Combat-related Amputations Research Articles

Fluid Collections in Amputations Are Not Indicative or Predictive of Infection

In the acute postoperative period, fluid collections are common in lower extremity amputations. Whether these fluid collections increase the risk of infection is unknown. The purposes of this study were to determine (1) the percentage of patients who develop postoperative fluid collections in posttraumatic amputations and the natural course of the collection; (2) whether patients who develop these collections are at increased risk for infection; and to ask (3) are there objective clinical or radiologic signs that are associated with likelihood of infection when a fluid collection is present? We performed a review of all 300 patients injured in combat operations who sustained at least one major lower extremity amputation (at or proximal to the tibiotalar joint) and were treated definitively at our institution between March 2005 and April 2009. We segregated the groups based on whether cross-sectional imaging was performed less than 3 months (early group) after closure, greater than 3 months (late group) after closure, or not at all (control group, baseline frequency of infection). Our primary study cohort where those patients with a fluid collection in the first three months. The clinical course was reviewed and the primary outcome was a return to the operating room for irrigation and débridement with positive cultures. For those patients with cross-sectional imaging, we also collected objective clinical parameters within 24 hours of the scan (white blood cell count, maximum temperature, presence of bacteremia, tachycardia, oxygen desaturation), extremity examination (presence of erythema, warmth, and/or drainage), and characteristics of the fluid collections seen (size of the fluid collection, enhancement, complexity (simple versus loculated), surrounding edema, skin changes, tract formation, presence of air, and changes within the bone itself). The presence of a fluid collection on imaging was analyzed to determine whether it was associated with infection. We further analyzed clinical parameters, objective physical examination findings at the extremity, and characteristics of the fluid collection to determine if there were other parameters associated with infection. Over half (55%) of the limbs demonstrated fluid collection in the early postoperative period and the prevalence decreased in the late group (11%; p = 0.001). There was no association between the presence of a fluid collection and infection. However, there was an association between objective clinical signs at the extremity (erythema and/or drainage) and infection (p < 0.001) in our primary study cohort. Fluid collections are common in combat-related amputations in the immediate postoperative period and become smaller and less frequent over time. In the absence of extremity erythema and wound drainage, imaging of a residual limb to evaluate for the presence of a fluid collection appears to be of little clinical use.

Initial injury severity and social factors determine ability to deploy after combat-related amputation

ObjectiveWhile many recent publications have examined the ability of amputees to return to active duty, it remains largely unknown why few amputees deploy after amputation and many amputees do not. The purpose of this study is to examine what predictor(s) exist for whether or not an amputee will deploy after sustaining a combat-related amputation. MethodsAll U.S. Service members who sustained major extremity amputations from September 2001 through July 2011 were analysed. Amputation level(s), mechanism of injury, time interval to amputation, age, rank, Physical Evaluation Board (PEB) disposition and ability to deploy after amputation were determined. ResultsDeployment information after amputation was obtained for 953 amputees. There were 47 (5%) amputees who deployed. There were no significant differences amongst service branches for the deployment of amputees (p>0.2). Amputees who underwent their amputation on the same day of their injury were significantly less likely to deploy after amputation than those who had their amputation on the day of injury (p=.01). Deployed amputees had significantly lower Injury Severity Scores than amputees who did not deploy (15.98 vs 20.87, p<0.01) and officers were significantly (p<.01) more likely to deploy and the average age of amputees who deployed was significantly higher than those who did not (27.5 vs 25.1, p<.01). Lastly, those amputees who sustained a transtibial amputation were significantly more likely to deploy than all other amputation levels (p<.01). Nine out of 19 (47%) Special Forces amputees were able to deploy. DiscussionThe vast majority of amputees do not able to deploy after undergoing amputation. The main predictors of deploying after sustaining a combat-related amputation appear to be: sustaining a transtibial amputation, being of senior rank or age and being a member of the Special Forces. Many of these factors appear to be non-treatment related and highlight the importance that individual and social factors play in the recovery of severe injuries.

Department of Veterans Affairs Amputation System of Care: 5 years of accomplishments and outcomes

INTRODUCTION For more than 150 years, the Department of Veterans Affairs (VA) has held the care provided to Veterans with limb amputations as a high priority. To many Americans, the Veteran with an amputation epitomizes the sacrifices made on our nation's behalf. The VA is dedicated to providing optimal care for these individuals in order to restore function and improve quality of life. This commitment has been reaffirmed over time through the passage of key legislation such as the Veterans Medical Programs Amendments of 1992 and the Veterans Health Care Eligibility Act of 1996 [1]. The life-changing effect of amputation on Veterans has also been acknowledged through the VA's long-standing commitment to amputation prevention programs [2]. In 2008, after years of planning and preparation, VA approved and began implementing the Amputation System of Care (ASoC) in order to enhance the quality and consistency of care provided to the Veteran with limb loss. In 2010, Dr. Sigford described this paradigm shift in VA amputation care and the implementation plan for the ASoC [3]. The driving force behind this program was the need to provide lifelong care for servicemembers with combat-related amputations from the military conflicts in Iraq and Afghanistan and for Veterans with amputations from diseases such as diabetes and peripheral vascular disease. The system is designed to provide the latest practices in medical care, prosthetic technology, and rehabilitation management in order to assist individuals with amputations in reaching their highest level of functional independence. In this article, we highlight the accomplishments and outcomes of the ASoC in the domains of program scope, organizational structure, clinical services, and additional performance metrics 5 yr after initial program implementation. PROGRAM SCOPE, ORGANIZATIONAL STRUCTURE, AND EVOLUTION The ASoC is an integrated, national healthcare delivery system. It provides patient-centered, gender-sensitive, age-appropriate, life-long, holistic care and care coordination for Veterans with limb amputations. Through the provision of quality rehabilitation and prosthetic care, the ASoC minimizes disability and enables the highest level of social, vocational, and recreational reintegration. The ASoC provides specialized expertise in amputation care through incorporating the latest practices in medical rehabilitation, therapy services, and prosthetic technology. This specialized expertise is provided in an interdisciplinary format lead by physician medical directors. Amputation rehabilitation coordinators assure coordination of services and provider communication both across the continuum of care and across facilities. These factors, along with specialized education and training, have enhanced the environment of care and created greater consistency in the delivery of rehabilitation services for Veterans with amputations. Achieving these goals provides the VA the opportunity to fulfill its vision to be a world leader in providing lifelong amputation care. The ASoC operates in close collaboration with the Department of Defense (DOD) amputation care programs. While the VA system of care has many features similar to the DOD amputation care programs, it also differs in several ways. Both the VA and DOD amputation care programs use a team approach to care and focus on individual treatment goals, can provide any prosthetic device that is commercially available, and are involved in collaborative research involving new prosthetic technology and treatment advances. The two systems differ in that the DOD specialized amputation care is focused primarily at three Advanced Rehabilitation Centers, whereas the VA system is more diffuse, using a tiered approach with services spread across 133 medical facilities. The DOD amputation care programs are focused primarily on providing initial prosthetic fitting and acute rehabilitation, whereas the VA system places a greater emphasis on lifelong care and care management. …

Amputation characteristics vary by branch of service.

This study examines the amputees from the Army and Marine Corps, the two military branches that have sustained the majority of combat-related amputations. All U.S. service members who sustained major extremity amputations from October 2001 through July 2011 were analyzed. Amputation levels, demographics, and mounted or dismounted status at injury were examined. There were 835 Army and 344 Marine amputees; 52.9% of all Marine amputees occurred during 2010 and 2011. Over 50% of Marine and 44% of Army amputees sustaining an amputation during 2010 and 2011 sustained multiple amputations. Dismounted service members had significantly (p < .0001) higher Injury Severity Scores and were significantly more likely to sustain double (p = .0082) and triple (p < .0001) amputations than mounted personnel. Marine amputees were significantly (p < .0001) more likely to be dismounted than Army amputees. The number of multiple amputees increased substantially in 2010 and 2011. Marine amputees, particularly dismounted, are at an increased risk of sustaining multiple amputations.

Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul

Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed. This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation. Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4months (range 1-28months). In the DPC group, secondary closure was performed with a mean time of 18.7days (range 4-45days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p=0.1). Forty-three patients were not prosthetic fitted at the last follow-up. This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.

Incidence and morbidity of concomitant spine fractures in combat-related amputees

Background contextHigh-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown. PurposeThis study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF. Study design/settingRetrospective case control. Patient sampleTwo hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis. Outcome measuresPhysiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up. MethodsData from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes. ResultsA total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005). ConclusionsThe incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.

Return-to-duty rates among US military combat-related amputees in the global war on terror

The purpose of this study was to identify the differences seen between military occupation services (MOS) in terms of amputation patterns, subsequent disabling conditions, and their ability to return to duty. A retrospective study of major extremity amputations sustained by US service members between October 1, 2001, and July 30, 2011, was performed. Data obtained from the amputation database, Joint Trauma Theater Database, and the Physical Evaluation Board Liaison Office included demographics, amputation location(s), Injury Severity Scores (ISSs), disabling conditions, disability ratings, and disposition status. There were 1,221 major extremity amputees identified during the specified time frame, of which 899 had data regarding disabling conditions, ratings, and disposition. All service branches were represented. Personnel from the US Army (USA) Infantry were significantly (p < 0.0001) more likely to sustain an amputation than other MOS. The USA Infantry, the US Marine Corps Infantry and the USA Armor represented the top three specialties and accounted for more than 57% of all amputees. Approximately 89% of all service members did not return to duty, and the mean combined for all amputees was 76. USA Special Forces (USA SF) operators were significantly more likely to return to duty (p = 0.0022) and be found fit for duty (p = 0.0015) than all other MOS despite having a mean ISS (20) that was no different from those of other service members. No USA SF personnel were found to have posttraumatic stress disorder as a disabling condition. All amputees, regardless of MOS, are not likely to return to active duty and especially unlikely to be found fit for duty, except for members of the USA SF. The reason(s) for the increased return to duty for USA SF personnel remains unknown but a lack of posttraumatic stress disorder may be a contributing factor.

Injury Severity Score Underpredicts Injury Severity and Resource Utilization in Combat-Related Amputations

Assess effectiveness of Injury Severity Score (ISS) in predicting injury severity in combat-related amputations. Retrospective evaluation of prospectively collected data. Military medical center. One hundred and nine patients with major extremity amputations sustained in overseas combat. Standard combat casualty care. Difference in injury severity as measured by ISS, numbers of extremity(s) amputated, number of associated injuries, blood products used, intensive care unit length of stay, hospital length of stay in those with an upper extremity amputation (UEA) compared with those with an isolated lower extremity amputation. Thirteen patients (11.9%) sustained at least one UEA. Patients with an UEA had a greater number of amputations per casualty compared with patients with a lower extremity alone (2.5 vs. 1.5; P < 0.001). The mean hospital length of stay (P = 0.02) and intensive care unit length of stay (P = 0.02) were significantly greater in those with an UEA. Mean blood product utilization was also significantly greater in those with an upper extremity amputation (P < 0.05). There was no difference in ISS between the two groups (P > 0.05). The presence of an UEA is associated with increased injury severity as evident by increased intensive care unit requirements, blood product utilization, and hospital length of stay. ISS underestimates the severity of injury and therefore resource utilization in patients with multiple combat-related amputations. Recognition of this limitation in addition to the development of a military-specific ISS is required for more effective resource utilization to continue to improve combat casualty care. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Functional Outcomes Following Bridge Synostosis with Non-Bone-Bridging Transtibial Combat-Related Amputations

The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation.

Effect of traumatic brain injury among U.S. servicemembers with amputation

Servicemembers with combat-related limb loss often require substantial rehabilitative care. The prevalence of traumatic brain injury (TBI), which may impair cognitive and functional abilities, among servicemembers has increased. The primary objectives of this study were to determine the frequency of TBI among servicemembers with traumatic amputation and examine whether TBI status was associated with discharge to civilian status and medical and rehabilitative service use postamputation. U.S. servicemembers who had a combat-related amputation while deployed in Iraq or Afghanistan between 2001 and 2006 were followed for 2 yr postamputation. Data collected includes injury mechanism; postinjury complications; Injury Severity Score (ISS); and follow-up data, including military service discharge status and number of medical, physical, occupational therapy, and prosthetic-related visits. Of the 546 servicemembers with combat-related amputations, 127 (23.3%) had a TBI diagnosis. After adjusting for ISS and amputation location, those with TBI had a significantly greater mean number of medical and rehabilitative outpatient and inpatient visits combined (p < 0.01). Those with TBI were also at greater odds of developing certain postinjury complications. We recommend that providers treating servicemembers with limb loss should assess for TBI because those who sustained TBI required increased medical and rehabilitative care.

Implementing outcome measures—The military physical therapist’s perspective

Outcome measures are a necessary part of rehabilitation. Various methods and measures have been used to assess patient progress and as criteria for discharge from inpatient care, routine outpatient care, and long-term rehabilitation in a variety of patient populations for many years. In the sports medicine setting, outcome measures become especially important in determining when injured athletes are able to return to the playing field. In a military setting, similar to sports medicine, the use of outcome measures is necessary to help determine when the patient is able to return to duty or deploy. In the case of servicemembers with traumatic limb loss, the ultimate goal for many is to return to Active Duty as a tactical athlete and member of today's Army, Navy, Air Force, Marine Corps, or Coast Guard. Determining the functional level and ability to meet the demands they may face is a challenge for the military healthcare system (MHCS) and more specifically for the providers rehabilitating servicemembers with major limb loss. The Armed Forces Amputee Patient Care Program is composed of three distinct centers: the Military Advanced Training Center (MATC) located at Walter Reed National Medical Center, the Center for the Intrepid (CFI) at Brooke Army Medical Center, and the Comprehensive Combat and Complex Casualty Care (C5) program center at the Naval Medical Center San Diego. Physical therapists caring for servicemembers with amputation at all three centers are particularly invested in making sure that the outcome measures we use systematically are appropriate. One of the challenges we faced early on was that most of the outcome measures used for people with amputation did not adequately measure the higher level of that servicemembers with amputation need to return to duty. The majority of combat-related amputations occur in relatively healthy males under the age of 35, a very different population from the civilian population with amputation, in which the vast majority are older and have comorbidities such as diabetes mellitus, peripheral vascular disease, and cardiovascular conditions. The outcome measures used in the civilian amputee population suffer from a ceiling effect when used to assess the typical young, physically active servicemember with amputation. A new paradigm and approach to testing high-level in people with amputation was needed for use in the military environment. In practice, there are already many sophisticated and instrumented outcome measures in use in the Armed Forces Amputee Patient Care Program. These measures include those obtained in the motion analysis/gait laboratories and the Computer Assisted Rehabilitation Environment virtual reality (VR) systems. Motion analysis is a proven technology, and the use of VR with patients with amputation appears to be useful in both patient treatment and research activities. The benefit to the patients in both of these systems is the real-time feedback they receive relative to weight bearing, lateral weight shifting, agility, pelvic obliquity, and shoulder symmetry. The learning that occurs with regard to agility, base of support, center of gravity, and proprioception is hidden underneath the facade of a video game. Biomechanical testing provides very detailed information on kinetics and kinematics of motion, but requires sophisticated equipment and expertise. These systems do not provide a relatively easy-to-administer test that culminates in a usable summary of abilities similar to the Amputee Mobility Predictor. Self-report measures can be used and are easier to administer than either biomechanical testing or performance-based tests. However, self-report measures, while they can be useful, are generally not strongly associated with actual performance-based measures. Many researchers feel that self-report measures alone do not adequately assess the broad concept of function and that performance-based measures are needed to capture the whole picture. …

High Prevalence of Stump Dermatoses 38 Years or More After Amputation

To highlight the prevalence and impact of skin disease at the stump site in patients who have undergone amputation. A cross-sectional health questionnaire of Vietnam War veterans with stump dermatoses at least 38 years after major limb amputation. A research registry of veterans with combat-related amputations who agreed to participate. Recruitment began January 1, 2006, and ended December 31, 2009, with a registry of 416 veterans. Results of a self-reported 35-item questionnaire. Participants were later contacted by telephone or asked to complete a Web survey. Of the 247 veterans, 119 (48.2%) reported at least 1 skin problem within the preceding year. The most common were skin breakdown (25.2%), rash (21.8%), and abrasion (21.0%). In addition, 25.2% experienced skin problems more than 50% of the time, and 37.1% had to alter or replace their prosthesis. Stump dermatoses limited or prevented prosthesis use in the preceding year for 55.6% and caused pain or discomfort at the stump site in 61.5%. More than 38 years after major limb amputation, skin complications at the stump site continue to cause significant morbidities and contribute to prosthesis abandonment. The high prevalence of stump dermatoses stresses the importance of disease prevention, early management, and advanced treatment of skin disease.

Reoperations Are Common with Combat-Related Upper-Extremity Amputations

Reoperations Are Common with Combat-Related Upper-Extremity Amputations

Incidence and Morbidity of Concomitant Spine Fractures in Combat-Related Amputees

Incidence and Morbidity of Concomitant Spine Fractures in Combat-Related Amputees

Development of Scoliosis Following Complex Combat-Related Lower-Extremity Amputations: Two Case Reports.

Combat casualties that have been subjected to high-energy blast trauma have experienced devastating lower-extremity injuries and soft-tissue damage, resulting in complex lower-extremity amputations. There have been limited reports of scoliosis following upper and lower-extremity amputations1-4. We report the development of scoliosis in two combat casualties following hemipelvectomy and hip disarticulation, respectively, for injuries sustained during the current conflicts in Iraq and Afghanistan. Both patients were informed that data concerning their cases would be submitted for publication, and they both provided consent. Case 1. A twenty-one-year-old active duty Army soldier had had a right hemipelvectomy and left hip disarticulation following the explosion of a rocket-propelled grenade (RPG). Approximately two years after injury, the patient had sitting imbalance. A sitting spinal radiograph demonstrated a right lumbar scoliosis from L1 to L5 of 37°, with a 1+ Nash-Moe rotation (Fig. 1). He had limited prosthetic use and no back pain; he had some mobility with use of a manual wheelchair. He was able to perform independent transfers to and from the wheelchair as well as most activities of daily living (ADL). Fig. 1 Anteroposterior radiograph of the spine (left) and anteroposterior radiograph of the pelvis (right) of the patient in Case 1 following a right hemipelvectomy and left hip disarticulation, demonstrating a right lumbar scoliosis from L1 to L5 of 37°, with a 1+ Nash-Moe rotation. Case 2. Following injury from an improvised explosive device (IED), a twenty-year-old active duty Marine had had bilateral transfemoral amputations, with the right lower-limb amputation considered a functional hip disarticulation. Approximately one year after injury, the patient reported moderate back pain. Radiographs demonstrated a right lumbar scoliosis from T12 to L5 …

Functional Gait Analysis Before and After Delayed Military Trauma-Related Amputation: A Report of Three Cases.

The current conflicts in Iraq and Afghanistan have produced a large number of service members with severe combat-related injuries. Eighty-two percent of service members with combat-related injuries have sustained extremity trauma, which accounts for 54% of wounds overall1. Of all the lower-extremity amputations performed at military treatment facilities, approximately 13% (125 of 975) were the result of delayed or “elective” procedures2. Recent studies have shown that the outcomes of extensive salvage procedures for severely injured limbs are not necessarily definitive in a nonmilitary population3 and that early amputation can be preferable to limb salvage in many such instances3-12. Some military and nonmilitary population studies have considered a delayed amputation as occurring within as little as twenty-four hours postinjury, while other studies have cited a range over years4,13,14. Up to 15% of combat-related amputations have occurred later than twelve weeks postinjury, and the military medical community has adopted this as a reasonable timeframe during which initial operative efforts at limb salvage can be attempted2,14. Given the incidence of trauma-related amputation in the active duty military population, as well as the likely underreported frequency of similar scenarios in civilian trauma settings3,8,15-17, the goal of this report is to provide an analysis of gait in combat-injured patients before and after delayed amputation. Our institutional review board approved the retrospective review of the data presented in this manuscript. The three patients included in this case series were informed that data would be submitted for publication, and they all gave consent. Case 1. A forty-one-year-old male U.S. Navy navigator was involved in a midair collision and was ejected from his aircraft. Upon landing, he sustained a Gustilo …

Posttraumatic Growth Among Operation Enduring Freedom and Operation Iraqi Freedom Amputees

Posttraumatic growth (PTG) is a positive psychological change experienced as a result of struggle with highly challenging life circumstances. This study tested the PTG Model in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans following a major combat-related amputation. Specifically, the relationships among social support, rumination, length of time since amputation, and PTG among these veterans were examined. This was a descriptive correlational design using a mailed survey. Data were collected from OEF and OIF veterans with a major traumatic amputation (excluding digit-only loss). A nationwide postal survey was conducted in 2007 of veterans with a major combat-related traumatic amputation. 210 veterans registered at the Department of Veterans Affairs were sent a survey packet containing a letter of introduction, informed consent form, stamped return envelope, and four surveys: a study-specific demographic questionnaire, the Posttraumatic Growth Inventory (PTGI), Postdeployment Social Support scale, and a Rumination scale. The mean PTGI score among OEF and OIF amputees (N= 56) was 59.1 (SD= 23). Rumination showed the strongest correlation with PTG: r= .43, p= .001. There was a small positive relationship between postdeployment social support and PTG: r= .24, p= .039. No statistically significant correlation between PTG and time since amputation was found in this sample. As proposed in the PTG model, the findings of this study support the benefit of rumination or cognitive processing of the traumatic event and postdeployment social support in the process of developing PTG following a major combat-related amputation. Following a life-threatening war injury, the patient's worldview is dramatically altered or shattered. Old assumptions and belief systems are rebuilt in the acute phase, rehabilitation, and reintegration into the community. The struggle in the aftermath of the traumatic event that results in personal transformation is known as PTG. Nurses contribute to a patient's physical and psychosocial adjustment by cultivating an environment in which the patient can explore and cognitively process the traumatic event and the resulting injury. Postdeployment social support in the form of emotional support (comforting gestures) or instrumental support (providing tangible goods or services) can be a means to foster PTG.

Infectious Complications and Soft Tissue Injury Contribute to Late Amputation After Severe Lower Extremity Trauma

Although most combat-related amputations occur early for unsalvageable injuries, >15% occur late after reconstructive attempts. Predicting which patients will abandon limb salvage in favor of definitive amputation has not been explored. The purpose of this study was to identify factors contributing to late amputation for type III open tibia fractures sustained in combat. Operative databases were reviewed to identify all combat-related type III open diaphyseal tibia fractures from March 2003 to September 2007. Patients were categorized based on their definitive treatment: group I, limb salvage; group II, early amputation (<12 weeks postinjury); group III, late amputation (≥ 12 weeks postinjury). Injury, treatment, and complication data were extracted from medical records and compared across groups. We identified 213 consecutive fractures, including 166 (77.9%) treated definitively with limb salvage, 36 (16.9%) with early amputation, and 11 (5.2%) with late amputation. There was no difference in fracture severity among the three groups. Before amputation, group III was more likely to use autograft and bone morphogenic protein (27.3%), compared with group I (4.8%) and group II (0%), and was more likely to undergo rotational flap coverage (45.5%), compared with group II (0%). Group III patients had the highest average number of revision surgeries and rate of deep soft tissue infection and were more likely to have osteomyelitis (54.5%) before amputation compared with group I (13.9%) and group II (16.7%). Patients definitively managed with late amputation were more likely to have soft tissue injury requiring flap coverage and have their limb salvage course complicated by infection.

Prevalence of Late Amputations During the Current Conflicts in Afghanistan and Iraq

During the current conflicts, over 950 soldiers have sustained a combat-related amputation. The majority of these are acute, but an unknown number are performed months to years after the initial injury. The goal of this study is to determine the prevalence of late amputations in our combat wounded. Electronic medical records and radiographs of all soldiers who had a combat-related, lower extremity injury that resulted in amputation were reviewed to confirm demographic, injury, and amputation information. Time to amputation was defined as a late amputation when it occurred more than 12 weeks following the date of injury. There were 348 major limb amputees that met inclusion criteria. Fifty-three (15.2%) amputees had a late amputation (range = 12 wk-5.5 yr). While the majority of combat-related amputations occur acutely, more than 15% occur late. This study demonstrates that further research is needed to identify predictive factors and outcomes of the late amputation.

Comparison of Development of Heterotopic Ossification in Injured US and UK Armed Services Personnel With Combat-Related Amputations: Preliminary Findings and Hypotheses Regarding Causality

Recent reports have documented the rate of heterotopic ossification (HO) formation in the residual limbs of combat-related amputees from the US Armed Forces injured in Operations Iraqi and Enduring Freedom. Final amputation level within the zone of injury and blast as the mechanism of injury were identified as possible risk factors for the occurrence and grade of HO. There has been no previous description of HO in combat-related amputees from the UK service personnel. The purpose of this study was to examine potential differences in the prevalence of HO between UK and US Allied Forces, with particular attention to these risk factors, patient exposures, and any treatment differences between these two groups. We reviewed the medical records and radiographs of 35 combat-related amputations from the UK and contrasted them with 213 previously reported amputations in US military personnel. We evaluated prevalence and severity of residual limb HO, Injury Severity Score (ISS), the mechanism and zone of injury, type and level of amputation, number of debridements, method of wound irrigation, presence of severe head injury and/or burns injury, use of topical negative pressure therapy and pulse lavage, number of days until wound closure, type of closure, and subsequent infections. All patients had a minimum of 2-month posthospital discharge radiographic follow-up. Comparisons were made using Fisher's exact, one-way analysis of variance, and chi2 analyses. There was no significant difference in either the overall prevalence of HO or the prevalence of moderate to severe HO in the two populations. Twenty of 35 (57.1%) limbs in the UK amputations developed HO compared with 134 of 213 (63%) in the US amputations (p > 0.05). The UK amputations had 12 cases (34.3%) of moderate to severe HO compared with 72 cases (33.8%) in the US amputations (p > 0.05). However, there was a significant difference in the number of UK amputations 0 of 20 (0%) versus the number of US amputations 25 of 134 (12%; p = 0.04), which required excision of symptomatic lesions. There was a significant association in the development of HO in UK personnel with the use of topical negative pressure treatment (p = 0.05) and increasing ISS scores (p = 0.04) and in the development of moderate to severe HO with increasing ISS (p = 0.006) and severe HI (p = 0.04). Unlike in the previous report, no significant association was found in UK personnel between any of the remaining hypothesized risk factors and either the presence or grade of HO. Although no difference was identified in the overall prevalence of HO, there are inconsistencies in the possible underlying causes of HO between the two cohorts. Further research is required in an ongoing effort to determine a causal relationship between treatment and subsequent HO formation.