A Qualitative Analysis of the Decision-Making Process for Patients with Severe Lower Leg Trauma

University of Michigan, Ann Arbor, Michigan, United States
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 12/2010; 126(6):2019-29. DOI: 10.1097/PRS.0b013e3181f4449e
Source: PubMed


Choosing the appropriate treatment for grade IIIB and IIIC open tibial fractures is a difficult decision for both the patient and the physician. Current research shows that the functional outcomes for reconstruction are similar to those for below-knee amputation, but little investigation of the qualitative outcomes of either treatment option has been performed from the patient perspective. This study was designed to perform a qualitative analysis of patient preferences for amputation or reconstruction.
Twenty patients with type IIIB or IIIC open tibial fractures participated in the study. These patients had undergone either amputation or reconstruction between 1997 and 2007. Semistructured interviews were conducted and qualitative outcomes were assessed.
Interviews highlighted several issues involved with medical decision-making. Participants described not having a role in deciding which medical treatment to choose. Family and spouses played a greater role, often because of patients being medicated when needing to make a treatment choice. Both amputation and reconstruction patients described being satisfied with the outcomes of their surgical treatments, but also expressed second thoughts about their treatment choices.
The findings of this study emphasize how difficult it is to assign preference to one medical treatment over another. The study reveals how the role of the patient is limited in making a decision about pursuing amputation or reconstruction. Instead, there is a continued need for physicians to discuss treatment options and risks with family members who act on the patient's behalf, and to incorporate the patient's preference in this complex decision.

1 Follower
19 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace. Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it. Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation. Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.
    The Journal of Bone and Joint Surgery 03/2012; 94(6):507-15. DOI:10.2106/JBJS.K.00254 · 5.28 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process. Methods: Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data. Results: Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics. Conclusions: There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing.
    Plastic and Reconstructive Surgery 06/2013; 131(6):880e-887e. DOI:10.1097/PRS.0b013e31828bd52b · 2.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Chronic wounds of the lower extremity are difficult to treat, especially in patients with peripheral arterial disease (PAD). This patient population frequently suffers from multiple comorbidities, which further impairs wound healing. Local flaps are often not available, or are insufficient to cover these defects, and limbs are frequently amputated, although they could possibly be salvaged by free tissue transplantation. Although there is a growing evidence that free tissue transfer may be feasible in these patients with otherwise doomed extremities, previous studies have mostly focused on short-term flap survival, but not long-term ambulatory status and independence. Therefore, we investigated the long-term results of limb salvage, ambulatory status, and social independence in patients with PAD who underwent free tissue transfer for chronic wounds of the lower extremities.In this study we retrospectively reviewed 38 patients who underwent free tissue transfer because of nontraumatic, chronic wounds of the lower extremities at our institution. All patients suffered from a nontraumatic occlusion of at least one major lower leg artery verified by angiography. After a mean time period of 34 months we assessed flap survival and limb preservation as well as pre- and postoperative ambulatory status and social independence. A subgroup of 14 patients with a "single-vessel-leg" was evaluated separately.It was observed that anterolateral thigh and latissimus dorsi musculocutaneous flaps were most often used to cover the defects. Overall 29 out of the 38 flaps healed completely (9 flap failures) and 34 extremities were salvaged, including 12 out of 14 single-vessel-legs. One patient had to be amputated despite a vital free flap because of persistent calcaneal osteomyelitis. After failure of free tissue transfer, six extremities could still be salvaged by secondary procedures (two secondary free flaps, two local flaps, and two skin grafts). Total 22 out of 34 patients with salvaged limbs maintained or improved their ambulatory status. In the amputee group, two patients remained on their preoperative level of mobility, while two declined. All patients with amputated limbs required assistance in activities of daily living while this was only true for 4 out of the 34 remaining patients.It was concluded that free tissue transfer is a valid option for salvaging lower extremities in patients with PAD. Long-term limb salvage can be achieved in a high percentage of cases, which allows the patients to ambulate freely and remain socially independent.
    Journal of Reconstructive Microsurgery 09/2013; 29(9). DOI:10.1055/s-0033-1354739 · 1.31 Impact Factor
Show more


19 Reads
Available from