mechanism, pattern of injury, management, length of hospital stay, number of operations and complications were extracted from the notes. We used 'Enneking score' as a validated tool for PROMs. Seventeen men and two women with mean age of 47 years; 20% had bilateral injuries and 34% had multi-level fractures. The mean number of theatre sessions was 5.21, while the mean length of hospital stay was 30.10 days. There was one mortality. Twelve patients (63%) required reconstruction with free tissue transfer, with one flap failure. The mean long-term Enneking percentage score was 57.33%. The mean Enneking score for patients in this study is lower than our institute's score for Gustilo 3B, highlighting the gravity of these injuries. Forklifts can cause grave injuries with massive energy transfer. This study highlights the seriousness of those injuries, thus guiding patient counselling and optimising planning of management.