A modified passive-dynamic ankle-foot orthosis: can it prevent amputation and arthrodesis in patients with ankle-foot trauma?

INTRODUCTION: High-energy lower extremity trauma (HELET) may cause severe damage within the foot-ankle complex. Occasionally, arthrodesis or amputation are the only remaining options to increase activity levels. The modified passive dynamic ankle-foot orthosis (PDAFO) may prove to be a nonsurgical alternative. This study evaluated the effect of a modified PDAFO with a 6-week training program on pain and performance in patients after HELET. MATERIALS AND METHODS: A retrospective cohort study was conducted on seventeen patients who considered an arthrodesis or an amputation after HELET. In an attempt to avoid surgery, the modified PDAFO with a 6-week training program was provided. Pain scores was measured with the Numeric Rating Scale and administered at the start of testing, immediately after the two performance tests and at the end of the day of testing. Performance was evaluated with the 6-min walk test (6MWT) and the Comprehensive high-level activity mobility predictor (CHAMP). RESULTS: A significant pain reduction was achieved after the treatment procedure. At the start of the test days (p = 0.002), after the 6MWT (p = 0.001), after the CHAMP (p < 0.001) and at the end of the day (p < 0.001). In addition, a significant improvement on performance was observed in the 6MWT (p < 0.001) and the CHAMP (p = 0.01). None of the patients considered a surgical intervention anymore. CONCLUSIONS: Patients after HELET show a decrease in pain and an improvement in performance after a 6-week training program with modified PD-AFO. The results suggest that the modified PDAFO is an effective alternative for a surgical approach.

Real-time visual biofeedback during weight bearing improves therapy compliance in patients following lower extremity fractures.

BACKGROUND: Individuals with lower extremity fractures are often instructed on how much weight to bear on the affected extremity. Previous studies have shown limited therapy compliance in weight bearing during rehabilitation. In this study we investigated the effect of real-time visual biofeedback on weight bearing in individuals with lower extremity fractures in two conditions: full weight bearing and touch-down weight bearing. METHODS: 11 participants with full weight bearing and 12 participants with touch-down weight bearing after lower extremity fractures have been measured with an ambulatory biofeedback system. The participants first walked 15m and the biofeedback system was only used to register the weight bearing. The same protocol was then repeated with real-time visual feedback during weight bearing. The participants could thereby adapt their loading to the desired level and improve therapy compliance. RESULTS: In participants with full weight bearing, real-time visual biofeedback resulted in a significant increase in loading from 50.9±7.51% bodyweight (BW) without feedback to 63.2±6.74%BW with feedback (P=0.0016). In participants with touch-down weight bearing, the exerted lower extremity load decreased from 16.7±9.77kg without feedback to 10.27±4.56kg with feedback (P=0.0718). More important, the variance between individual steps significantly decreased after feedback (P=0.018). CONCLUSIONS: Ambulatory monitoring weight bearing after lower extremity fractures showed that therapy compliance is low, both in full and touch-down weight bearing. Real-time visual biofeedback resulted in significantly higher peak loads in full weight bearing and increased accuracy of individual steps in touch-down weight bearing. Real-time visual biofeedback therefore results in improved therapy compliance after lower extremity fractures.

Technical Aspects and Validation of a New Biofeedback System for Measuring Lower Limb Loading in the Dynamic Situation.

BACKGROUND: A variety of techniques for measuring lower limb loading exists, each with their own limitations. A new ambulatory biofeedback system was developed to overcome these limitations. In this study, we described the technical aspects and validated the accuracy of this system. METHODS: A bench press was used to validate the system in the static situation. Ten healthy volunteers were measured by the new biofeedback system and a dual-belt instrumented treadmill to validate the system in the dynamic situation. RESULTS: Bench press results showed that the sensor accurately measured peak loads up to 1000 N in the static situation. In the healthy volunteers, the load curves measured by the biofeedback system were similar to the treadmill. However, the peak loads and loading rates were lower in the biofeedback system in all participants at all speeds. CONCLUSIONS: Advanced sensor technologies used in the new biofeedback system resulted in highly accurate measurements in the static situation. The position of the sensor and the design of the biofeedback system should be optimized to improve results in the dynamic situation.

Degloved foot sole successfully reconstructed with split thickness skin grafts.

INTRODUCTION: The current opinion is that split thickness skin grafts are not suitable to reconstruct a degloved foot sole. The tissue is too fragile to carry full bodyweight; and therefore, stress lesions frequently occur. The treatment of choice is the reuse of the avulsed skin whenever possible, or else the use of a full thickness fascio-cutaneus flap. PRESENTATION OF THE CASE: A young male sustained a crush injury to his right foot with deglovement of the plantar surface and part of the dorsum. DISCUSSION: Split thickness skin grafts are not suitable for full weight bearing, but in special circumstances, certain patients, a lot of time and patience, early mobilization and gradual increasing partial weight bearing it is worthwhile to try. To toughen the foot sole pressure distribution is necessary and can be reached in several ways, soft and springy materials of the inlay, but also socks, orthopedic shoes, casting, orthotics or walking aids. CONCLUSION: This case-report illustrates that the reconstruction of a degloved foot sole with split-thickness skin grafts can be successful; a silicon inner sole was used to prevent stress lesions.

Acute phase complications following traumatic spinal cord injury in Dutch level 1 trauma centres.

OBJECTIVE: To assess the number and nature of complications during the acute phase following traumatic spinal cord injury and to explore the relationship between number of complications and length of hospital stay. DESIGN: Multi-centre prospective cohort study. PATIENTS: A total of 54 patients with traumatic spinal cord injury, referred to 3 level 1 trauma centres in The Netherlands. METHODS: The number and nature of complications were registered weekly from September 2009 to December 2011. RESULTS: A total of 32 patients (59%) had 1 or more medical complications. The most common complications were pressure ulcers (17 patients, 31%) and pulmonary complications (15 patients, 28%). PATIENTS with 3 or 4 complications had significantly (p < 0.01) longer hospital stays (58.5 [32.5] days) compared with those with 1 or 2 complications (33.1 [14.8] days) or no complications (21.5 [15.6] days). CONCLUSION: Complications, particularly pressure ulcers and pulmonary complications, occurred frequently during the acute phase following traumatic spinal cord injury. More complications were associated with longer hospital stays. Despite the existence of protocols, more attention is needed to prevent pressure ulcers during the acute phase following traumatic spinal cord injury for patients in The Netherlands.

Trends in moderate to severe paediatric trauma in Central Netherlands.

INTRODUCTION: Trend analyses of hospital discharge data can raise signals for prevention policies, but are often flawed by changes in health care consumption. This is a trend analysis of the clinical incidence of paediatric trauma that used international criteria to overcome this bias. The objective is to describe trends in clinical incidence of moderate to severe paediatric trauma, and to identify target groups for prevention activities. PATIENTS AND METHODS: Included were all paediatric trauma patients (0-18 years) that were discharged from the hospitals of trauma care region Central Netherlands from 1996 to 2009. Selection was made on ISS ≥ 4, and on trauma related International Classification of Diseases diagnostic codes, and trauma related external causes of injury and poisoning codes. Trend analyses were performed using Poisson loglinear regression with correction for age and gender. RESULTS: 23,682 Patients were included, the mean incidence rate was 477/100,000 person-years. Since 2001 the incidence rate of moderate to severe trauma increased with 1.1% annually (95% confidence interval (CI) 0.7-1.5), caused by an increase of falls (3.9%, 95% CI 3.3-4.5), sport injuries (5.4%, 95% CI 4.3-6.5), and bicycle injuries (3.8%, 95% CI 2.8-4.8). The incidence of falls and sport injuries peaked in young children (0-9) and older boys (10-18) respectively. Bicycle injuries affected all children between 5 and 18. CONCLUSIONS: The incidence of paediatric trauma in the centre of the Netherlands increased since 2001. Trend analyses on moderate and severe injuries may identify target groups for prevention in a trauma region.

Dynamic weight loading in older people with hip fracture.

OBJECTIVE: Hip fractures have a high morbidity and mortality in elderly patients. Improving mobility outcomes is crucial in order to decrease the burden of this injury. The objective of this study was to investigate dynamic weight loading in older people with hip fractures using a new device. DESIGN: In an observational study, low-energy hip fracture patients were monitored one day per week with the FeetB@ck system during their admission. Pain, gait and balance scores were noted. Outcome measures of the FeetB@ck system are steps, walking bouts and loading rate. RESULTS: A total of 21 patients with hip fracture were included in the study (mean age 80.3 years (standard deviation 8.3 years)). The number of steps, walking bouts and loading rate had a positive linear relationship with rehabilitation (i.e. gait and balance scores) (p < 0.05). These parameters also differed significantly between patients with short (less than 8 weeks, n = 7), intermediate (between 8 and 12 weeks, n = 8) and long (longer than 12 weeks, n = 6) of rehabilitation (p < 0.01). CONCLUSION: The loading rate is a sensitive weight loading parameter for analysis of dynamic weight loading during rehabilitation in elderly hip fracture patients. This parameter correlates with clinical improvement and can differentiate between fast and slow rehabilitation.

Determinants of limitations in unpaid work after major trauma: a prospective cohort study with 15 months follow-up.

OBJECTIVE: To identify determinants of limitations in unpaid work (household work, shopping, caring for children and odd jobs around the house) in patients who had suffered major trauma (ISS≥16) and who were in full-time employment (≥80%) at the time of injury. DESIGN: Prospective cohort study. SETTING: University Medical Centre Utrecht, a level 1 trauma centre in the Netherlands. METHOD: All severely injured (ISS≥16) adult (age≥16) trauma survivors admitted from January 1999 to December 2000 who were full-time employed at time of the injury were invited for follow-up (n=214). Outcome was assessed with the 'Health and Labour Questionnaire' (HLQ) at a mean of 15 months (SD=1.5) after injury. The HLQ was completed by 211 patients. RESULTS: Response rate was 93%. Logistic regression analyses identified the percentage of permanent impairment (% PI), level of participation (RtW), co-morbidity, lower extremity injury (LEI) and female gender as determinants of limitations in unpaid work. Patients with a post-injury status of part-time or no return to work experienced more limitations in unpaid work than those who returned to full-time employment. CONCLUSIONS: Resuming paid work after major trauma is not associated with reductions in unpaid activities. To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives.

Keep moving forward: a new energy returning prosthetic device with low installation height after Syme or Pirogoff amputation.

BACKGROUND: The incidence of foot amputations increased in the Netherlands to 3.3/100,000 people up to 1994. Despite these numbers, only a few basic prosthetic and orthotic devices are available, and all lack functionality to restore ankle and foot mobility. OBJECTIVES: The aim of this explorative study was to design and test a unique prosthesis for Syme or Pirogoff amputees with the necessary low installation height but restoring ankle and foot mobility. STUDY DESIGN: A case study was performed. METHODS: The new prosthesis was designed and numerically analyzed on aspects concerning strength and deformation. A prototype was tested in a case study to assess the biomechanical behavior of the new foot. As a reference, six Syme/Pirogoff amputees were measured. Additionally, all volunteers filled out a questionnaire to evaluate their prosthetic feet. RESULTS: The self-selected and maximum walking speed of the case subject at 0° and 5° slopes was higher using the new foot (0.36 m/s and 0.53 m/s, respectively) comparing to the Low Rider (Otto Bock HealthCare) (0.31 m/s and 0.31 m/s, respectively). Using the new foot, a more symmetrical walking pattern was achieved. CONCLUSION: The case study shows that this new prosthetic foot could be an improvement compared to existing prosthetic feet. CLINICAL RELEVANCE: Foot amputees with low available installation height still experience daily the inconvenience of missing ankle and foot mobility. Their low velocity and cosmetically poor walking pattern influence on their sound leg and overall walking functionality. A more functional prosthesis would have a great impact on their daily activities.

The effects of regionalization of pediatric trauma care in the Netherlands: a surveillance-based before-after study.

BACKGROUND: System changes in pediatric trauma care may reduce childhood injury mortality. The Dutch system of trauma care has been regionalized in 1999/2000. We evaluated changes in referral behavior and in-hospital mortality before and after regionalization of trauma care in the Netherlands. METHODS: A surveillance-based before-after study was performed on all children aged up to 18 years that were discharged from one of the hospitals of the trauma care region "Central Netherlands" between 1996 and 1998 and between 2001 and 2006. The in-hospital mortality rate and referral behavior was compared before (1996-1998) and after (2001-2006) regionalization of trauma care in the Netherlands. RESULTS: A total of 21,585 children were included, with a mean (SD) age of 9.6 (5.5) years and a mean (SD) Injury Severity Score (ISS) of 4.3 (4.4). After regionalization, the mean ISS was lower (p = 0.000), and the mean length of stay was lower (p = 0.000). The in-hospital mortality rate was significantly lower for the adolescent group (age, 13-18 years; n = 7,846; standardized mortality ratio, 0.64; 95% confidence interval, 0.34-0.93) after correction for the ISS. No changes were found for the younger children (age, 0-12 years; n = 13,739). No significant differences were found in referral behavior for both age categories. CONCLUSION: Regionalization of trauma care in the Netherlands reduced the in-hospital mortality rates for adolescents in the last decade. However, this reduction was not caused by a change in referral behavior. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Are existing outcome instruments suitable for assessment of spinal trauma patients?

OBJECT: Valid outcome assessment tools specific for spinal trauma patients are necessary to establish the efficacy of different treatment options. So far, no validated specific outcome measures are available for this patient population. The purpose of this study was to assess the current state of outcome measurement in spinal trauma patients and to address the question of whether this group is adequately served by current disease-specific and generic health-related quality-of-life instruments. METHODS: A number of widely used outcome measures deemed most appropriate were reviewed, and their applicability to spinal trauma outcome discussed. An overview of recent movements in the theoretical foundations of outcome assessment, as it pertains to spinal trauma patients has been attempted, along with a discussion of domains important for spinal trauma. Commonly used outcome measures that are recommended for use in trauma patients were reviewed from the perspective of spinal trauma. The authors further sought to select a number of spine trauma-relevant domains from the WHO's comprehensive International Classification of Functioning, Disability and Health (ICF) as a benchmark for assessing the content coverage of the commonly used outcome measurements reviewed. RESULTS: The study showed that there are no psychometrically validated outcome measurements for the spinal trauma population and there are no commonly used outcome measures that provide adequate content coverage for spinal trauma domains. CONCLUSIONS: Spinal trauma patients are currently followed either as a subset of the polytrauma population in the acute and early postacute setting or as a subset of neurological injury in the long-term revalidation medicine setting.

Psychometric properties of questionnaires evaluating health-related quality of life and functional status in polytrauma patients with lower extremity injury.

BACKGROUND: Long term disability is common among polytrauma patients. However, as yet little information exists on how to adequately measure functional status and health-related quality of life following polytrauma. AIMS: To establish the unidimensionality, internal consistency and validity of two health-related quality of life measures and one functional status questionnaire among polytrauma patients. METHODS: 186 Patients with severe polytrauma including lower extremity injury completed the Sickness Impact Profile-136 (SIP-136), the Medical Outcomes Study 36-Item Short Health Survey (SF-36) and the Groningen Activity Restriction Scale (GARS) 15 months after injury. Unidimensionality and internal consistency was assessed by principal components analysis and Cronbach's alpha (alpha). To test the construct validity of the questionnaires, predetermined hypotheses were tested. RESULTS: The unidimensionality and internal consistency of the GARS and the SF-36, but not the SIP-136 were supported. The construct validity of the SF-36, GARS and to a lesser extent the SIP-136 was confirmed. CONCLUSION: The SF-36 and the GARS appear to be preferable for use in polytrauma patients over the SIP-136.

Long-term health condition in major pediatric trauma: a pilot study.

PURPOSE: Major trauma is the leading cause of death in children of developed countries. However, little is known about its long-term health consequences in survivors. Our aim was to describe the health condition in children at long-term after major trauma. METHODS: Prospective cohort study of severely injured children (Injury Severity Score > or =16, age <16) admitted to a Dutch level I trauma center in 1999 to 2000 (N = 40). About 7 years after trauma (median, 7.3; range, 6.3-8.2 years), survivors' health condition was assessed with the following: guides to the evaluation of permanent impairment of the American Medical Association (AMA-guides), Glasgow Outcome Scales (GOS/GOSE), Vineland Adaptive Behavior Scales (VABS), Child Behavior Checklist (CBCL), and Strengths and Difficulties Questionnaire (SDQ). RESULTS: Of 40 children, 28 were followed up. Most (n = 16; 57%) had no impairments (AMA guides); minor to severe impairments were found in 12 of the respondents. About 80% (n = 22) had good recovery (GOS 5 and GOSE 7/8); the remaining had moderately disability (GOS 4 or GOSE 5/6). The mean scores on the VABS and the frequency of behavioral problems on the CBCL (24%) and the SDQ (20%) were comparable to healthy peers. CONCLUSIONS: This long-term follow-up study after major trauma revealed that most children had a health condition comparable to healthy peers; about 40% of the respondents was physically impaired or restricted in daily activities. Our experiences with different measures may be helpful to apply age-appropriate outcome measures for the clinical follow-up of children after major trauma and to design future longitudinal studies.

Long-Term Health-Related Quality of Life in Major Pediatric Trauma: A Pilot Study.

BACKGROUND: Major trauma is the leading cause of mortality and morbidity in children of developed countries. Little research has been done about the health-related quality of life (HRQL) in these children. The aim of the current research is to describe the HRQL of children in the long term after major trauma and to compare it with healthy peers. METHODS: A prospective cohort study of severely injured children (ISS ≥ 16, age < 16 years) who survived the trauma and were admitted to the emergency department of a Dutch level 1 trauma center in 1999 and 2000 (n = 40) was conducted. Between 6 and 8 years after trauma (mean 7.3, SD 0.7 years), outcome was assessed by the Pediatric Quality of Life Inventory (PedsQL 4.0), the EuroQol 5D (EQ-5D), and the EuroQol Visual Analogue Scale (EQ-VAS). RESULTS: The mean age at the time of the accident was 8.9 years (SD 4.6 years), the mean ISS was 24.9 (SD 11.1), and 25 (63%) cases were male; 28 out of 40 patients were followed up. The mean score on the PedsQL was 81.2 and this did not differ significantly from the norm value. On the EQ-5D, more health problems were reported than in a healthy reference population. The mean EQ-VAS score was 79.4 and was significantly lower than in healthy peers. The lowest scores on the PedsQL and the EQ-VAS were seen in teenagers and in respondents with spinal cord and/or severe cerebral injury. CONCLUSION: The results on HRQL in children in the long term after major trauma are inconclusive. Special attention should be given to teenagers with spinal cord or severe cerebral injury who reported the lowest HRQL.

Health-related quality-of-life measures for long-term follow-up in children after major trauma.

OBJECTIVE: Our objective was to review measures of health-related quality of life (HRQL) for long-term follow up in children after major trauma and to determine the measures that are suitable for a large age range, reliable and valid, and cover a substantial amount of the domains of functioning using the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO). METHODS: The Medline and EMBASE databases were searched in all years up to October 2007 for generic HRQL measures suitable for children aged 5-18 years old and validated in English or Dutch. Measures were reviewed with respect to the age range for which the measure was suitable and reliability, validity, and content related to the ICF. RESULTS: The search resulted in 1,235 hits and 21 related articles. Seventy-nine papers met the inclusion criteria, describing in total 14 measures: Child Health and Illness Profile Adolescent and Child Edition (CHIP-AE/CE), Child Health Questionnaire Child and Parent Forms (CHQ-CF87/PF50/PF28), DISABKIDS, Functional Status II (FS II)(R), Health Utilities Index Mark 2 (HUI 2), KIDSCREEN 52/27, KINDL, Pediatric Quality of Life Inventory (PedsQL), TNO Institute of Prevention and Health and the Leiden University Hospital (TNO-AZL), TNO-AZL Children's Quality Of Life (TACQOL), and Youth Quality of Life Instrument--Research Version (YQOL-R). Measures that were suitable for a large age range were CHQ-PF50/PF28, DISABKIDS, FS II(R), HUI 2, KIDSCREEN, PedsQL, and TACQOL. All measures had moderate to good psychometric properties, except for CHQ-PF50/PF28, KINDL, and TACQOL, which had either low internal consistency or bad test-retest reliability. The measures that covered more than six chapters of the ICF domains were CHIP-AE/CE, CHQ-CF87/PF50, DISABKIDS, KIDSCREEN-52, PedsQL, and TACQOL. CONCLUSIONS: DISABKIDS, KIDSCREEN 52, and PedsQL are suitable for long-term follow-up measurement of HRQL in children after major trauma. They cover a large age range, have good psychometric properties, and cover the ICF substantially.

Individual and population burdens of major trauma in the Netherlands.

OBJECTIVE: To assess the impact of major trauma on individual and population health. METHODS: Data from a regional trauma registry were used, including all trauma fatalities and nonfatal severely injured patients (injury severity score >15) in 1999 and 2000. The impact of fatalities was expressed in terms of years of life lost (YLL). The impact of severe injury on survivors was expressed in terms of years lived with disability (YLD). Disability weights were based on quality of life at 15 months after injury, measured with EuroQol-5D. Disability-adjusted life years (DALYs) were calculated as the sum of YLLs and YLDs. FINDINGS: There were 567 fatalities and 335 survivors. At the individual level, trauma fatalities (32 YLLs per patient) and nonfatal cases of major trauma (12 YLDs per patient) both led to a substantial loss of healthy life years. Each victim of major trauma contributed an average of 25 DALYs to the burden of disease. At the population level, major trauma caused 10 DALYs per 1000 inhabitants. Road-traffic injury was the main contributor to the population burden of major trauma. CONCLUSION: Both at individual and population levels, major trauma has a massive impact on health. Most severely injured victims of road-traffic crashes reach the hospital and have good chances of survival. Injury prevention and trauma care policies should aim at further reduction of both fatalities and permanent consequences among survivors.

Return to work after major trauma.

OBJECTIVE: To quantify the prevalence of return to work after major trauma, and to investigate the determinants of postinjury work status. DESIGN: Prospective cohort study. SETTING: University Medical Centre Utrecht, a level 1 trauma centre in the Netherlands. METHOD: All severely injured (ISS > 16) adult (age = 16+) trauma survivors admitted from January 1999 to December 2000 who were full-time employed at the time of the injury were selected for follow-up (n = 214). Response rate was 93%. Outcome was assessed at a mean of 15 months (SD = 1.5) after injury. Multivariate logistic regression analyses identified determinants at hospital discharge and at follow-up. RESULTS: Following injury 58.4% of the patients (n = 125) were able to return to full-time employment, 21.5% had a part-time job, and 20.1% did not return to work. Univariate analysis yielded the following significant determinants of postinjury work status: age, comorbidity, injury severity score, brain injury, spinal cord injury, length of stay in an intensive care unit, hospital stay, discharge destination, percentage of permanent impairment (according to the fourth American Medical Association guide (AMA)), limitations in activities of daily living and cognitive complaints. Logistic regression analyses (23% explained variance) identified spinal cord injury, duration of hospital stay, discharge destination and age as determinants of return to work at hospital discharge. At follow-up, determinants of return to work included AMA, activities of daily living, cognitive complaints and being discharged home (51% explained variance). CONCLUSIONS: Around 60% of the patients returned to their pre-injury work status after major trauma. The return to work rate was only partly explained by disability at follow-up. Independent determinants of return to work differ with the time of assessment.

Determinants of long-term functional consequences after major trauma.

OBJECTIVE: The purpose of this study was to describe the long-term functional consequences from major trauma and to quantify the effect of sociodemographic, injury-related, and physical determinants of its outcome. METHODS: A prospective cohort study was performed at the University Medical Center Utrecht (Level I trauma center) in the Netherlands during 1999 and 2000. All severely (injury severity score [ISS] >or=16) injured adult (age >or=16) trauma survivors (n = 359) were selected for follow-up. Between 12 and 18 months after trauma, outcome was assessed by means of Glasgow Outcome Scale (GOS), EuroQol (EQ-5D), and cognitive complaints. RESULTS: Follow-up assessments (overall response rate 93%) were obtained of 335 patients (249 men, 86 women) with a mean age of 38 years (SD = 17) and a mean ISS of 25 (SD = 10.6). The mean visual analog scale score on the EuroQol (EQvas) was 73.5 (SD = 17.8) and the mean utility score (EQus) was 69.1 (SD = 29.9), both below the norm. Patients reported limitations of mobility (48%); self-care (18%); daily activities (55%); pain and discomfort (63%); anxiety or depression (28%); and cognitive complaints (65%). In multivariate analyses, injury localization (spinal cord injury, lower extremity injury, or brain injury) was significantly associated with EQvas, EQus, and other outcome measures. Educational level was significantly associated with EQvas, anxiety/depression, and cognitive complaints. Comorbidity was significantly associated with EQvas, EQus, all dimensions of the EQ-5D (except anxiety/depression), and cognitive complaints. CONCLUSION: In addition to the injury localization, educational level and comorbidity were identified as important independent predictors of long-term functional consequences after major trauma. These determinants need further attention in outcome research and clinical practice.