DOD paradigm shift in care of servicemembers with major limb loss

Abstract

INTRODUCTION Military operations in Iraq and Afghanistan present a multitude of challenges for the U.S. Armed Forces. Whether operating in an urban environment, such as Baghdad, or the rural mountains of Afghanistan, combat military units need to be flexible to adapt to the constant changes on the battlefield. In support of these military operations, the Military Health Care System (MHCS) needs to be equally flexible. Advances in body armor, expertly trained field medics, forward-area surgical support, and modernized evacuation systems greatly increase combat wound survival rates. Despite these advances, to date more than 4,000 servicemembers have died in the line of duty and countless others have been injured. Military professionals continue to serve their country far from their loved ones in hostile environments and treacherous terrain. Many have served on multiple deployments and have witnessed horrific human tragedy. The MHCS remains committed to these heroes and their families, not only to provide the best healthcare that is available today but to continually explore new technology and science to deliver even better care tomorrow. The majority of severe injuries that occur in the combat theater result from a blast. Blast injuries may occur from the primary blast wave or the secondary or tertiary effects caused by flying debris or violent displacement of the individual. Given the relative vulnerability of the servicemember's arms and legs, severe limb trauma is frequently encountered. Although modern surgical reconstructive techniques have contributed to a greater preservation rate of limbs than possible in prior wars, many injured limbs still require amputation. As of January 2010, more than 950 servicemembers sustained one or more major limb amputations from injuries sustained in Iraq or Afghanistan. Servicemembers with traumatic limb loss represent a much different patient demographic than their civilian counterparts. More than 85 percent of the servicemembers who undergo amputation because of combat-related injuries are under the age of 35, whereas in the civilian population more than 81 percent are over the age of 44. Additionally, most amputations in the civilian population occur as a result of diseases such as diabetes or peripheral vascular disease as opposed to the traumatic injuries due to military conflict. Further, while traumatic amputations do occur in civilian settings, the types of trauma and associated injuries are often much different than those experienced by our military servicemembers. EARLY CLINICAL CARE Extremity wounds, especially those occurring as the result of a blast, are extensively contaminated and typically involve massive soft-tissue disruption. Because of the complex nature of these wounds, military surgeons work collaboratively with various subspecialists to perform innovative soft-tissue, bone, nerve, muscle, and vascular grafts to preserve as much of the limb as possible. For injuries that require amputation, the precise level is often not defined until weeks after the injury to allow for adequate wound debridement and ensure tissue vitality. Every effort is made to preserve as much limb length as possible, including saving precious joints such as the elbow and knee to help maximize long-term functional outcomes. Saving a joint may require the amputation to be performed through the zone of injury, potentially complicating soft tissue coverage and creating significant challenges for achieving adequate prosthetic socket fit and comfort. Considerable debate exists as to the optimal level of amputation, particularly for the transtibial versus Symes amputation, or a knee disarticulation versus a transfemoral amputation. Involving rehabilitative experts, prosthetists, and family members in these surgical decisions often benefits the patient, helping to ensure realistic rehabilitation expectations and fully engaging the patient and his/ her family on the road to recovery. …