Recent advances in lower extremity amputations and prosthetics for the combat injured patient

Improvement in quality of life of transfemoral amputees: Comparison between 2 types of transfemoral sockets and their influence on functionality and user comfort - A case report

Among the components of lower limb prostheses, a perfectly adapted prosthetic socket is crucial to a successful rehabilitation process. Thus, developing a more comfortable socket could improve the quality of life for transfemoral (TF) amputees. The objective of this case report was to compare 2 TF sockets by evaluating the relationship between socket stiffness and user comfort and their influence on functionality to improve the quality of life of TF amputees. The participant received 2 different sockets: (A) flexible Flixt® socket; (B) conventional socket. He used each socket for 90 days, and after that was submitted to an evaluation at the Gait Laboratory (kinematic and dynamic analyses), completed the Prosthesis Evaluation Questionnaire, and performed Timed Up and Go test, 6-Minute March Test (6MWT), 10-Meter Walk Test, and Amputee Mobility Predictor test. After results were analyzed, the socket that obtained the best degree of satisfaction was assigned to the amputee participant. Combined measures showed that socket B does not considerably change the kinematic parameters neither dynamics parameters namely at stance phase. At Prosthesis Evaluation Questionnaire results, socket A had a better rating than socket B. The results of the Timed Up and Go test, 6MWT, 10-Meter Walk Test, and Amputee Mobility Predictor test obtained identical values, except for the 6MWT. This case report shows evidence of participant satisfaction improvement when using the flexible socket. The study also demonstrates that both sockets are quite effective.

A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients

Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n = 38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n = 16, 36% vs n = 1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n = 7, 33% vs Lisfranc: n = 7, 16%; p = .011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.

Evaluation and Management of Adult Footdrop

Footdrop is a common musculoskeletal condition defined by weakness in ankle joint dorsiflexion. Although the etiology varies, footdrop is characterized by specific clinical and gait abnormalities used by the patient to overcome the loss of active ankle dorsiflexion. The condition is often associated with deformity because soft-tissue structures may become contracted if not addressed. Patients may require the use of special braces or need surgical treatment to address the notable level of physical dysfunction. Surgical treatment involving deformity correction to recreate a plantigrade foot along with tendon transfers has been used with notable success to restore a near-normal gait. However, limitations and postoperative dorsiflexion weakness have prompted investigation in nerve transfer as a possible alternative surgical treatment.

Pattern of upper limb amputation associated with lower limb amputation: the UK military experience from Iraq and Afghanistan

INTRODUCTION

The conflicts in Iraq and Afghanistan resulted in large numbers of personnel sustaining extremity injuries. In the context of polytrauma, partial hand amputation is often unrecorded. The aim of this work was to quantify the burden of upper limb (UL) amputation at any level occurring concurrently with a major (ankle and proximal) lower limb (LL) amputation. Knowledge of this cohort could aid in prosthetic modification to further improve quality of life outcomes in a population with dexterity loss.

METHOD

A trauma database search was undertaken for all UK military LL amputees from the conflicts in Iraq and Afghanistan. A manual search method was employed to identify from the major LL amputees those who had a concurrent UL amputation at any level (including isolated finger amputation). Demographics, level of amputation, and injury profile data were recorded.

RESULTS

Sixty-eight individuals were identified; the most prevalent population was bilateral LL with a unilateral UL amputation (60%). Most UL amputations were partial hand (75%). The was no statistically significant difference between left or right side (p=0.13). On the left side, correlation was found between amputation of the thumb and third digit (rho=0.34; p=0.005) not seen on the right.

CONCLUSION

We have determined the rate of UL amputation at any level, in combination with LL amputation as a result of blast injury. Knowledge of these combinations enables further research to support anecdotal evidence that there is a need for tailored prosthetics in the context of potential dexterity loss making donning and doffing problematic.

The Impact of Graduate Medical Education on Scholarly Activity at a Military Medical Treatment Facility

INTRODUCTION

Graduate medical education (GME) faculty and trainees have required scholarly activities to meet accreditation requirements. The impact of this contribution to the Military Health System, especially regarding innovations in military medicine, has not been previously examined. This study measured the contribution of GME in published manuscripts from a tertiary military medical center.

MATERIALS AND METHODS

Utilizing the Scopus database, published manuscripts from the primary military GME institutions for the San Antonio Uniformed Services Health Education Consortium were identified from 2008 to 2018. Manuscripts were sorted based on the number of citations in Scopus and analyzed for their overall impact in medicine to include military unique topics.

RESULTS

A total of 3,700 manuscripts were identified through Scopus and based on a 10 citation minimum, 1,365 manuscripts were further analyzed; 1,152 (84.4%) included authors with GME affiliation and 554 (40.6%) had direct applicability to unique aspects of military medicine. The mean number of citations per manuscript was 39.2 ± 63.6; Mean Cite Score was 2.97 ± 2.14 and Field Weighted Citation Index of 2.22 ± 3.27. Analysis of number of citations (10-19; 20-39; or >40) did not show any significant differences in Cite Score or military relevance, whereas the percentage of military relevant articles remained consistent yearly.

CONCLUSIONS

These findings highlight the importance of military medical research and addressing specific medical needs of the warfighter. Graduate medical education in a tertiary Military Health System facility has enormous impact in scholarly activity, in particular the importance related to military medicine topics that emphasize combat casualty care and military readiness.

Closed Distal Dislocation of the Intermediate Cuneiform in a Complex Lisfranc Fracture-Dislocation: A Case Report

CASE

A 21-year-old, active duty male sustained an irreducible, complex Lisfranc fracture-dislocation with distal extrusion of his intermediate cuneiform. He was treated in a staged manner with external fixator placement, followed by an extended midfoot fusion with autograft bone. At 19 months, he could perform all activities of daily living independently with minimal pain using an Intrepid Dynamic Exoskeletal Orthosis.

CONCLUSIONS

Complex Lisfranc injuries are severe and often result in chronic pain and disability after operative management. To our knowledge, this is the only case report describing a Lisfranc fracture-dislocation with a distally extruded intermediate cuneiform treated with a fusion.

Comparison of the demographic and clinical characteristics, functional status and quality of life of lower extremity amputees to identify the reason for undergoing amputation

OBJECTIVE

The aim of the study was to evaluate and compare clinical and demographic characteristics, functional status and quality of life among patients who underwent amputation for the most common reason in our region.

METHODS

Demographic data, level of and reasons for undergoing amputation and clinical data on the use of prostheses in 126 patients were recorded. The amputees were divided into three groups: vascular, trauma and landmine. Variables related to clinical and demographic characteristics, daily life activities and quality of life were investigated. Duration of prosthesis use, daily walking distance with prosthesis, 10-m walking speed with the prosthesis and 6-min walking distance of the amputees were recorded. The Short Form-36, Turkish version of the Trinity Amputation and Prosthesis Experience Scales and Beck Depression Inventory were used to evaluate the patients' quality of life. The residual limb pain scale was used to evaluate the severity of pain.

RESULTS

Comparison between the amputees in the trauma and vascular groups showed highly significant results (P< 0.001) in amputees in the trauma group with respect to all parameters of daily life activities, functional status and quality of life. Comparison between the vascular and landmine amputees showed significant results (P< 0.001) in the landmine amputees with respect to all parameters except emotional role functioning, social functioning and mental health. Comparison between the amputees in the trauma and landmine groups showed no significant results (P> 0.05) with respect to all parameters expect emotional role functioning and mental health.

CONCLUSIONS

While the clinical and demographic characteristics, functional status and quality of life parameters were similar in the amputees in the trauma and landmine groups, they showed statistically significant differences in almost all parameters compared with those in vascular amputees.

Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma

BACKGROUND

The Intrepid Dynamic Exoskeletal Orthosis (IDEO) is a custom energy-storing carbon fiber ankle-foot orthosis developed for lower-extremity trauma patients. Studies conducted at the military treatment facility where the IDEO was developed demonstrated benefits of the IDEO when used with the Return to Run Physical Therapy (RTR PT) program. The current study was designed to determine if results could be replicated at other military treatment facilities and to examine whether early performance gains in patient-reported functional outcomes remained at 12 months.

METHODS

Study participants included service members who had functional deficits that interfered with daily activities at least 1 year after a traumatic unilateral lower-extremity injury at or below the knee. Participants were evaluated before receiving the IDEO, immediately following completion of RTR PT, and at 6 and 12 months. Agility, strength/power, and speed were assessed using well-established performance tests. Self-reported function was measured using the Short Musculoskeletal Function Assessment (SMFA). The Orthotics and Prosthetics Users' Survey was administered to assess satisfaction with the IDEO. Of 87 participants with complete baseline data, 6 did not complete any physical therapy and were excluded from the analysis. Follow-up rates immediately following completion of the RTR PT and at 6 and 12 months were 88%, 75%, and 79%, respectively.

RESULTS

Compared with baseline, improvement at completion of RTR PT was observed in all but 1 performance test. SMFA scores for all domains except hand and arm function were lower (improved function) at 6 and 12 months. Satisfaction with the IDEO was high following completion of RTR PT, with some attenuation at the time of follow-up.

CONCLUSIONS

This study adds to the evidence supporting the efficacy of the IDEO coupled with RTR PT. However, despite improvement in both performance and self-reported functioning, deficits persist compared with population norms.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Innovative Techniques for Maximizing Limb Salvage and Function

Concurrent injuries to multiple extremities present unique challenges to the reconstructive surgeon. The primary goal in such scenarios is to optimize functional outcomes. The goal of this article is to present an overview of various techniques necessary to provide sufficient soft tissue and preserve amputation limb lengths and function. The concept of innovative techniques for maximizing limb savage and function is presented using an index patient with multiple extremity third- and fourth-degree burn injuries resulting in nonsalvageable lower extremities and severe left-hand wounds. A review of other potential innovative techniques is discussed. The burn injury resulted in a need for bilateral guillotine below-knee amputations. Above-knee amputation was avoided in the left leg using a parascapular free fasciocutaneous flap, while through-knee amputation was preferred to above-knee amputation in the right leg. The preservation of areas with questionable viability resulted in salvaging the left hand of the patient using digital palmar flaps to resurface the dorsum with creation of a first web-space. Maintenance of maximal viable length of limbs and any residual function in the limbs can be of significant functional benefit to multiple limb amputation patients. Maximizing the limb length in such patients is critical, and typical "rules" that have traditionally been utilized to minimize numbers of operations and optimize prosthetic fit may not apply.

Gait biomechanics following lower extremity trauma: Amputation vs. reconstruction

BACKGROUND

Surgical advances have substantially improved outcomes for individuals sustaining traumatic lower extremity injury. Injuries once requiring lower limb amputation are now routinely managed with limb reconstruction surgery. However, comparisons of functional outcomes between the procedures are inconclusive.

PURPOSE

To compare gait biomechanics after lower limb reconstruction and transtibial amputation.

METHODS

Twenty-four individuals with unilateral lower limb reconstruction wearing a custom ankle-foot orthosis (Intrepid Dynamic Exoskeletal Orthosis), 24 with unilateral, transtibial amputation, and 24 able-bodied control subjects underwent gait analysis at a standardized Froude speed based on leg length. Lower extremity joint angles, moments, and powers, and ground reaction forces were analyzed on the affected limb of patients and right limb of able-bodied individuals. ANOVA with Tukeys post-hoc tests determined differences among groups and post-hoc paired t-tests with Bonferroni-Holm corrections determined differences between limbs.

RESULTS

The ankle, knee, and hip exhibited significant kinematic differences between amputated, reconstructed and able-bodied limbs. The reconstruction group exhibited less ankle power and range of motion while the amputee group exhibited lower knee flexor and extensor moments and power generation.

CONCLUSION

Gait deficiencies were more pronounced at the ankle following limb reconstruction with orthosis use and at the knee following transtibial amputation with prosthesis use. Although both groups in the cohorts tested can replicate many key aspects of normative gait mechanics, some deficiencies still persist. These results add to the growing body of literature comparing amputation and limb reconstruction and provide information to inform the patient on functional expectations should either procedure be considered.

Patient Response to an Integrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: The PRIORITI-MTF Study

Although limb salvage is now possible for many high-energy open fractures and crush injuries to the distal tibia, ankle, hindfoot, and midfoot, orthotic options are limited. The Intrepid Dynamic Exoskeletal Orthosis (IDEO) is a custom, energy-storing carbon fiber orthosis developed for trauma patients undergoing limb salvage. The IDEO differs from other orthoses in that it allows patients with ankle weakness to have more normal ankle biomechanics and increased ankle power. This article describes the design of a study to evaluate the effectiveness of the IDEO when delivered together with a high-intensity, sports medicine-based approach to rehabilitation. It builds on earlier studies by testing the program at military treatment facilities beyond the Brooke Army Medical Center and the Center for the Intrepid where the device was developed. The PRIORITI-MTF study is a multicenter before-after program evaluation where participants at least 1 year out from a traumatic lower extremity injury serve as their own controls. Participants are evaluated before receiving the IDEO, immediately after 4 weeks of physical therapy with the IDEO and at 6 and 12 months after the completion of physical therapy. Primary outcomes include functional performance, measured using well-validated assessments of speed, agility, power, and postural stability and self-reported functioning using the Short Musculoskeletal Function Assessment (SMFA) and the Veterans Health Survey (VR-12). Secondary outcomes include pain, depression, posttraumatic stress, and satisfaction with the IDEO.

Limb Salvage With Intrepid Dynamic Exoskeletal Orthosis Versus Transtibial Amputation: A Comparison of Functional Gait Outcomes

OBJECTIVES

To determine if there is a difference in functional gait outcomes between patients with limb injuries treated with either transtibial amputation or limb preservation with the Intrepid Dynamic Exoskeletal Orthosis.

DESIGN

Retrospective prognostic study.

SETTING

Tertiary referral military hospital.

PATIENTS

This study included 10 transtibial amputees and 10 limb preservation patients using the Intrepid Dynamic Exoskeletal Orthosis who were matched by body mass index after excluding for nontraumatic, proximal ipsilateral, contralateral, spine, or traumatic brain injuries. Transtibial amputation patients were also excluded if they did not have a gait study between 6 and 12 months after independent ambulation. Limb preservation were excluded if they did not complete the "Return to Run" program.

INTERVENTIONS

An observational study of functional outcomes using instrumented gait analysis.

OUTCOME MEASURES

Spatiotemporal, kinetic (vertical ground reaction force), unified deformable power, work, and efficiency.

RESULTS

Limb preservation patients walked with a significantly slower cadence (P = 0.036) and spent less time on their affected limb in stance (P = 0.045), and longer in swing (P = 0.019). Amputees had significantly increased maximum positive power in both limbs (P = 0.004 and P = 0.029) and increased maximum negative power on the unaffected limb (P = 0.035). Amputees had significantly increased positive and negative work in the affected limb (P = 0.0009 and P = 0.014) and positive work in the unaffected limb (P = 0.042). There was no significant difference in the kinetic data or efficiency.

CONCLUSIONS

Limb preservation patients spend less time on their affected limb as a percentage of the gait cycle. The unified deformable power demonstrated more dynamic gait in amputees, with peak values closer to normative data.

LEVEL OF EVIDENCE

Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Demographics of Lower Limb Amputations in the Pakistan Military: A Single Center, Three-Year Prospective Survey

INTRODUCTION : The Pakistan military has been actively engaged in the war against terror for more than a decade. Many officers and soldiers have lost their limbs in this war. But the data on traumatic lower limb amputations in Pakistan is sparse. The aim of this study is to prospectively document the epidemiological profile of lower limb military amputees presenting at the largest rehabilitation centre of Pakistan over a three-year period. MATERIALS & METHODS : A prospective three-year survey was conducted at the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Pakistan. One hundred twenty-three consecutive patients with lower limb amputations were enrolled in the survey. The demographic data, etiology, associated injuries, complications profile, and type of prosthesis provided were documented. The data analysis was done using the statistical analysis tool SPSS V 20 (IBM®,NY, USA). RESULTS : All patients were male. Most had traumatic amputation (119), were between 20-40 years (106), with unilateral amputation (115). Mine blast injury was the leading cause in 73 (59.3%) and most (58.5%) were fitted with modular prosthesis. Transtibial amputation was the commonest level (65), followed by transfemoral (30). The time of surgical amputation was not documented in 87% of the patients. Half of the patients (54%) had associated injuries. Seventy-nine patients had at least one complication with phantom pain being the commonest in 25% cases. CONCLUSIONS : This is the largest prospective demographic survey of lower limb amputees in Pakistan military to date. Scores of soldiers and civilians in Pakistan have suffered lower limb amputation. The availability of demographic data can improve the trauma and rehabilitation services for better understanding and management of such cases. There is a need to conduct large scale community-based epidemiological surveys to direct future policies and develop amputee rehabilitation services in the public sector.

Comparing the surgical timelines of military and civilians traumatic lower limb amputations

The care and challenges of injured service have been well documented in the literature from a variety of specialities.

The aim of this study was to analyse the surgical timelines of military and civilian traumatic amputees and compare the surgical and resuscitative interventions.

A retrospective review of patient notes was undertaken. Military patients were identified from the Joint Theatre Trauma Registry (JTTR) in 2009. Civilian patients were identified using the hospital informatics database. Patient demographics, treatment timelines as well as surgical and critical care interventions were reviewed.

In total 71 military patients sustained traumatic amputations within this time period. This represented 11% of the total injury demographic in 2009. Excluding upper limb amputees 46 patients sustained lower extremity amputations. These were investigated further. In total 21 civilian patients were identified in a 7-year period.

Analysis revealed there was a statistically significant difference between patient age, ITU length of stay, blood products used and number of surgical procedures between military and civilian traumatic amputees. This study identified that military patients were treated for longer in critical care and required more surgical interventions for their amputations.

Despite this, their time to stump closure and length of stay were not statistically different compared to civilian patients. Such observations reflect the importance of an Orthoplastic approach, as well as daily surgical theatre co-ordination and weekly multi-disciplinary meetings in providing optimal care for these complex patients. This study reports the epidemiological observed differences between two lower limb trauma groups.

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There are different population characteristics between civilian and military traumatic amputees.

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There was no significant difference in hospital in-patient length of stay between groups.

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An Orthoplastic approach to this injury group is crucial to optimal management.

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Daily surgical co-ordination prompts optimal operative planning and treatment.

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A weekly multidisciplinary planning meeting optimizes the treatment and timelines for these complex patients.

Identifying obstacles to return to duty in severely injured combat-related servicemembers with amputation

The capacity of servicemembers with amputation to return to duty after combat-related amputation and the associated disabilities remains largely unknown. The purpose of this study was to examine the disabling conditions and return to duty rates of servicemembers with amputation across all service branches following major limb amputations from September 2001 through July 2011. Pertinent medical information, military occupation status, return to duty designation, disabling conditions, and disability ratings for each servicemember were obtained from the Physical Evaluation Board Liaison Office (PEBLO). Across all service branches, 16 (2%) servicemembers were found fit for duty (Fit) and allowed to continue with their preinjury occupation. Another 103 (11%) were allowed to continue on Active Duty (COAD) in a less physically demanding role. More than half (554, 56%) were determined fully disabled (PEBLO rating > 75); the average disability rating was 73. COAD and Fit Army servicemembers had lower Injury Severity Scores than other servicemembers (17.4, p = 0.009 and 11.2, p < 0.001, respectively). Despite improvements in their care and rehabilitation, only 13% of all servicemembers with amputation are able to return to Active Duty and many have multiple disabling conditions that contribute to a very high level of disability.

Early versus Delayed Amputation in the Setting of Severe Lower Extremity Trauma

Leg-threatening injuries present patients and clinicians with the difficult decision to pursue primary amputation or attempt limb salvage. The effects of delayed amputation after failed limb salvage on outcomes, such as prosthetic use and hospital deposition, are unclear. We evaluated the timing of amputations and its effects on outcomes. We retrospectively reviewed all trauma patients undergoing lower extremity amputation from January 1,2000 through December 31, 2010 at a Level 2 trauma center. Patients undergoing early amputation (amputation within 48 hours of admission) were compared with patients undergoing late amputation (amputations >48 hours after admission). Patient demographics, injury specifics, operative characteristics, and outcomes were documented. During the 11-year study period, 43 patients had a lower extremity amputation and 21 had early amputations. The two groups were similar except for a slightly higher Mangled Extremity Severity Score in the early amputation group. Total hospital length of stay significantly differed between groups, with the late amputation group length of stay being nearly twice as long. The late amputation group had significantly more ipsilateral leg complications than the early group (77% vs 15%). There was a trend toward more prosthetic use in the early group (93%vs 57%, P = 0.07). Traumatic lower extremity injuries requiring amputation are rare at our institution (0.3% incidence). Regardless of the amputation timing, most patients were able to obtain a prosthetic. Although the late group had a longer length of hospital stay and more local limb complications, attempted limb salvage still appears to be a viable option for appropriately selected trauma patients.

Assessing functional mobility after lower limb reconstruction: a psychometric evaluation of a sensor-based mobility score

OBJECTIVE

To develop and validate a robust, objective mobility assessment tool, Hamlyn Mobility Score (HMS), using a wearable motion sensor.

BACKGROUND

Advances in reconstructive techniques allow more limbs to be salvaged. However, evidence demonstrating superior long-term outcomes compared with amputation is unavailable. Lack of access to quality regular functional mobility status may be preventing patients and health care staff from optimizing rehabilitation programs and evaluating the reconstructive services.

METHODS

In this prospective cohort study, 20 patients undergoing lower limb reconstruction and 10 age-matched controls were recruited. All subjects completed the HMS activity protocol twice under different instructors at 3 months postoperatively, and again at 6 months, while wearing an ear-worn accelerometer. Demographic and clinical data were also collected including a short-form health survey (SF-36). HMS parameters included standard test metrics and additional kinematic features extracted from accelerometer data. A psychometric evaluation was conducted to ascertain reliability and validity.

RESULTS

The HMS demonstrated excellent reliability (intraclass correlation coefficient >0.90, P < 0.001) and internal consistency (Cronbach α = 0.897). Concurrent validity was demonstrated by correlation between HMS and SF-36 scores (Spearman ρ = 0.666, P = 0.005). Significant HMS differences between healthy subjects and patients, stratified according to fracture severity, were shown (Kruskal-Wallis nonparametric 1-way analysis of variance, χ = 21.5, P < 0.001). The HMS was 50% more responsive to change than SF-36 (effect size: 1.49 vs 0.99).

CONCLUSIONS

The HMS shows satisfactory reliability and validity and may provide a platform to support adaptable, personalized rehabilitation and enhanced service evaluation to facilitate optimal patient outcomes.

Characterisation and outcomes of upper extremity amputations

BACKGROUND

The purpose of this study is to characterise the injuries, outcomes, and disabling conditions of the isolated, combat-related upper extremity amputees in comparison to the isolated lower extremity amputees and the general amputee population.

METHODS

A retrospective study of all major extremity amputations sustained by the US military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, and the Physical Evaluation Board Liaison Offices were queried in order to obtain injury characteristics, demographic information, treatment characteristics, and disability outcome data.

RESULTS

A total of 1315 service members who sustained 1631 amputations were identified; of these, 173 service members were identified as sustaining an isolated upper extremity amputation. Isolated upper extremity and isolated lower extremity amputees had similar Injury Severity Scores (21 vs. 20). There were significantly more non-battle-related upper extremity amputees than the analysed general amputation population (39% vs. 14%). Isolated upper extremity amputees had significantly greater combined disability rating (82.9% vs. 62.3%) and were more likely to receive a disability rating >80% (69% vs. 53%). No upper extremity amputees were found fit for duty; only 12 (8.3%) were allowed continuation on active duty; and significantly more upper extremity amputees were permanently retired than lower extremity amputees (82% vs. 74%). The most common non-upper extremity amputation-related disabling condition was post-traumatic stress disorder (PTSD) (17%). Upper extremity amputees were significantly more likely to have disability from PTSD, 13% vs. 8%, and loss of nerve function, 11% vs. 6%, than the general amputee population.

DISCUSSION/CONCLUSION

Upper extremity amputees account for 14% of all amputees during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts. These amputees have significant disability and are unable to return to duty. Much of this disability is from their amputation; however, other conditions greatly contribute to their morbidity.

Prosthetic options available for the diabetic lower limb amputee

Although the rate of lower limb amputation in patients with diabetes is decreasing, amputation still remains a major complication of diabetes. Prosthetics have been long used to help amputees ambulate. The last decade has seen many advances in prostheses with the enhanced understanding of the mechanics of ambulation and improved use of technology. This review describes the different types of prosthetic options available for below knee, ankle, and foot amputees, emphasizing the latest advances in prosthetic design.

Special Considerations for Multiple Limb Amputation

It has been estimated that more than 1.6 million individuals in the United States have undergone at least one amputation. The literature abounds with research of the classifications of such injuries, their etiologies, epidemiologies, treatment regimens, average age of onset (average age of amputation), and much more. The subpopulation that is often overlooked in these evaluations, however, is comprised of individuals who have suffered multiple limb loss. The challenges faced by those with single-limb loss are amplified for those with multiple limb loss. Pain, lifestyle adjustment, and quality of life return are just a few key areas of concern in this population. Along with amputations resulting from trauma, many individuals with multiple amputations have endured them as a result of dysvascular disease. Over recent years, amputations as a result of dysvascular disease have risen to comprise more than 80 % of new amputations occurring in the United States every year. This compares to just 54 % of total current prevalence. Those with diabetes comorbid with dysvascular disease make up 74 % of those with dysvascular amputations, and these individuals with diabetes comorbid with dysvascular disease have a 55 % chance of enduring an amputation of their contralateral limb within 2-3 years of their initial amputation. With the well-documented aging of the nation's population and the similarly skyrocketing prevalence of dysvascular disease and diabetes, it can be expected that the number of individuals with multiple limb loss will continue to increase in the United States. This article outlines the recommended measures of care for this particular subpopulation, including pain management, behavioral health considerations, strategies for rehabilitation for various levels and variations of multiple limb loss, and the assistive technology and adaptive equipment that might be available for these individuals to best enable them to continue healthy, fulfilling lives following amputation.

Deployment after limb salvage for high-energy lower-extremity trauma

BACKGROUND

Many wounded warriors experienced high-energy lower-extremity trauma (HELET) that may be limb threatening. Volumetric muscle loss, posttraumatic osteoarthritis, nerve injuries, and pain may severely limit physical function. Several wounded warriors express a strong desire to return to their units and be deployed in their original military occupational specialty. We began the return-to-run (RTR) clinical pathway at our institution 2 years ago to facilitate high-performance goals such as these. It involves an energy storing ankle foot orthosis, the intrepid dynamic exoskeletal orthosis in combination with high-intensity, progression-oriented rehabilitation. We sought to determine the rate of deployment or predeployment training after participation in this noninvasive intervention.

METHODS

A retrospective analysis of the RTR database was performed to determine the rate of deployment or predeployment training among those service members who began participation in the RTR between November of 2009 and March of 2011. Medical records were reviewed for demographics, injury, surgical data, and major complications. Requests for delayed amputation were recorded, and charts were reviewed to determine if patients eventually elected to proceed with amputation or if they chose to continue with limb salvage.

RESULTS

Between November 2009 and March 2011, 87 service members completed the RTR. Of these, 17 (19.5%) have been deployed to combat or are in predeployment training. Sixteen serve in combat arms (nine Special Forces, four infantry/ranger, two combat engineers, and one gunner), and one is a member of the military intelligence community. Fifteen patients sustained their injuries as a result of HELET (four gunshot, five motor vehicle collisions, four explosions, one parachute injury, and one fall from height), one had idiopathic avascular necrosis of the talus, and one had an iatrogenic nerve injury after pelvic surgery. Six of the patients underwent circular external fixation, five received joint fusions (three ankle, two subtalar joint), and nine had major nerve injuries. Four initially desired amputation of their injured limb but have subsequently countermanded their request.

CONCLUSION

Returning to high-level physical function after HELET is challenging. After implementation of the RTR clinical pathway with the intrepid dynamic exoskeletal orthosis, 19.5% of wounded warriors treated with the RTR have been deployed or will be deployed in the coming year.

Should preparation for elite sporting participation be included in the rehabilitation process of war-injured veterans?

BACKGROUND

Participation in sport and exercise training, while aiding in the reintegration and confidence building of wounded service personnel, also has potential to prepare them for elite sport competition. It is this encouragement of the war injured to use sport and recreational physical activity as a means of rehabilitation back into civilian life, which has become the worldwide phenomenon of Paralympic sport.

OBJECTIVES

This paper evaluates existing research relating to the incidence of types of war injuries and the use of sport within the rehabilitation process.

STUDY DESIGN

Literature review.

METHODS

Initial searches were conducted in the electronic databases EBSCOHost, ScienceDirect and Pubmed using the keywords 'veterans' and 'sport' or 'physical activity'. These searches were then supplemented by tracking all key references from the appropriate articles identified. A narrative literature review methodology was employed.

RESULTS

Although it is clear from the reported literature that further development of available rehabilitation services is necessary to provide the required level of care for the types of mental and physical injuries and the concept of 'therapeutic recreation' is becoming popular, there is still a need for the development of specific protocols to identify individuals who can participate and excel in a specific sport at an elite level.

CONCLUSIONS

Drawing on the US military experience it can be argued that sport in the UK and other parts of the world should be more widely recognized as a component of rehabilitation. This is not just for the role that sport can play as a tool for rehabilitation but also for the intrinsic and extrinsic benefits that participation in elite sport can offer.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Comparative effect of orthosis design on functional performance

BACKGROUND

High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace.

METHODS

Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it.

RESULTS

Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation.

CONCLUSIONS

Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.

Return to running and sports participation after limb salvage

BACKGROUND

The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage.

METHODS

We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining.

RESULTS

The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon.

CONCLUSION

Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage.