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Michael J Bosse

Publications and source records attributed to Michael J Bosse.

At least 19 recordsLinked to original sources
PubMed2007

Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies.

PURPOSE: Leg threatening injuries present patients and clinicians with a difficult decision: whether to pursue primary amputation or limb salvage? The purpose of our study was to review the literature in an effort to inform this management decision. METHODS: We systematically searched and selected observational studies that reported on individuals presenting with leg threatening injuries comparing outcomes of limb salvage versus primary amputation. We searched MEDLINE, CINAHL, and EMBASE. We reported on the following outcomes, and pooled data across trials when possible: length of hospital stay, total rehabilitation time, cost, clinical outcomes, failure rate for limb salvage, function & quality of life, pain, return to work, factors associated with poor outcome, and patient preference. RESULTS: Nine observational studies contributed data to our systematic review. The current evidence suggests that while length of hospital stay is similar for limb salvage and primary amputation, length of rehabilitation and total costs are higher for limb salvage patients. Salvage patients requires greater additional surgery and are significantly more likely to undergo re-hospitalization. Long-term functional outcomes (up to 7 years post injury) are equivalent between limb salvage and primary amputation; both forms of management are associated with high rates of self-reported disability (40%; to 50%;), and functional status continues to worsen over time. Report of pain following limb salvage or primary amputation is similar. Return to work is essentially the same between limb salvage and primary amputation groups, with approximately half of such patients returning to competitive employment at 2 years post injury. Both clinical and psychosocial factors are associated with poorer functional outcomes. At the time of injury patients prefer limb salvage, but the majority of failed salvage patients would opt for early amputation if they could decide again. CONCLUSION AND SIGNIFICANCE: Functional outcome among patients who present with leg-threatening injuries are not significantly different, at least up to 7 years, whether they are managed with limb salvage or primary amputation. Research to optimize triage decisions to avoid failed limb salvage as well as on interventions targeting important psychosocial prognostic variables should be considered a priority.

Amputation, Surgical↗
PubMed2006

Prevalence of chronic pain seven years following limb threatening lower extremity trauma.

Although the etiology of chronic pain following trauma is not well understood, numerous retrospective studies have shown that a significant proportion of chronic pain patients have a history of traumatic injury. The present analysis examines the prevalence and early predictors of chronic pain in a cohort of prospectively followed severe lower extremity trauma patients. Chronic pain was measured using the Graded Chronic Pain Scale, which measures both pain severity and pain interference with activities. Severe lower extremity trauma patients report significantly higher levels of chronic pain than the general population (p<0.001). Their levels are comparable to primary care migraine headache and back pain populations. A number of early predictors of chronic pain were identified, including: having less than a high school education (p<0.01), having less than a college education (p<0.001), low self-efficacy for return to usual major activities (p<0.01), and high levels of average alcohol consumption at baseline (p<0.05). In addition, high reported pain intensity, high levels of sleep and rest dysfunction, and elevated levels of depression and anxiety at 3 months post-discharge were also strong predictors of chronic pain at seven years (p<0.001 for all three predictors). After adjusting for early pain intensity, patients treated with narcotic medication during the first 3 months post-discharge had lower levels of chronic pain at 84 months. It is possible that for patients within these high risk categories, early referral to pain management and/or psychologic intervention may reduce the likelihood or severity of chronic pain.

Adult↗
PubMed2006

Physical disability after severe lower-extremity injury.

OBJECTIVE: To investigate the use of a combined measure of decreased walking speed and gait deviation to identify high physical disability in patients with lower-limb salvage. DESIGN: Longitudinal study of patients with severe lower-extremity trauma. SETTING: Eight level I trauma centers. PARTICIPANTS: Patients (N=276) with lower-limb salvage from the Lower Extremity Assessment Project. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability from the physical dimension of the Sickness Impact Profile (SIP), walking speed, and gait deviation were measured at 24 months of follow-up. A 1-way analysis of variance and planned comparisons compared mean SIP scores across and between the following 3 outcome groups: no impaired speed and no gait deviation, impaired speed or gait deviation, and impaired speed and gait deviation. RESULTS: Mean SIP scores for the physical dimension and its 2 categories of ambulation and body care and movement differed statistically across the planned comparisons. The mobility category showed that the impaired speed or deviation group was statistically similar to the group without impaired speed and gait deviation. CONCLUSIONS: The combination of decreased walking speed and gait deviation appears to provide a valid measure of physical disability among patients with lower-limb salvage.

Analysis of Variance↗
PubMed2006

Early predictors of long-term work disability after major limb trauma.

BACKGROUND: A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. METHODS: Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. RESULTS: Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. CONCLUSIONS: Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

Adolescent↗
PubMed2006

Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial.

BACKGROUND: Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. METHODS: Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. RESULTS: Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. CONCLUSIONS: The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Adult↗
PubMed2006

Gait symmetry and walking speed analysis following lower-extremity trauma.

BACKGROUND AND PURPOSE: Gait has been shown to be a major determining factor of function following limb-salvage surgery. However, little is known regarding the measures associated with gait recovery for this patient population. The purpose of this study was to identify clinical measures associated with impaired walking speed and gait asymmetry in patients with lower-extremity reconstruction. SUBJECTS: Study subjects were 381 patients from the Lower Extremity Assessment Project (LEAP) who had undergone reconstruction following severe lower-extremity trauma. METHODS: The LEAP study was a longitudinal study of outcomes following lower-extremity reconstruction. The present study used 24-month clinical follow-up data. A combined outcome measure of reduced walking speed and gait deviation was chosen to provide a comprehensive measure of impaired physical mobility. RESULTS: The most significant clinical factors associated with decreased walking speed and gait deviation were impaired ankle plantar-flexion range of motion, knee flexion strength, and a nonreciprocal stair-climbing pattern. DISCUSSION AND CONCLUSION: The findings provide clinicians with specific clinical measures associated with functional recovery in patients with lower-limb reconstruction. These measures, in turn, can be considered to inform treatment decision making and to prioritize interventions.

Adolescent↗
PubMed2006

Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP).

The Lower Extremity Assessment Project (LEAP) is a multicenter study of severe lower extremity trauma in the US civilian population. At 2- and 7-year follow-ups, the LEAP study found no difference in functional outcome between patients who underwent either limb salvage surgery or amputation. However, outcomes on average were poor for both groups. This study and others provide evidence of wide-ranging variations in outcome following major limb trauma, with a substantial proportion of patients experiencing long-term disability. In addition, outcomes often are more affected by the patient's economic, social, and personal resources than by the initial treatment of the injury--specifically, amputation or reconstruction and level of amputation. A conceptual framework for examining outcomes after injury may be used to identify opportunities for interventions that would improve outcomes. Because of essential differences between the civilian and military populations, the findings of the LEAP study may correlate only roughly with combat casualty outcomes.

Amputation, Surgical↗
PubMed2005

Use and perceived need of physical therapy following severe lower-extremity trauma.

OBJECTIVE: To examine the utilization of physical therapy (PT), the level of perceived need for PT, and the proportion of patients with perceived need receiving no PT in a cohort of severe lower-extremity trauma patients treated at level I trauma centers. DESIGN: Longitudinal, observational study of severe lower-extremity trauma patients. Patients were interviewed by a research coordinator and examined by an orthopedic surgeon and a physical therapist during initial admission, and at 3, 6, 12, and 24 months postdischarge. SETTING: Eight level I trauma centers. PARTICIPANTS: Of 601 patients age 18 to 65 enrolled in the parent study over a 40-month period, 550 with unilateral study injuries and followed up at least once over the 2-year study period were included in this analysis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patient reported number of PT visits at each follow-up time point, inpatient rehabilitation admissions, and their perceived need for PT. Perceived need for PT was also assessed by an orthopedic surgeon and a physical therapist. Overall, concordance between physician, physical therapist, and patient's assessment of need for PT was low, with kappa statistics ranging between .12 and .41. RESULTS: Amputation and reconstruction patients used comparable amounts of PT services. Regardless of the criteria used to evaluate need, the proportion of patients with perceived need for PT receiving no PT services increased over the course of the follow-up, from 23% to 46% at first follow-up to over 68% by 2 years. Factors associated with increased risk for having a perceived need but receiving no therapy included lack of private insurance, pain, lower levels of education, lower fitness levels at time of injury, being a smoker, and having severe muscle injury. CONCLUSIONS: The results suggest a significant proportion of patients in the severe lower-extremity trauma population have perceived need for PT, yet receive no PT services.

Adolescent↗
PubMed2005

Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures.

OBJECTIVES: Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders. SETTING: Eight Level I trauma centers. PATIENTS: Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105). OUTCOME MEASURE: Time to fracture healing, diagnosis of infection, and osteomyelitis. METHODS: Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics. RESULTS: After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection. CONCLUSION: Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Adolescent↗
PubMed2005

Acute care surgery.

Explore the source record for details and available documents.

Attitude of Health Personnel↗
PubMed2005

The insensate foot following severe lower extremity trauma: an indication for amputation?

BACKGROUND: Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation. METHODS: We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups. RESULTS: The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation. CONCLUSIONS: Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Amputation, Surgical↗
PubMed2005

Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up.

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 > or = 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.

Adult↗
PubMed2004

The modified ilioinguinal approach.

A modified ilioinguinal approach for acetabular fractures is presented. The approach allows surgical exposure of the anterior column as well as the contralateral rami, the symphysis pubis, and the medial wall of the acetabulum. Direct access to the quadrilateral surface and retroacetabular surface for plate or screw application is also possible.

Abdominal Muscles↗
PubMed2004

Unstable proximal extraarticular tibia fractures: a biomechanical evaluation of four methods of fixation.

OBJECTIVE: To compare the biomechanical stability of extraarticular proximal tibia fractures reconstructed using a double-plate construct, locking plate system, hybrid external fixator, and single lateral periarticular plate, all from the same manufacturer. DESIGN: Standardized proximal tibial fractures (AO classification 41-A3.2 and A3.3) in synthetic tibiae were stabilized using one of the four constructs. Load versus proximal fragment translation and rotation were monitored in each case. Fixation was evaluated for moderately unstable and completely unstable fractures simulated by wedge and gap osteotomies of the proximal femur. SETTING: Academic medical center biomechanical engineering laboratory. MAIN OUTCOME MEASUREMENTS: Proximal fragment axial displacement, varus rotation, and posterior rotation versus applied load for each of the constructs. RESULTS: The double-plate construct was significantly stiffer than all other constructs with regard to resistance to axial displacement, varus rotation, and posterior rotation for both types of unstable fractures. With regard to axial stiffness, the double-plate construct was statistically similar to an intact tibia for moderately stable fractures. The locking plate and the external fixator were similar for stabilization of moderately unstable fractures, whereas the locking plate and the periarticular plate were significantly stiffer than the external fixator construct for completely unstable fractures. CONCLUSION: For axial load applied to a wedge or gap osteotomy of the proximal tibia, the double-plate construct provided significantly more rigidity than the other constructs. The locking plate, periarticular plate, and hybrid external fixator tested provided similar rigidity for the wedge osteotomy, but for the gap osteotomy the external fixator could not support 600N without complete closure of the gap.

Biomechanical Phenomena↗