Bilateral Lower Extremity Amputations Research Articles

Race and geography impact validity of maximum allowable standing height equations for para-athletes

World Athletics use maximum allowable standing height (MASH) equations for para-athletes with bilateral lower extremity amputations to estimate stature and limit prosthesis length since longer prostheses can provide running performance advantages. The equations were developed using a white Spanish population; however, validation for other races and geographical groups is limited. This study aimed to determine the validity of the MASH equations for Black and white Americans and whether bias errors between calculated and measured stature were similar between these populations. Sitting height, thigh length, upper arm length, forearm length, and arm span of 1899 male and 1127 female Black and white Americans from the Anthropometric Survey of US Army Personnel database were input into the 6 sex-specific MASH equations to enable comparisons of calculated and measured statures within and between Black and white groups. Two of 12 MASH equations validly calculated stature for Black Americans and 3 of 12 equations were valid for white Americans. Bias errors indicated greater underestimation or lesser overestimation of calculated statures in 10 equations for Black compared to white Americans and in 2 equations for white compared to Black Americans. This study illustrates that race and geography impact the validity of MASH equations.

Gender differences in prosthesis-related outcomes among veterans: Results of a national survey of U.S. veterans.

Women with lower extremity amputations (LEAs) tend to have poorer prosthesis-related outcomes than men, although the literature is sparse. To our knowledge, there are no prior studies examining prosthesis-related outcomes of women veterans with LEAs. To examine gender differences (overall and by type of amputation) among veterans who underwent LEAs between 2005 and 2018, received care at the Veterans Health Administration (VHA) prior to undergoing amputation, and were prescribed a prosthesis. It was hypothesized that compared to men, women would report lower satisfaction with prosthetic services, poorer prosthesis fit, lower prosthesis satisfaction, less prosthesis use, and worse self-reported mobility. Furthermore, it was hypothesized that gender differences in outcomes would be more pronounced among individuals with transfemoral than among those with transtibial amputations. Cross-sectional survey. Linear regressions were used to assess overall gender differences in outcomes and gender differences based on type of amputation in a national sample of veterans. VHA medical centers. The sample consisted of 449 veterans who self-identified their gender (women = 165, men = 284) with transtibial (n = 236), transfemoral (n = 135), and bilateral LEAs (n = 68) including all amputation etiologies. Not applicable. The Orthotics and Prosthetics User's Survey, Trinity Amputation and Prosthesis Experiences Scale, and Prosthetic Limb Users Survey of Mobility-Short Form were used to assess satisfaction with prosthetic services, prosthesis fit, prosthesis satisfaction, prosthesis use, and self-reported mobility. Women had poorer self-reported mobility than men (d = -0.26, 95% confidence interval -0.49 to -0.02, p < .05); this difference was small. There were no statistically significant gender differences in satisfaction with prosthetic services, prosthesis fit, prosthesis satisfaction, daily hours of prosthesis use, or by amputation type. Contrary to the hypothesis, prosthesis-related outcomes were similar between men and women with LEAs. Minimal differences may in part be due to receiving care from the VHA's integrated Amputation System of Care.

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.

Combat-related acetabular fractures: Outcomes of open versus closed injuries

IntroductionSince the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. MethodsWe performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. ResultsThe mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DiscussionOpen acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Dismounted complex blast injuries

Category: Trauma Introduction/Purpose: The United States Medical Corps has continued to evaluate and define the injury patterns of our service members in an effort to prevent injury and improve combat casualty care. The pattern of injury can be predicted by the mechanism of injury. One of the more recently described and studied mechanisms has been coined the ‘dismounted complex blast injury. This injury pattern involves traumatic amputation of at least one leg with a second injury involving another extremity in addition to an injury to either the pelvis, the abdomen, or the urogenital region. The purpose of this study was to better define and describe the injuries occurring to the non amputated extremity. Methods: This is a retrospectively review of data from the US and UK Joint Theater Trauma Registries (JTTR) of consecutive patients admitted to the UK Role 3 hospital at Camp Bastion, Afghanistan, from January 1, 2009, to February 29, 2012. Data was obtained from the US JTTR (Joint Theatre Trauma Registry). Each patient was assigned an Injury Severity Score (ISS) and an Abbreviated Injury Scale (AIS) score. Only those patients with an AIS of 3 or greater (a serious injury) were included. All xrays and CT scans were evaluated by two board certified orthopaedic surgeons and one board certified musculoskeletal radiologist. Fisher’s exact test was used to compare categorical data and binomial logistic regression was be used to compare proportions of types of injuries by traumatic amputation level observed. Results: There were 295 patients with lower extremity injuries identified. 201 had traumatic lower extremity amputations, 140 with bilateral lower extremity amputations, 61 with single leg amputations. The mean age was 23.38 +/-3.77 years. All were male. Below the knee amputation was the most frequent amputation type observed, representing 55.7% of the amputations (29/52), the next most frequent was the through knee amputation representing 25%. The least frequent was the through ankle amputation. The presence of a symes level amputation was associated with an 8.1% increase in the odds of the presence of a skeletal foot injury in the rear lower extremity. There was also an association found between AKA level amputation and skeletal injury in the contralateral upper extremity . Conclusion: This is among the first studies to correlate level of injury and associated musculoskeletal injury for the Afghanistan theater of operations. The results of this data set demonstrate that proximal lower extremity amputation levels are significantly associated with distal upper extremity skeletal injury. In addition, the Symes level of amputation is significantly associated with contralateral foot fractures. Amputation levels proximal to the ankle often present with associated Genitourinary injuries. Unique to this study is the demonstration of a significant association of upper extremity injury with a more proximal lower extremity amputation level .

Severe amputation injuries after Israeli military operations in Gaza: a retrospective, clinical follow-up study

BackgroundFour major attacks on Gaza since 2006 have killed around 4000 and injured more than 17 000 Palestinians. An unknown number of the wounded suffered extremity injuries with amputations. The long-term functional, somatic, and psychosocial consequences of traumatic amputations in Gaza have not been reported. We describe the demography, anatomical distribution, and causative factors of a sample of traumatic amputations in Gaza in this ongoing study. MethodsWe studied 147 randomly selected Palestinian surviving casualties in Gaza who had suffered traumatic amputations following Israeli military operations during the period 2006–2014. All participants were aged over of 16 years when included. One additional patient was invited to participate but declined. We organised the study at a key rehabilitation centre, the Artificial Limb and Polio Centre (ALPC) in Gaza City. Data were collected from June to October, 2014. We recorded date and mechanism of injury as well as results of in-depth clinical examinations in each survivor. Records and self-administrated questionnaires in Arabic were translated into English and data analysed with SPSS common version 21·0. The Palestinian Ministry of Health, the board and directors at Al-Shifa Hospital, and ALPC approved the protocol. We obtained written informed consent from each patient. Findings11 women (7·5 %) and 136 men (92·5 %) with traumatic amputations participated. The mean age was 30·6 years (range 16–64). 85 patients (57·8 %) had unilateral lower extremity amputations, 31 (21·1%) bilateral lower extremity amputations, and 31 (21·1%) other amputations. Attacks from drones were reported by the survivors as the reason for explosions that caused amputation injury in 85 of the cases (57·8%). 52 (61.2 %) of such drone attacks had occured during declared military operations. 24 (31·6 %) had occurred during periods of ceasefire. Nine (11·8%) participants reported only the month and year of attack, not the exact day. InterpretationMilitary operations in Gaza have caused a large, unknown number of traumatic amputations. In our study, most participants had unilateral or bilateral lower limb amputations and the majority of injuries followed attacks with drone-carried weapons. Several participants were wounded during ceasefire periods. The need for rehabilitation is difficult to meet because of limited local resources. FundingNone.

Combat-related pelvic ring fractures in survivors

Background: Pelvic fractures have been associated with rates of mortality up to 20%, with open injuries approaching rates up to 50%. This study compares differences in patients with open and closed pelvic ring injuries sustained during combat. Methods: Retrospective review of 114 patients who sustained a pelvic ring fracture and were alive upon presentation to the United States. We collected demographics, associated injuries, transfusion requirements, and outcomes to include residual bowel or bladder dysfunction and ambulatory status. Results: There were 114 patients, 98% male, with 75 closed and 39 open injuries. Average age was 26.6 yr. An average of 8.1 and 28.1 units of red blood cells were transfused in closed and open injuries, respectively (P&lt;0.0001). Bilateral lower extremity amputations occurred in 11% of closed and 59% of open injuries (P&lt;0.0001). Unstable fracture patterns occurred in 39% of closed fractures compared to 51% in open fractures (P=0.233). The time to weight bearing was 93 and 126 days for closed and open injuries (P=0.039). At latest follow-up, abnormal bladder and bowel function both occurred in 10% of closed and, respectively, 39% and 33% of open injuries (P=0.006). The rate of ambulation was 94% for closed injuries and 89% for open injuries (P=0.439). Conclusions: In the largest report of combat-related pelvic fractures in surviving patients, the incidence of open fractures was 34%. Although there are significant differences in associated injuries, transfusion requirements and time to weight bearing, patients with open pelvic fractures are able to return to a similar level of ambulatory function as those with closed fractures.

Effect of Free Swing Gait Training on Back Pain in a Patient with Bilateral Lower Extremity Amputations: A Case Report

Introduction: Back pain is a common occurrence in persons with a lower extremity amputation, and can cause a chronic disability. Early physical therapy interventions of gait training with prosthesis could prevent amputees from becoming disabled by chronic back pain. Free swing gait training is sometimes utilized in physical therapy with transfemoral amputees learning to use prosthesis. However, there is a lack of evidence for the benefits of free swing gait training on decreasing back pain. The purpose of this study is to describe the effect of free swing gait training on low back pain in an amputee. Case Description: The patient was a 57 year old Caucasian male with a history of a left transtibial amputation and a recent right transfemoral amputation. He was referred to physical therapy to learn how to utilize his new transfemoral prosthetic and find functional independence as a bilateral amputee. One of his chief complaints was debilitating low back pain that had increased since his latest amputation. Intervention: Physical therapy intervention included free swing gait training intended to normalize the patient’s gait pattern while ambulating with a left transfemoral and a right transtibial prostheses. It was hypothesized that the normalization of the patient’s gait pattern would decrease his complaint of back pain. Results: After 8 weeks of physical therapy, including 3 weeks of free swing gait training, the patient demonstrated decreased low back pain, increased strength, and improved gait quality and distance. Discussion: The results of this case report demonstrate that the use of free swing gait training can be beneficial to decrease back pain in a bilateral amputee.

Poster 80 Bilateral Lower Extremity Amputation after Toxic Shock Syndrome Presents with Locked Knee: ACase Report.

Poster 80 Bilateral Lower Extremity Amputation after Toxic Shock Syndrome Presents with Locked Knee: ACase Report.

From Impairment to Empowerment: A Longitudinal Medical School Curriculum on Disabilities.

All physicians will care for individuals with disabilities; however, education about disabilities is lacking at most medical schools. Most of the schools that do include such education exclusively teach the medical model, in which disability is viewed as an impairment to be overcome. Disability advocates contest this approach because it overlooks the social and societal contexts of disability. A collaboration between individuals with disabilities, educators, and physicians to design a medical school curriculum on disabilities could overcome these differences. A curriculum on disabilities for first- and second-year medical students was developed during the 2013-2014 academic year and involved a major collaboration between a medical student, medical educators, disability advocates, and academic disability specialists. The guiding principle of the project was the Disability Rights Movement motto, "Nothing about us without us." Two small-group sessions were created, one for each medical school class. They included discussions about different models of disability, video and in-person narratives of individuals with disabilities, and explorations of concepts central to social perceptions of disability, such as power relationships, naming and stigmatization, and disability as identity. According to evaluations conducted after each session, students reported positive feedback about both sessions. Through this curriculum, first- and second-year medical students learned about the obstacles faced by individuals with disabilities and became better equipped to understand and address the concerns, hopes, and societal challenges of their future patients. This inclusive approach may be used to design additional curricula about disabilities for the clinical and postgraduate years.

An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation

Background and purpose — Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods — 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results — The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25–0.91) and by 46% (HR =0.54, 95% CI: 0.35–0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation — With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.

Bilateral Hemiarthroplasty in a Patient with Below-Knee and Above-Knee Amputations: A Case Report.

This case involved a sixty-two-year-old male patient with bilateral femoral neck fractures that occurred six months apart in the setting of bilateral lower-extremity amputation. Hemiarthroplasty was performed at each presentation, with the use of a standard femoral stem on the right side and a short stem on the left. At the time of follow-up, the patient had returned to his preoperative ambulatory status. This case report illustrates successful bilateral hemiarthroplasty in a patient who had previously undergone bilateral lower-extremity amputation, with use of an implant with a short stem for the limb with above-knee amputation.

Hip Arthroscopy in Patients With Lower-Extremity Amputations: Patient Positioning and Traction Technique

Improved battlefield survival rates have resulted in a significant number of young active patients with lower-extremity amputations. Because of the increased demands placed on their hips, patients with amputations may be more susceptible to the sequelae of hip pathology and femoroacetabular impingement. Arthroscopic management of hip pathology may be successfully performed in patients with ipsilateral, contralateral, or bilateral lower-extremity amputations. We describe our experience in this unique patient population. A technique for secure patient positioning that provides sufficient countertraction in the case of contralateral amputation is described, as is the use of skeletal traction with a temporary external fixator for joint distraction in patients with ipsilateral amputations. Considerations specific to patients with high transfemoral amputations are discussed as well.

Quality of Life of Caregiver Spouses of Veterans With Bilateral Lower Extremity Amputations

Background:Providing care for patients with chronic disability affects caregivers’ social lives and relationships and can lead to poor health and lower quality of life.Objectives:In this study, our goal was to assess the quality of life in spouses of war veterans with bilateral lower limb amputations to find factors affecting caregivers’ quality of life.Patients and Methods:In a cross-sectional study, spouses of 244 veterans with war-related bilateral lower limb amputations for at least one year were invited to participate in this study; 189 couples accepted to participate. Information about age, gender, education level, duration of time since amputation, duration of care provided by the spouses and SF-36 questionnaire for both veterans and their spouses were collected.Results:The average age of spouses was 47 years and duration of care provided by spouses was 25 years. We found lower scores for general health domains in amputees’ spouses compared to the general population. Factors correlated with both Physical Component Summary (PCS) and Mental Component Summary (MCS) included the duration of care, duration of marriage, spouses’ education level and the veterans’ PCS and MCS scores. Veterans’ age, spouses’ age and the number of children only correlated with PCS. Veterans’ education level only correlated with MCS. In multivariable analysis, only spouses’ education level correlated with MCS and the veterans’ PCS only correlated with that of spouses.Conclusions:The quality of life of amputees and their spouses were closely correlated; therefore, any improvement in one is likely to improve the other. In addition, lower education level should be considered as a risk factor for poorer quality of life in amputees’ spouses.

The epidemiology of Critical Care Air Transport Team operations in contemporary warfare.

Critical Care Air Transport Teams (CCATTs) have evolved as a vital component of the U.S. Air Force's aeromedical evacuation system. Previous epidemiological research in this area is limited. The objective of this commentary is to highlight the importance of obtaining robust epidemiological data regarding patients transported by CCATTs. A limited epidemiological analysis was performed to describe CCATT patients transported during Operation Enduring Freedom and the waning months of Operation Iraqi Freedom. CCATT transports for the calendar year 2011 were examined as recorded in the U.S. Transportation Command Regulating and Command and Control (C2) Evacuation System database. As many as 290 CCATT primary patient transport records were reviewed. Of these, 58.6% of patients had multiple injuries, 15.9% of patients had traumatic brain injury, 7% had acute coronary syndromes, and 24.8% of all transports were for nonbattle-related injuries. The most common International Classification of Disease, 9th Edition, Clinical Modification coded injury was bilateral lower extremity amputation (40%). Explosive blasts were the top mechanism of injury for patients requiring CCAT. The distribution of injuries and illnesses requiring CCAT appear to have changed compared to previous conventional conflicts. Understanding the epidemiology of casualties evacuated by CCATT during modern warfare is a prerequisite for the development of effective predeployment training to ensure optimal outcomes for critically ill and injured warriors.

The Lesser Known Side-Effect of Warfarin: Warfarin-Induced Venous Limb Gangrene

An 84-year-old woman receiving warfarin for antiphospholipid antibody syndrome and who had a history of bilateral lower extremity amputations presented to the emergency department with severe bilateral necrotic changes over her legs and arms (Figures 1 and 2). She had begun warfarin therapy 3 months earlier for newly diagnosed antiphospholipid antibody syndrome. Her International normalized ratio (INR), which had been 6.04 six days prior to admission, was 3.63 on admission. Skin biopsy specimens revealed necrosis secondary to vascular thrombosis. A warfarin-induced etiology was suspected, and the drug was discontinued.Figure 2Additional ischemic changes on patient's right elbow. There were no ischemic changes noted on patient's breasts or abdomen, as would normally present in warfarin-induced skin necrosis.View Large Image Figure ViewerDownload (PPT) Unlike warfarin-induced skin necrosis, which classically presents centrally over adipose tissue approximately 3 days after starting warfarin in the setting of congenital protein C deficiency,1Warkentin T.E. Elavathil L.J. Hayward C.P. Johnston M.A. Russett J.I. Kelton J.G. The pathogenesis of venous limb gangrene associated with heparin-induced thrombocytopenia.Ann Intern Med. 1997; 127: 804-812Crossref PubMed Scopus (427) Google Scholar warfarin-induced venous limb gangrene is a less well-described side-effect of warfarin and presents in the distal extremities2Haimovici H. Bergan J.J. Coumadin-induced skin necrosis versus venous gangrene of the extremities.J Vasc Surg. 1987; 5: 655-656Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar and paradoxically with a supratherapeutic INR.3Warkentin T.E. Venous limb gangrene during warfarin treatment of cancer-associated deep venous thrombosis.Ann Intern Med. 2001; 135: 589-593Crossref PubMed Google Scholar It can occur in patients with hypercoagulable states, such as heparin immune thrombocytopenia1Warkentin T.E. Elavathil L.J. Hayward C.P. Johnston M.A. Russett J.I. Kelton J.G. The pathogenesis of venous limb gangrene associated with heparin-induced thrombocytopenia.Ann Intern Med. 1997; 127: 804-812Crossref PubMed Scopus (427) Google Scholar or antiphospholipid antibody syndrome.4Grim Hostetler S. Sopkovich J. Dean S. Zirwas M. Warfarin-induced venous limb gangrene.J Clin Aesthet Dermatol. 2012; 5: 38-42PubMed Google Scholar The increase in INR has been shown to reflect a concurrent depletion of protein C,3Warkentin T.E. Venous limb gangrene during warfarin treatment of cancer-associated deep venous thrombosis.Ann Intern Med. 2001; 135: 589-593Crossref PubMed Google Scholar which is normally balanced by warfarin's ability to prevent thrombin formation by depleting other procoagulant factors. However, in patients with warfarin-induced venous limb gangrene, warfarin does not adequately prevent thrombin-antithrombin complex formation.3Warkentin T.E. Venous limb gangrene during warfarin treatment of cancer-associated deep venous thrombosis.Ann Intern Med. 2001; 135: 589-593Crossref PubMed Google Scholar This patient's hypercoagulability from her antiphospholipid antibody syndrome, abrupt depletion of protein C as reflected by her elevated INR, and failure of warfarin to prevent thrombin-antithrombin formation, likely led to formation of multiple microthrombi in the distal extremities. It is unclear why this phenomenon occurs in some patients but not others.

Bilateral lower-extremity amputation wounds are associated with distinct local and systemic cytokine response

Approximately 25% of U.S. military members sustaining extremity amputations in recent military conflicts have bilateral lower-extremity amputations (BLA). We investigated among combat-related extremity wounds whether BLA exhibit different bacterial burden, inflammatory response, and local complications. A total of 75 patients with combat-related extremity wounds (19 BLA) were evaluated for age, tobacco use, body mass index, Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and delayed primary closure time. Blood, wound exudates, and muscle biopsies were obtained and analyzed for cytokine and quantitative bacteriology, excluding patients using nonsteroidal anti-inflammatory medications and corticosteroids, due to potential effects on their inflammatory profile. BLA was not associated with differences in age, tobacco use, body mass index, and delayed primary closure time, but these patients had increased Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and rates of critical colonization. Proinflammatory cytokines including tumor necrosis factor-α (exudate), interleukin (IL)-1 (exudate) and IL-6 (serum) were increased in BLA patients. They also had serum and exudate increased IL-8 and decreased IL-13 and granulocyte-macrophage colony-stimulating factor. Both wound dehiscence (WD) and heterotopic ossification (HO) were more common in BLA patients. BLA patients were more likely to exhibit critical bacterial colonization, a distinct inflammatory response, and develop WD and HO. Modulating this response represents an attractive target in an effort to prevent complications such as WD and HO.

Bilateral Lower Extremity Amputation Wounds are associated With Distinct Local and Systemic Cytokine Response

Bilateral Lower Extremity Amputation Wounds are associated With Distinct Local and Systemic Cytokine Response

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Introduction: US Air Force Critical Care Air Transport Teams (CCATTs) are a unique component of the military medical evacuation system. An understanding of the epidemiology of contemporary warfare is essential for pre-deployment training and optimal outcomes for critically injured warriors. We performed an epidemiological analysis of military patients transported by CCATTs during a discrete period of time. Hypothesis: The epidemiology of contemporary wartime casualties requiring critical care air transport contrasts with the characteristcs of patients seen in previous conventional conflicts. Methods: The primary source of data was the US Transportation Command (TRANSCOM) Regulating and Command and Control (C2) Evacuation System (TRAC2ES). Secondary sources were reviewed and abstracted to compare injury patterns. Descriptive statistics were used to describe the cohort. Results: Final analysis of 2011 TRAC2ES data included 396 CCATT patient transports, representing 290 patients after duplicate transports were removed. The median age was 25 years (IQR, 22 to 33). The majority of transports were male (97.6 %). The most common ICD-9-CM diagnosis was bilateral lower extremity amputation (40%). Nineteen cases of acute coronary syndromes were reported (6.6%). Nine patients with stroke were transported (3.1%). Forty-six cases of traumatic brain injury were reported (15.9%), although reporting for this injury was inconsistent. Only two patients (0.7%) had a primary diagnosis of burns. 125 subjects were injured as the result of an improvised explosive device (IED) explosion (43%), of which 87 (66%) occurred while patients were dismounted from vehicles. In 2011, more non-battle related injuries and illnesses were reported, as compared to historic data from 2001-06. Conclusions: The epidemiology of patients transported by CCATT has changed with contemporary warfare. Amputations and IED injuries were more prevalent in 2011. A higher prevalence of non-battle related injuries and explosion-related injuries may be expected in similar future conflicts. Studies of CCATT epidemiology will help focus training programs and direct evidence-based practices aimed at improving both survival and morbidity for the most severely injured casualties.