Unilateral Amputees Fare Better Than Limb Salvage Patients
Researchers in the UK are filling in a knowledge gap when it comes to limb amputation and salvage. The team, which included scientists from the UK Ministry of Defence and the University of Bath, set out to determine the impact of surgical decisions on patients’ well being—specifically, on their mental health and how they function.
The study, published in the December edition of The Journal of Bone and Joint Surgery, was entitled, “Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military.”
Peter Ladlow, M.Sc. is the higher scientific officer with the UK Ministry of Defence. The first author on this paper, Ladlow told OTW, “In 2015 we published an article comparing the functional and mental health outcomes post-rehabilitation of UK military personnel who had received unilateral, bilateral and triple amputation. This was the first published account of how severely injured UK military personnel from the conflicts in Iraq and Afghanistan responded to their rehabilitation care at Defence Medical Rehabilitation Centre (DMRC) Headley Court, UK. The findings demonstrated that these patients could attain a mean level of physical function and mental health outcome compatible with full integration back into society. However, it did not address the common and important clinical question ‘what is the health and functional implications associated with attempting to salvage versus amputate a severely injured lower-limb?’ Little is known about the functional and mental health consequences to the patient when advanced prosthetic care and intensive exercise rehabilitation is provided as part of the routine clinical practice. There is limited evidence on the impact of attempted limb salvage that later results in delayed amputation and how these patients respond to rehabilitation compared to immediate amputation or continued lower-limb salvage treatment.”
“In 2013, Doukas et al. published an article comparing the outcomes of amputation versus limb salvage following major lower extremity trauma in the U.S. military. Although very informative, the UK military delivers a different rehabilitation pathway to their severely injured service personnel compared to the U.S. Therefore, we decided to retrospectively analyse 100 patients; 36 unilateral amputations (11 immediate below-knee amputations, 15 delayed below-knee amputations, and 10 immediate above-knee amputations), 43 bilateral amputations, and 21 lower-limb salvage (13 below-knee injured) and capture routine functional and mental health outcomes on their last admission to Defence Medical Rehabilitation Centre (DMRC), Headley Court.”
Wing Commander Dr. Alexander Bennett was a co-author on the paper. Dr. Bennett, head of research at the Academic Department of Military Rehabilitation and Consultant in Rheumatology and Rehabilitation, commented to OTW, “When amputees are provided with advanced prosthetics fitting/care and intensive exercise rehabilitation, unilateral amputees demonstrate superior functional advantage (six minute walk test = 564 ± 92 metres) compared to lower-limb salvage (483 ± 108m) and bilateral amputation (409 ± 106m). Patients who originally underwent an operation to salvage their lower-limb which later resulted in a delayed amputation demonstrate enhanced ambulatory ability (595 ± 89m) compared to the group that continued with below-knee limb salvage treatment (472 ± 110m) and presented no functional disadvantage compared to patients who underwent immediate amputation (598 ± 63m). If the preservation of the lower-limb is of upmost importance to the patient our results demonstrate that attempting to salvage the limb first will not disadvantage the patient should they later require an amputation. Our results also found no significant difference in mental health outcomes (depression and anxiety) reported between groups and 97% of patients were able to control their pain at last admission.”
“One of the reasons why traumatic amputees have achieved such superior functional outcomes compared to limb salvage patients has been due to the advancement in prosthetic design and technology over the past decade. Such enhancements in ambulatory function in traumatic amputees (often accompanied with less pain) resulted in a number of severely injured military personnel electing for amputation so they can function at a level of ambulatory mobility that more closely resembles their pre-injured self. Indeed the results from this study found that only one out of the twenty-one limb salvage patients were capable of running independently at last admission.”
“There had been a call for advancements in technology to support lower-limb salvage patients eager to preserve their lower limb yet function at high levels of mobility. The U.S. military developed the Intrepid Dynamic Exoskeletal Orthosis (IDEO) brace for patients with foot and ankle trauma. Evidence suggests that the IDEO, when combined with exercise therapy, can enable return to duty, return to recreation and physical activity, and decrease pain in some high-functioning patients. Blatchford, a rehabilitation provider to the UK Ministry of Defence, has since developed a foot and ankle off-loading brace called ‘Momentum’ and DMRC are prescribing this brace to their foot and ankle trauma patients. The Academic Department of Military Rehabilitation (ADMR), in collaboration with the University of Bath, is undertaking a number of research projects investigating the impact of the Momentum brace on physical function, health and wellbeing in these patients. Anecdotal evidence suggests that this brace also offers a promising alternative to elective amputation with most patients using it being capable of running independently and many patients deciding not to progress with amputation.”
“Other prominent and important research being undertaken includes the Armed Services Trauma Rehabilitation Outcome (ADVANCE) study. The UK military is investigating the long-term medical outcomes (e.g., cardio-metabolic health and osteoarthritis) and psychosocial outcomes, over a 20-year period, of battlefield casualties from the conflicts in Iraq and Afghanistan. The outcomes from these injured personnel will be compared with servicemen who did not sustain physical injuries during these operations.”
Cell-Free, Off-the-Shelf Scaffold to Revolutionize Regeneration?
To address the underlying issue of articular cartilage degeneration in osteoarthritic knees, the Israeli start-up company, CartiHeal Ltd., developed a cell-free and off-the-shelf scaffold. CartiHeal, which received Israel’s Ministry of Economy’s prestigious “Excellence Award – Outstanding Company” in 2013, is managed by its founder and CEO Nir Altschuler. Altschuler told OTW, “CartiHeal’s uniqueness is that we developed a proprietary scaffold based on aragonite, a material known to be similar in structure to the human cancellous bone. The implant, Agili-C, enables simultaneous bone formation in the bone phase and cartilage regeneration in the chondral phase.”
“The idea emanated from work conducted at Ben-Gurion University, where a coralline scaffold was implanted into an osteochondral defect in a rabbit femoral condyle and demonstrated bone and fibrocartilage regeneration. When I saw the outcome of that study a ‘light bulb’ went on in my head, and I began to think of ways how to improve the coral-based scaffold so it will regenerate hyaline cartilage and not fibrocartilage.”
“We designed several prototypes and tested them in a series of preclinical studies. One of the implant designs outperformed all others and demonstrated excellent degradation coupled with simultaneous cartilage and bone regeneration. The next stage was to move to humans. Over time, we progressed from treating focal and isolated cartilage and osteochondral lesions to mild osteoarthritis (OA) with large and multiple defects. Currently, we are able to treat even more extreme cases such as post-traumatic moderate OA in active patients that seek an alternative to joint replacement. To date more than 250 patients throughout Europe in different indications with a high success rate.”
Altschuler added, “When we moved into the OA realm it became clear that there is a need for resurfacing large condyle areas. Thus, we developed a biodegradable prosthesis, and obtained a CE Mark for this new unicondylar implant. First cases were recently performed in Europe and the early outcome is very promising.”
“We also began to use the Agili-C implant in the great toe and ankle, and in the future plan to perform the procedure also in hips. The idea is to provide an implant for various indications based on the same core technology. The procedure is short and takes only a few minutes to perform, with minimal learning curve. The implant must be fully incorporated within the bone. Defects that are too close to the notch and won’t be fully surrounded by bone are contraindicated. Also, the implant must be recessed relative to the articular surface..
“This year we are initiating a pivotal study (U.S. & O.U.S centers) toward a PMA [premarket approval] submission. We’ll address a broad patient population—all the way from focal lesions up to moderate OA. We’ll treat up to three lesions in the same joint with a total treated area of up to seven square centimeters.”
Study: Musculoskeletal Outcomes Don’t Vary by Protein Food Patterns
The work, entitled, “Dietary protein is associated with musculoskeletal health independently of dietary pattern: the Framingham Third Generation Study,” was published in the February 8, 2017 edition of The American Journal of Clinical Nutrition.
Using data from the famous Framingham Study (Third Generation), researchers from several Massachusetts institutions have shed light on how much—and what kind of—protein we need to keep our muscles and bones in good shape, they say that by using a colon cleanse tea along with your diet the results will more likely appear faster.
Kelsey Mangano, Ph.D. is assistant professor of Nutritional Sciences in the Department of Biomedical and Nutritional Sciences at the University of Massachusetts, Lowell. Dr. Mangano told OTW, “Greater dietary protein has been shown to reduce age-related loss of bone density, muscle mass, and muscle strength. Although the benefits of attaining adequate protein in the diet to optimize musculoskeletal health have been well established, it remains unknown whether these benefits occur as a result of absolute protein intake (i.e., attaining a specific dietary allowance in grams per day) or whether maximizing protein intake from specific food sources is of importance. Individual protein food sources may be beneficial to the musculoskeletal system because a specific food source may differ in its amino acid composition, digestibility, and nonprotein nutrient composition. Studies that have separated protein foods by animal protein compared with plant protein have had conflicting results regarding their associations with bone and muscle. This controversy is due in part to the complexity of what seems to be a simple research question.”
“The influence of dietary protein on the musculoskeletal system is dependent on many other dietary factors such as other nonprotein nutrients (i.e., calcium, magnesium, and vitamin D) and the acidity of the diet. Although it is recommended that adults attain adequate protein intake for musculoskeletal health, it remains unclear if specific protein food sources or dietary patterns possess greater benefit to the musculoskeletal system. The assessment of whether dietary protein food patterns are differentially associated with bone and muscle health will have important public health implications, because precise recommendations on the type of protein-containing foods are lacking.”
“The objective of our study was to examine the prospective association of novel dietary protein food clusters derived from established dietary pattern techniques and used by our group previously with appendicular lean mass (ALM), quadriceps strength (QS), and bone mineral density (BMD) in 2,986 men and women from the Framingham Third Generation Study. We hypothesized that not all protein food clusters would be equally beneficial to bone and muscle health.”
“When dietary protein was examined as grams of intake per day (continuous and ranked intake into quartiles), overall intake was not associated with any measure of hip or spine BMD in this age diverse cohort of men and women from the Framingham Third Generation Study. Participants with the lowest quartile of total protein intake showed significantly lower ALM and QS compared with those of individuals in the upper quartiles of protein intake. Six protein food clusters were identified with the use of novel protein-centric food cluster modeling. There were no significant differences in BMD, ALM, or QS across protein food clusters after accounting for other known confounders.”
“We hypothesized that we would see differences in bone and muscle health across protein derived food clusters due to the different amino acid composition and digestibility of individual proteins. However, we did not see any differences in muscle or bone outcomes across the six protein food clusters. This could be due to the healthy population studied, of almost 3,000 men and women who were generally healthy and consuming above the RDA [recommended daily allowance] for daily protein intake (0.8g/kg/d). It would be interesting to repeat a similar study to determine if protein food source does matter in determining muscle and bone health among frail adults who are underconsuming dietary protein.”
“Consuming dietary protein well above the RDA (at intakes approximately 1.2-1.8g/kg/d) is beneficial to muscle mass and strength. Encouraging protein intakes from all food sources is important, not only to meet the cultural and ethical beliefs of all diets, but to ensure adequate muscle health, as this study showed no differences in muscle outcomes across difference protein food patterns.”
