Major Limb Loss Research Articles

Major traumatic limb loss among women veterans and servicemembers

The number of women veterans is rapidly growing, and little is known regarding the health and healthcare needs of women veterans with traumatic limb loss. The objective of this study was to summarize physical and mental health conditions and rates of prosthetic prescriptions among women service members and veterans with major traumatic limb loss. Researchers and clinicians who administered the Survey for Prosthetic Use contacted and enrolled 283 servicemembers and veterans of Operation Iraqi Freedom/Operation Enduring Freedom with major traumatic limb loss. Participants provided information on health status; comorbidities; other combat injuries; and prosthetic device use, rejection, and replacement. Of the 283 veterans, 9 (3%) were women. Compared with men, women reported more than a threefold higher prevalence of migraine (67% vs 20%, p = 0.001). Compared with men, women received 0.42 more prostheses per year, rejected 0.11 more prostheses per year, but replaced 0.18 fewer prostheses per year. With the exception of migraine headaches, men and women servicemembers and veterans with major traumatic limb loss report similarly high prevalence of physical and mental health conditions. Women report higher rates of prosthesis receipt and rejection and lower rates of prosthesis replacement than men. These findings highlight some potential issues specific to women veterans that may require additional clinical attention.

More than the final score: Development, application, and future research of Comprehensive High-Level Activity Mobility Predictor

Since September 11, 2001, the United States has become involved in two major conflicts [1]. As of December 3, 2012, the Congressional Research Service reported that the number of battle-injury amputations from Operation New Dawn, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) was 1,715 [2]. Explosions or blasts have produced the highest percentage (54%) of limb injuries seen among wounded servicemembers (SMs) since World War II [3]. Owens et al. reported almost symmetrical distribution between wounds to the upper (51%) and lower limbs (49%) with SMs wounded in action in OIF/OEF from October 2001 through January 2005 [3]. Prior to 2005, approximately 75 percent of major limb amputations occurred to the lower limbs, with 15 percent of SMs sustaining multiple limb loss [4]. By 2009, the numbers had increased such that 82 percent of major limb amputations were to the lower limbs, with 24 percent sustaining multiple limb loss and the majority occurring in bilateral lower limbs. Since 2010, the number of SMs sustaining more than one limb loss has continued to increase, with also greater concomitant injuries [5]. Historically, SMs who sustained a major limb amputation were medically retired from Active Duty (AD) military service [6]. Today, however, expectations have changed and provisions have been established to allow SMs with major limb loss, who so desire, to remain on AD. A report published in 2009 found that 11 percent of SMs with major lower-limb loss who have completed the medical boarding process either qualified for Continuation on AD or Continuation on Active Reserve or were determined to be Fit for Duty [7]; by 2010, the number rose to 16 percent [8]. With military SMs achieving such high levels of activity after major limb loss, it became clear to the rehabilitation community that the outcome measures for this unique patient population needed to be adjusted. In 2006, Pasquina and Fitzpatrick reported the need to develop novel outcome measures for use in assessing patient progress and determining optimal treatment strategies for SMs with lower-limb loss receiving care at Walter Reed Army Medical Center, Bethesda, Maryland [9]. They reported that these patients were quickly exceeding functional outcome expectations and quickly reaching a ceiling effect on existing outcome measurement tools such as the Amputee Mobility Predictor (AMP) or Timed Up and Go Test. They therefore concluded that a need existed to develop a more robust outcome measure geared toward assessing high levels of mobility for this specific population in order to better quantify functional capability, change in function over time, and readiness to return to AD and/or competitive sports. Developing a novel high-level mobility outcome measurement tool would require extensive academic rigor, especially to develop one that was both reliable and valid. The single-topic section of this issue of the Journal of Rehabilitation Research and Development (JRRD) describes the development of the Comprehensive High-Level Activity Mobility Predictor (CHAMP), which we propose the rehabilitation community consider using when providing state-of-the-art care for today's people with amputation who want to return to high-level activity. The CHAMP was developed to be a performance-based assessment instrument to measure high-level mobility of people with lower-limb amputation. In developing the CHAMP, we analyzed existing military, amputation, and nonamputation literature and determined that balance, postural stability, coordination, power, speed, and agility were the most important factors that influenced high-level mobility. We then examined published outcome measures that had been purported for use with individuals with lower-limb amputation and found that the Single Limb Stance, Edgren Side Step Test, T-Test, and Illinois Agility Test best captured these factors. Therefore, we used these measurement tools as the basis for constructing the CHAMP. …

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. …

Midterm Results of Replacement of Synthetic Graft and Arterial Infection in the Groin With Femoropopliteal Vein

Infection of synthetic grafts or femoral arteries in the groin is a challenging problem to treat. Femoropopliteal vein (FPV) is an ideal conduit, but extensive replacement of infected aortic grafts with FPV has been associated with significant morbidity. The aim of this study was to evaluate early and long-term outcome of limited replacement with FPV of infected femoral arteries/grafts in the groin. Data from 37 patients who underwent excision of infected femoral grafts and replacement with FPV over an 18-year period from 1994 to 2012 were retrospectively analyzed. Surgical intervention was performed in 41 limbs of 27 men and 10 women (mean age, 67.5 years) at a median of 2.5 years after the original synthetic implantation (aortofemoral n = 21, femorofemoral n = 3, femorodistal n = 5, patch angioplasty n = 2) or, on average, 22.2 days after cardiac catheterization (n = 6) and one mycotic aneurysm. Presentation included draining sinus (n = 7), abscess (n = 4), persistent fevers (n = 6), and pseudoaneurysm (n = 10; intact, 4; ruptured, 6). Twenty-five patients (61%) underwent muscle flap cover of the FPV reconstruction. In-hospital/30-day mortality was 5.4% (2 of 37); one from respiratory failure 20 days postoperatively, and the second, a 93-year-old woman, after withdrawal of care at 24 hours. No patients required fasciotomy, and five wound hematomas required reoperation. Focal femoropopliteal vein thrombosis occurred in five limbs. Over a mean follow-up of 2.5 years (range, 0.03-13.3) 11 patients died of unrelated causes at a mean of 3.7 years (range, 0.2-10.6 years). Graft reintervention was required in seven patients during follow-up for graft thromboses (n = 2) stenoses (n = 2), and anastomotic false aneurysms (n = 3). Apart from the latter, there was no other suggestion of graft reinfection in any patient. Major limb loss occurred in one patient at 6 months despite a patent graft. Long-term FPV harvest morbidity included mild leg swelling in 10 patients. Replacement of infected synthetic grafts/femoral arteries in the groin with FPV is safe and results in excellent limb preservation and freedom from reinfection. FPV should be considered the preferred conduit in good-risk patients with infection limited to the groin.

Resources for wounded warriors with major traumatic limb loss

INTRODUCTION Servicemembers and veterans who experience major limb loss are provided assistance in recovery and rehabilitation but are often frustrated when it comes to finding resources to help them along the way. More than 850 servicemembers and veterans from Operation Iraqi Freedom/ Operation Enduring Freedom (OIF/OEF) [1] and more than 2,500 from the Vietnam war [2] have major limb loss. Many organizations are available to provide assistance and resources to these men and women. The needs of the servicemembers and veterans vary by level of limb loss, severity of other injuries and comorbidities, stage of rehabilitation, need for financial support, benefits, and many other factors. Fortunately, many agencies established services for servicemembers and veterans with major limb loss. This article identifies information sources for individuals with major limb loss as follows: (1) resources for military personnel, (2) resources from the Department of Veterans Affairs (VA), (3) other resources for veterans, (4) resources for family members, and (5) resources in the public domain. Five detailed tables identify the agencies, their contact information, and services available for each category. These resources were considered helpful by the participants of the Survey for Prosthetic Use (Appendix 1, available online only) and the Expert Panel members (Appendix 2, available online only); are known by us to support servicemembers, veterans, and others with limb loss; and are in the public domain. This list is not all-inclusive; resources and organizations change rapidly. RESOURCES FOR MILITARY PERSONNEL Numerous support systems are in place for servicemembers with traumatic limb loss while on Active Duty--notably, Walter Reed Army Medical Center, Washington, DC; Brooke Army Medical Center, San Antonio, Texas; and Naval Medical Center, San Diego, California. Military and civilian organizations and agencies provide a broad spectrum of services. Several programs are described next. Table 1 provides additional resources for military personnel. Army Career and Alumni Program The U.S. Army created the Army Career and Alumni Program (ACAP) (http://www.acap.army.mil/) to provide transition assistance to soldiers and family members separating or retiring from Active Duty with ACAP Centers located on most major U.S. Army installations. The program is mandated by Congress and part of U.S. Army/ Department of Defense (DOD) policy. ACAP provides preseparation counseling, employment workshops, VA briefings, employment assistance, tools for writing resumes and cover letters, advice, and support. ACAP's Disabled Transition Assistance Program (DTAP) is offered for servicemembers who are leaving military service because of disability. This program encourages and assists servicemembers with their decisions about the VA's Vocational Rehabilitation and Employment Service. DTAP facilitates applications for vocational rehabilitation benefits and services. Group sessions explain eligibility, benefits, and availability of educational and vocational counseling. DTAP sessions for hospitalized or convalescing servicemembers are coordinated by the VA Regional Office. Hope For The Warriors Established in 2006, Hope For The Warriors[TM] (http:// www.hopeforthewarriors.org) is a civilian, 501(c)(3) nonprofit organization whose mission is to enhance quality of life for wounded U.S. servicemembers and their families with short- and long-term care and to ensure that fallen warriors are not forgotten, nor their families left in need. Its programs include the award-winning Warrior's Wish, recreational outings, athletic events, transitional housing, financial support for immediate needs, support groups, professional development, and a rehabilitation center. Military OneSource Military OneSource (http://www.militaryonesource.com) has services and information for military personnel and their families who need help with child care, personal finances, emotional support, relocation information, education, elder care, legal advice, and other special circumstances. …

Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts

The goals of rehabilitation after major limb loss include not only functional restoration but also a return to a high quality of life (QOL). Few studies have identified which factors are associated with QOL in veterans and servicemembers with combat-associated major limb loss. We enrolled Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans and servicemembers in a national survey on prosthetic device use. In the Vietnam group, multivariate analysis found multiple limb loss (adjusted odds ratio [aOR] = 3.1, 95% confidence interval [CI] = 1.57-6.02) and satisfaction with current prostheses (aOR = 1.2, 95% CI = 1.05-1.38) are associated with better overall QOL, while a higher amputation impact rank (aOR = 0.66, 95% CI = 0.59-0.74) and depression (aOR = 0.21, 95% CI = 0.08-0.54) are associated with worse overall QOL. In the OIF/OEF group, three factors are significantly associated with worse overall QOL: combat-associated head injury (aOR = 0.78, 95% CI = 0.61-0.99), combat-associated injury to the nonamputated limb (aOR = 0.71, 95% CI = 0.57-0.88), and assistance needed in daily living (aOR = 0.12, 95% CI = 0.02-0.72). Improving satisfaction with prosthetic devices, improving mental health care, and treating other combat-associated injuries may significantly improve the overall QOL for these veterans and servicemembers.

Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: Survey methods, participants, and summary findings

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

Comparison of satisfaction with current prosthetic care in veterans and servicemembers from Vietnam and OIF/OEF conflicts with major traumatic limb loss

Prosthetic care is a vital aspect of healthcare and rehabilitation for veterans and servicemembers with major traumatic limb loss. Our survey queried 581 veterans and servicemembers with limb loss from the Vietnam and Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) conflicts. Among survey participants, 78.2% from the Vietnam conflict and 90.5% from the OIF/OEF conflict currently use prosthetic devices. In Vietnam respondents, 78% received prosthetic care from private sources, 16% from Department of Veterans Affairs (VA) prosthetic laboratories, 0.9% from Department of Defense (DOD), and 5% from multiple sources. In OIF/OEF respondents, 42% received prosthetic care from private sources, 9% percent from VA, 39% from DOD, and 10% from multiple sources. Participants identified their satisfaction with current prosthetic devices and prosthetic services. Reports of pain, sweating, skin irritation, and problems with socket fit continue to be significant issues for participants from both conflicts regardless of level of amputation or site of service. In those with upper-limb loss who used myoelectric prostheses, minimal effect on prosthesis use and satisfaction was noted. Among lower-limb loss participants from both conflicts, notable differences existed in prosthesis satisfaction by source of care.

Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss

Veterans injured in theaters of combat operations are eligible for benefits, including medical care and compensation. This article describes veterans with service-connected disability for major lower- and/or upper-limb loss resulting from combat-field-associated injuries sustained in the Vietnam war, Operation Desert Shield/Operation Desert Storm, and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Using the Department of Veterans Affairs (VA) Compensation and Pension Mini-Master file, we identified 2,690 veterans who in August 2007 received compensation for loss of one or more limbs. More than 97% sustained their injuries in Vietnam; most were young men who served in the U.S. Army or Marine Corps. All but 5% had at least 50% combined service-connected disability and nearly half had a 100% rating. In addition to limb loss, one of the most prevalent compensable conditions was posttraumatic stress disorder, present in 46% of OIF/OEF and 20% of Vietnam veterans. Of these veterans, 82% visited VA outpatient clinics in 2007, although only 4% were hospitalized. A special obligation exists to those who have sustained serious injuries related to combat; this responsibility extends for the life of the servicemember and beyond to his or her spouse and dependents.

DOD paradigm shift in care of servicemembers with major limb loss

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. …

Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts.

Paradigm shift for VA amputation care

INTRODUCTION As the Department of Defense (DOD) identified a need to modify the type and delivery of services to the combat-injured with major traumatic limb loss, so too has the Department of Veterans Affairs (VA). While the majority of veterans with amputations receiving care in VA medical facilities have sustained their amputations because of medical conditions such as diabetes and peripheral vascular disease, a significant number of individuals also sustain amputations because of trauma on the battlefield. Each major military operation has resulted in a new cohort of veterans with combat-incurred traumatic amputation: almost 21,000 in the Union Army during the Civil War, more than 4,000 during World War I, about 15,000 during World War II, over 1,000 in the Korean war, an estimated 6,000 during the Vietnam war, and 15 during the Persian Gulf war [1]. To date, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) conflicts have resulted in nearly 1,000 amputations. The VA has always been committed to the principles of rehabilitation, and one of the major goals driving care is to restore the capability of veterans with disabilities to the greatest extent possible and improve their quality of life and that of their families. To this end, the VA has invested significant resources into creating a new paradigm of care to meet the needs of the newly combat-injured veterans from OIF/OEF while also improving care to all veterans with amputations due to medical causes. CHALLENGES IN CARE FOR COMBAT-INJURED The VA has faced several challenges in providing care to this new group of veterans. A major challenge is that battlefield injuries are often complex, resulting in amputations and residual limbs that prove challenging for later prosthetic fitting because of length, scarring, heterotopic ossification, and additional associated injuries, such as burns or complex fractures. In addition, these veterans access VA healthcare at varying stages in their recovery and rehabilitation, challenging the system to provide care across the entire continuum. Also, these veterans are widely distributed across the country and the VA healthcare system so that any particular VA medical facility may have the opportunity to provide care for only a few individuals. Finally, this is a young, highly trained group of individuals committed to an active lifestyle who are early in their developmental life cycle. They are computer literate and take an active role in learning about and directing their healthcare. They are often working, going to school, or raising families and thus require efficient and convenient service. VA'S VISION FOR NEW AMPUTATION SYSTEM OF CARE First and foremost, care must be person-centered. The person receiving care must drive the process and set the goals. Care is delivered by an integrated, interdisciplinary team, including medical professionals, therapists, prosthetists, mental health professionals, and other specialists as needed. The focus of care is on meeting the goals of the veteran, maximizing function, community integration, and participation. Care must be evidence-based, comprehensive, and holistic, addressing medical needs and comorbidities, as well as the individual's psychosocial needs, developmental stage in life, and goals (functional, vocational, and leisure). A prosthesis is viewed as a medical device requiring careful evaluation, resulting in a prescription based on joint decision making, best medical evidence, and practice. Finally, care must be provided, as needed, throughout the person's life. The team must provide regular checkups to continually reassess function, satisfaction, and lifestyle and interest changes, and to manage medical problems such as pain, skin problems, cardiovascular changes, or weight loss/gain. Routine checkups can also introduce new developments in componentry that may contribute to an improvement of function or increase in satisfaction. …

Wheeled mobility: Factors influencing mobility and assistive technology in veterans and servicemembers with major traumatic limb loss from Vietnam war and OIF/OEF conflicts

Returning wounded veterans and servicemembers to their highest level of function following traumatic injury is a priority of the Departments of Defense and Veterans Affairs. We surveyed 245 veterans from the Vietnam war and 226 servicemembers and veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts with at least one major traumatic lower-limb loss to determine their use of mobility assistive technology (AT) and patterns of limb abandonment. Prosthetic device use without wheelchair use is found in 50.5% of Vietnam and 42.8% of OIF/OEF groups. Prostheses and supplementary wheelchairs are used by Vietnam (32%) and OIF/OEF (53%) groups (p < 0.01). Exclusive wheelchair use is more frequent in the Vietnam group (18%) than in the OIF/OEF group (4.0%, p < 0.01). In Vietnam participants, multivariate analysis found that multiple-limb loss (adjusted odds ratio [AOR] = 14.5; 95% confidence interval [CI] 5.5-38.5), bilateral lower-limb loss (AOR = 12.7; 95% CI 6.2-26.1), and number of comorbidities (AOR = 1.3; 95% CI 1.2-1.5) are associated with increased likelihood of wheelchair use. In OIF/OEF participants, bilateral lower-limb loss (AOR = 29.8; 95% CI 11.0-80.7), multiple-limb loss (AOR = 16.3; 95% CI 3.1-85.3), cumulative trauma disorder (AOR = 2.4; 95% CI 1.2-4.9), and number of combat injuries (AOR = 1.4; 95% CI 1.2-1.7) are associated with wheelchair use. Combined use of different types of mobility ATs promotes improved rehabilitation and ability to function.

Unilateral lower-limb loss: Prosthetic device use and functional outcomes in servicemembers from Vietnam war and OIF/OEF conflicts

Rehabilitation goals following major combat-associated limb loss in World War II and the Vietnam war focused on treatment of the injury and a return to civilian life. The goal for Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) servicemembers is to restore function to the greatest possible degree and, if they desire, return them to Active Duty, by providing them with extensive rehabilitation services and a variety of prosthetic devices. Our study determines the usefulness of these diverse types of prosthetic devices for restoring functional capability and documents prosthesis use and satisfaction. We compare servicemembers and veterans with major combat-associated unilateral lower-limb loss: 178 from the Vietnam war and 172 from OIF/OEF conflicts. Of survey participants with unilateral lower-limb loss, 84% of the Vietnam group and 94% of the OIF/OEF group currently use at least one prosthetic device. Reasons for rejection varied by type of device, but common reasons were pain, prosthesis too heavy, and poor fit. Abandonment is infrequent (11% Vietnam group, 4% OIF/OEF group). Future efforts should aim to improve prosthetic-device design, decrease pain, and improve quality of life for these veterans and servicemembers.

Wounded warriors' perspectives: Helping others to heal

[ILLUSTRATION OMITTED] They have walked the walk and paid the price. A very high price. They are veterans who sustained major limb loss during the Vietnam or Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts. Their names are Juan Arredondo, Ned Foote, and Jonathan Pruden. All three have adapted to their limb loss, but daily struggles still exist for them, as well as for others who have moved on with their postmilitary lives. Jonathan Pruden and Juan Arredondo served during a different military era (OIF/OEF) than did Ned Foote (Vietnam); but despite the differences in age, the three men share a common goal, a common passion: to see that all wounded servicemembers receive the best possible care through a supportive rehabilitation process and a smooth transition from Active Duty into the Veterans Healthcare System and, especially, to receive comprehensive prosthetic care services and other benefits they deserve. Their mission now is to help other wounded warriors navigate through the recovery process and restore a satisfying lifestyle. As active volunteers in national programs that assist fellow wounded warriors, they were invited to participate in the Expert Panel meeting, convened in Seattle, Washington, in 2008, to examine rehabilitation care issues and prosthetic device challenges for the study described in this issue of the JRRD. In addition, they participated in a joint interview to discuss their experience through the recovery process and share valuable lessons learned on how best to adapt to limb We hope their stories will provide guidance and inspiration to others with disabilities. THE BATTLEFIELD INJURY Ned Foote was drafted into the U.S. Marine Corps and was sent to Vietnam in 1969 with the 3rd Marine Division as an infantryman. While Foote was on patrol in the demilitarized zone, a mine was detonated during an ambush, killing two and injuring Foote and six others. His severely injured foot was later amputated on a hospital ship. He was sent to Guam for further surgery. As a result of infections and other complications, his amputation was later revised to above the knee. He returned home to New York to continue his medical rehabilitation, including physical therapy and fitting and training for his prosthetic device at the Department of Veterans Affairs (VA), Veterans Health Administration. Juan Arredondo, a U.S. Army sergeant in the 2nd Infantry Division, was driving on patrol in Iraq with two other servicemembers in 2006. A cellular phone-detonated device exploded through the door of their vehicle, seriously injuring all three men. The explosion instantly severed Arredondo's left hand below the elbow and inflicted extensive damage to his legs. Although the injuries to his legs were not life-threatening, his severed hand could not be reattached. He was sent to Brooke Army Medical Center in San Antonio, Texas, to begin his recovery process. Jonathan Pruden, a lieutenant in the U.S. Army serving in Iraq in 2003, was wounded on July 1, 2003, becoming one of the first improvised explosive device casualties of OIF. He was hit with 173 pieces of shrapnel and 1 bullet. After initial surgeries in Iraq, he was medevaced to Landstuhl Regional Medical Center in Germany for additional surgeries and then transported to Walter Reed Army Medical Center (WRAMC). Arriving at WRAMC was the first step in his recovery. Over 3 years at seven different military hospitals, he had 20 surgeries, including the amputation of his right leg. Pruden, now a retired captain, recalls his many surgeries and long rehabilitation process with a positive light: I would have died even 20 years ago due to the extensive injuries and blood loss. STEPS TO RECOVERY During the Vietnam conflict, nearly 25 percent of wounded servicemembers succumbed to their injuries, largely because of the inability to reach mobile surgical hospitals [1]. With improvements in protective gear, Kevlar vests, and rapid medical evacuation to medical or surgery units, nearly 90 percent of servicemembers wounded during the OIF/OEF conflicts survive [2]. …

Treatment of acute limb ischemia with focus on endovascular techniques

Acute limb ischemia is still the most frequent cause of major limb loss. Timely and fast revascularization is the key for limb salvage and patient survival. Large randomized trials showed equivalency of surgical and endovascular revascularization by means of local lysis with urokinase (TOPAS, STILE). New lytic agents and their modified application such as via a pulse spray catheter or combined with an ultrasound catheter and the combination with glycoprotein IIb/IIIa receptor antagonists have increased the efficacy and speed of thrombolysis. Recently, mechanical thrombectomy devices have become more widespread because intervention time and bleeding complications can be reduced. This review article summarizes the clinical presentation of and the treatment options for acute arterial occlusive disease caused either by embolism or local thrombosis.

Self-Management Improves Outcomes in Persons With Limb Loss

Wegener ST, Mackenzie EJ, Ephraim P, Ehde D, Williams R. Self-management improves outcomes in persons with limb loss. Objective To test the acceptance and effectiveness of a community-based self-management (SM) intervention designed to improve outcomes after limb loss. A priori hypothesis was that an SM intervention will be more effective than standard support group activities in improving outcomes. Design Randomized controlled trial. Setting General community. Participants Intervention (N=287) and control participants (N=235) with major limb loss. Intervention(s) Nine, 90-minute SM group sessions delivered by trained volunteer leaders. Retention rates at immediate postintervention and 6-month follow-up were 97% and 91% for the SM group. Main Outcome Measure(s) Primary outcomes were depression, positive mood, and self-efficacy. Secondary outcomes were improved functional status and quality of life. Results By using intent-to-treat analyses, the odds for being depressed are significantly lower for those in SM group, 50% less likely at treatment completion (95% confidence interval [CI]=0.3–0.9) and 40% less likely at the 6-month follow-up (95% CI=.03–1.1). Treatment completers have a 70% reduction in likelihood of being depressed at posttreatment ( P<.01) and this persists at six months ( P<.05). For those in the SM group, functional limitations were significantly lower at 6 months ( P<.05), and general self-efficacy was significantly higher at immediate posttreatment ( P<.05) and at 6 months ( P<.05). Treatment completers have generally significantly larger effect sizes at all follow-up points. Pain intensity, self-efficacy for pain control, and quality of life were not significantly different between the groups. Subgroup analyses indicated the impact of the intervention was greater for participants who were less than 3 years postamputation, participants who were less than 65 years of age, or participants who showed at least 1 secondary condition at baseline. Conclusions The study provides evidence that SM interventions can improve the outcomes of persons with limb loss beyond benefits offered by support groups.

QS162. Regional Antibiosis for The Treatment of Experimental Prosthetic Graft Infections

Background: Prosthetic graft infections are a source of major morbidity, limb loss, and mortality following bypass procedures. Traditional treatment has centered on parenteral antibiosis and extra-anatomic bypass. At our institution, we have recently begun utilizing local antibiotic delivery systems for the treatment of prosthetic graft infections using polymethylmethacrylate (PMMA) beads. The objectives of this research were to evaluate local antibiosis in the treatment of prosthetic graft infections using an experimental model to compare the results of local antibiosis with both a bacteriostatic and bacteriocidal drug regimen.

Systematic review of preservation methods and clinical outcome of infrainguinal vascular allografts

We systematically reviewed clinical studies on the use of venous and arterial allografts for infrainguinal revascularization. We attempted to find evidence for the best infrainguinal vascular allograft by a systematic review of the available literature. An electronic search of the MEDLINE, EMBASE, and Cochrane databases was used to determine key articles from studies on the different types of vascular allografts used in infrainguinal reconstruction from 1966 to 2004. Articles were independently reviewed by using previously defined inclusion and exclusion criteria. Study results were gathered with cumulative primary patency as the primary end point. Secondary end points were major complications, graft disintegration, and major limb loss. Quantitative analysis was performed on the prospective randomized trials, and linear regression analysis was performed on cumulative primary patency. Fontaine's classification system was applied. No systematic review of randomized controlled trials was found. Five randomized controlled trials, 3 prospective cohort or case series, and 15 retrospective case series with 3,837 vascular allografts were found. Methods of allograft preservation were cryopreservation (5 studies), cold storage (3 studies), and glutaraldehyde preservation of human umbilical veins (15 studies). One-year cumulative primary patency rates were 13% to 79% for cryopreservation, 63% to 80% for cold storage, and 40% to 91% for glutaraldehyde. The weighted mean 1-year cumulative primary graft patency rate was 41% for cryopreservation, 71% for cold storage, and 70% for glutaraldehyde allografts. Four randomized trials on femoropopliteal bypasses demonstrated higher patency rates of glutaraldehyde-preserved human umbilical veins than polytetrafluoroethylene grafts. Statistical heterogeneity between studies (I(2) = 91.4%) was too high to perform a formal meta-analysis. The rate of major limb loss was 20% to 58% for cryopreservation, 10% to 69% for cold storage, and 0% to 65% for glutaraldehyde, and the percentage of graft disintegration was 2% to 6% for cryopreservation, 4% to 15% for cold storage, and 0% to 11% for glutaraldehyde. A firm conclusion could not be made because there were no studies available in which direct comparison was performed between different preservation methods of vascular allografts. In addition, heterogeneity of the individual studies hampered direct comparison of different types of vascular allografts. However, the overall graft performance of glutaraldehyde-preserved human umbilical vein allografts may be superior to that of other vascular allografts.

Comparative Safety and Efficacy of Urokinase and Recombinant Tissue Plasminogen Activator for Peripheral Arterial Occlusion: A Meta‐Analysis

To evaluate differences in the efficacy and safety of recombinant tissue plasminogen activator (rt-PA) and urokinase in the treatment of peripheral arterial occlusion. Systematic review and meta-analysis of prospective comparative trials. PubMed/MEDLINE database from 1966-October 2004. The literature was systematically searched to identify prospective comparative trials of urokinase and rt-PA for the treatment of peripheral arterial occlusion. The primary outcome measure was successful complete lysis of the occlusion. Other outcome measures were hemorrhage (major, minor, or combined), intracranial hemorrhage, limb loss, and mortality. Six trials were identified, five of which were randomized. On meta-analysis, the rate of clot lysis was higher with rt-PA than with urokinase (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.12-2.10, p=0.007). However, urokinase was associated with lower rates of minor (OR 0.52, 95% CI 0.28-0.97, p=0.04) and total (OR 0.51, 95% CI 0.29-0.91, p=0.02) bleeding. Rates of major hemorrhage, intracranial hemorrhage, limb loss, and mortality were similar between agents. Urokinase was less effective than rt-PA in successfully lysing acute peripheral arterial occlusion, but it was associated with lower rates of total and minor bleeding. Overall, rt-PA was a reasonable substitute for urokinase, now that urokinase has been removed from the market in the United States. However, judicious monitoring for minor bleeding is necessary.