Short-term physical and mental health outcomes for combat amputee and nonamputee extremity injury patients

Heterogeneous trajectories of depression and resilience following limb amputation

OBJECTIVE

To identify longitudinal trajectories of depression in the first 6 months following limb loss and to explore baseline predictors of trajectories, including pain and demographic factors. A secondary aim was to evaluate whether trajectories of depression were associated with elevated symptoms of posttraumatic stress (PTS) at 6 months.

DESIGN

Secondary longitudinal data analysis of an inception cohort study of persons with new-onset limb loss. Participants completed assessments at three intervals (initial, 3 months, and 6 months).

SETTING

Hospitalized care, acute rehabilitation, ambulatory care, and community.

PARTICIPANTS

Participants were recruited from consecutive cases of amputation surgery in a metropolitan hospital system over a period of 4 years (2002-2007). The final sample (n = 203) was predominantly White (79.3%) and male (78.8%) with an average age of 49.4 years (standard deviation [SD] = 14.6).

MAIN OUTCOME MEASURE(S)

Depression was assessed via the Patient Health Questionnaire-9 (PHQ-9); posttraumatic stress symptoms were measured via the PTSD checklist- Civilian Version (PCL-C).

RESULTS

Four trajectories of depression were identified via Latent Growth Mixture Modeling: Resilience (73.2%), Chronic Depression (11.2%), Emerging Depression (8.9%), and Recovery (6.7%). Average pain intensity significantly predicted trajectory membership. Membership in the Chronic Depression class predicted elevated 6-month PTS compared to all other classes; membership in the Resilience class predicted lower PTS than in the Chronic and Emerging Depression classes but did not differentiate from the Recovery trajectory.

CONCLUSIONS

Findings reveal that the course of depression post-amputation is heterogenous, with varying profiles of symptom development, maintenance, and remission. A majority of individuals were classified as Resilient, whereas a substantial minority of individuals developed clinically significant depression between 3 and 6 months (Emerging Depression), suggesting that early screening during acute care may be insufficient. We detected a significant prospective relation between depression trajectories and distal PTS, advancing the potential clinical utility of trajectory modeling as a risk surveillance tool.

All-cause and cause-specific mortality rates after severe extremity injuries among previously deployed active duty service members

BACKGROUND

Previous research has shown that active duty military personnel who sustain extremity injuries while in service are at elevated risk for serious physical and psychological health issues that could affect their long-term functioning and quality of life yet longer-term mortality has not been studied in this population.

OBJECTIVE

To determine whether rates of all-cause and cause-specific mortality are elevated for active duty U.S. service members who sustained traumatic limb injuries in service, compared to the broader population of deploying service members. To assess differences in mortality rates between service members with traumatic limb injuries that did versus did not result in amputation.

DESIGN

Retrospective cohort study; archival Department of Defense deployment, personnel, medical, and death records were combined and analyzed. Standardized mortality ratios (SMR) adjusted for age, sex, and ethnoracial group, along with associated 95% confidence intervals (CIs), were calculated to directly compare all-cause and cause-specific mortality rates in each of the two injury groups to rates in the total study population.

SETTING

Not applicable.

PARTICIPANTS

Service members who deployed in support of the global war on terror between 2001 and 2016 were eligible for inclusion; the final sample included 1,875,206 individuals surveilled through 2019.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality rates.

RESULTS

Overall, the number of deaths was over three times higher than expected among service members with amputations (SMR = 3.01; CI: 2.36-3.65), and nearly two times higher among those with serious limb injuries not resulting in amputation (SMR = 1.72; CI: 1.54-1.90) when compared to the larger study population. Rates for both internal and external causes of death were significantly elevated among those with limb injuries.

CONCLUSIONS

Long-term mortality rates are elevated among service members with traumatic limb injuries, though mortality patterns may differ based on whether the injury results in amputation. Although further research into causal mechanisms is needed, these results may inform the development of interventions to improve long-term health outcomes among injured military personnel.

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

A review of the first wave of lower limb amputees from the Great March of Return in Gaza: Taking stock and preparing for the task ahead

AIM

Ballistic injuries during the Great March of Return (GMR) protests in Gaza have resulted in young, civilian amputees. This article defines this unique population, their injuries and clinical variables that impacted on amputation.

METHOD

A multidisciplinary team (MDT) assessed 103 lower limb amputees (104 stumps). Individualized prescriptions of care were formulated and applied for both stump and prosthesis management. The cohort's health state was assessed at screening by applying the EQ-5D-L5 questionnaire. The EQ-5D-L5 will be repeated on completion of the prescription of care.

RESULTS

The population is predominantly young, male, suffering unilateral amputation with an equal ratio of above knee (AKA) to below knee (BKA) amputations. 18% were amputated immediately and 82% with delay. Most amputations occur within 15 days of gunshot wound (GSW). All tissue elements were affected by the severe, ballistic injury. Division, gapping and tissue loss consolidated the decision for amputation rather than limb salvage. Knee zone injury was common, influencing the high numbers AKAs. Primary injury ramified beyond the amputated leg: 38% have contralateral leg injuries. 20% had physiological challenges requiring Intensive care unit (ICU) admissions. Infection was reported in 49% of amputees with 12% reporting acute sepsis. Psychologically, 49% reported severe, or extreme, anxiety and depression. AKAs were associated with greater morbidity: amputees are significantly younger, have more proximal vascular injuries, receive delayed amputations and experience longer time intervals to stump healing. ICU care and contralateral leg injuries were more frequent. One third of amputees used their prostheses', one third did not and one third do not have a prosthesis yet. The limiting factor for repair was supply of materials. 11% of amputees needed no adjustment to stump or prosthesis. Surgical stump revision was recommended in 26% of stumps and prosthetic management in 41%. A further 22%, subject to the success or failure of prescribed prosthetic adjustment, could require stump revision.

CONCLUSION

Youth, proximal injury, high numbers of AKA, psychosocial issues and the need for stump and prosthetic support define this group of amputees. Unifying expertise within a National MDT will promote continuity of care necessary for decades to come. The ultimate aim is an evidence-based amputee care system in Gaza, with lower limb specialists promoting best outcomes, judicious allocation of funds and maximising amputee quality of life.

Mental health outcomes of male UK military personnel deployed to Afghanistan and the role of combat injury: analysis of baseline data from the ADVANCE cohort study

BACKGROUND

The long-term psychosocial outcomes of UK armed forces personnel who sustained serious combat injuries during deployment to Afghanistan are largely unknown. We aimed to assess rates of probable post-traumatic stress disorder (PTSD), depression, anxiety, and mental health-associated multimorbidity in a representative sample of serving and ex-serving UK military personnel with combat injuries, compared with rates in a matched sample of uninjured personnel.

METHODS

This analysis used baseline data from the ADVANCE cohort study, in which injured individuals were recruited from a sample of UK armed forces personnel who were deployed to Afghanistan and had physical combat injuries, according to records provided by the UK Ministry of Defence. Participants from the uninjured group were frequency-matched by age, rank, regiment, deployment, and role on deployment. Participants were recruited through postal, email, and telephone invitations. Participants completed a comprehensive health assessment, including physical health assessment and self-reported mental health measures (PTSD Checklist, Patient Health Questionnaire-9, and Generalised Anxiety Disorder-7). The mental health outcomes were rates of PTSD, depression, anxiety, and mental health-associated multimorbidity in the injured and uninjured groups. The ADVANCE study is ongoing and is registered with the ISRCTN registry, ISRCTN57285353.

FINDINGS

579 combat-injured participants (161 with amputation injuries and 418 with non-amputation injuries) and 565 uninjured participants were included in the analysis. Participants had a median age of 33 years (IQR 30-37 years) at the time of assessment. 90·3% identified as White and 9·7% were from all other ethnic groups. The rates of PTSD (16·9% [n=89] vs 10·5% [n=53]; adjusted odds ratio [AOR] 1·67 [95% CI 1·16-2·41], depression (23·6% [n=129] vs 16·8% [n=87]; AOR 1·46 [1·08-2·03]), anxiety (20·8% [n=111] vs 13·5% [n=71]; AOR 1·56 [1·13-2·24]) and mental health-associated multimorbidity (15·3% [n=81] vs 9·8% [n=49]; AOR 1·62 [1·12-2·49]) were greater in the injured group than the uninjured group. Minimal differences in odds of reporting any poor mental health outcome were noted between the amputation injury subgroup and the uninjured group (AOR range 0·77-0·97), whereas up to double the odds were noted for the non-amputation injury subgroup compared with the uninjured group (AOR range 1·74-2·02).

INTERPRETATION

Serious physical combat injuries were associated with poor mental health outcomes. However, the type of injury sustained influenced this relationship. Regardless of injury, this cohort represents a group who present with greater rates of PTSD than the general population, as well as increased psychological burden from multimorbidity.

FUNDING

The ADVANCE Charity.

Mental and physical health, and long-term quality of life among service members injured on deployment

Background

More than 52,000 casualties have been documented in post-9/11 conflicts. Service members with extremity injuries (EIs) or traumatic brain injury (TBI) may be at particular risk for long-term deficits in mental and physical health functioning compared with service members with other injuries.

Methods

The present study combined medical records with patient reports of mental health and health-related quality of life (HRQOL) for 2,537 service members injured in overseas contingency operations who participated in the Wounded Warrior Recovery Project. Combined parallel-serial mediation models were tested to examine the pathways through which injury is related to mental and physical health conditions, and long-term HRQOL.

Results

Results revealed that injury was indirectly related to long-term HRQOL via its associations with physical health complications and mental health symptoms. Relative to TBI, EI was associated with a higher likelihood for a postinjury diagnosis for a musculoskeletal condition, which were related to lower levels of later posttraumatic stress disorder (PTSD) symptoms, and higher levels of physical and mental HRQOL. Similarly, EI was related to a lower likelihood for a postinjury PTSD diagnosis, and lower levels of subsequent PTSD symptoms, and therefore higher physical and mental HRQOL relative to those with TBI. Despite this, the prevalence of probable PTSD among those with EI was high (35%). Implications for intervention, rehabilitation, and future research are discussed.

Depression, Anxiety, and Post-Traumatic Stress Disorder Following Orthopedic War Injuries

Introduction

There are ongoing wars worldwide, during which significant numbers of people are injured. Several studies have indicated that high rates of depression and anxiety are seen in war-injured patients.

Methods

Eighty-one male patients treated between November 2019 and January 2021 far from home in a Turkish hospital due to war injuries that happened in the Libyan Civil War were investigated. Demographic characteristics and injury data of the patients were evaluated regarding age, Injury Severity Score (ISS), location of injuries, type and mechanism of injuries, operations, and accompanying traumas. The psychological statuses of the patients were evaluated with the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and post-traumatic stress disorder (PTSD) records filled out at the first admission to the hospital.

Results

The mean age of the patients was 29.8±7.7 (19-56) years. While 59 patients had fractures, 22 patients had only soft tissue injuries. Eighteen patients suffered from other accompanying injuries. While 85.2% of the patients showed symptoms of depression, 82.7% of the patients suffered from anxiety and PTSD symptoms were seen in 86.4% of the patients. Statistical analysis was performed to investigate the effects of injury severity, duration of hospitalization, number of operations, and age on depression, anxiety, and PTSD among these patients with war injuries. The results did not indicate any significant effect of injury severity, hospitalization duration, or operations.

Conclusion

Depression, anxiety, and PTSD are common in patients injured in wars. Injury severity does not seem to affect depression, anxiety, or PTSD in these patients.

Financial difficulty in community-dwelling persons with lower limb loss is associated with reduced self-perceived health and wellbeing

BACKGROUND

Socioeconomic status has been shown to be an important factor in the disparate prevalence and selected treatment of limb loss, but how personal financial difficulty affects patients' health outcomes is currently unclear.

OBJECTIVE

Examining how presence and experience of personal financial difficulty affects perceived health and wellbeing in individuals with lower limb loss.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 90 participants (68 males, mean age 58.7 ± 16.7 years) were recruited from local physical therapy and prosthetic and orthotic clinics, rehabilitation hospitals, and a regional amputee patient support group. All participants were community-dwelling, non-military adults with amputation involving at least one major lower limb joint. Participants were interviewed, and each completed a survey that included basic demographic/medical information, self-reported health and wellbeing (Short-Form Health Survey, SF-36v2), and a question to determine their financial situation after limb loss. Multiple regression analyses were used to examine the effect of financial difficulty on the eight subscales of SF-36v2 while accounting for age, gender, and amputation level.

RESULTS

Experiencing financial difficulty significantly and negatively affected Role-Physical and Role-Emotional subscale scores (p < 0.01 and p = 0.02, respectively). Individuals with financial difficulty scored approximately 60% lower in these two specific subscales.

CONCLUSION

Experiencing financial difficulty is a significant predictor for diminished work or daily activity participation due to physical and emotional stresses. Clinicians and health policy makers need to understand how socioeconomic factors may prevent individuals with lower limb loss from achieving higher levels of functional recovery and community re-integration after amputation.

CLINICAL RELEVANCE

Our findings showed that presence or experience of financial difficulty was significantly associated with diminished community re-integration in community-dwelling, non-military adults with lower limb loss. It affects both physical and emotional aspects of wellbeing. Clinicians should be aware how socioeconomic factors may affect social re-integration after amputation.

Psychosocial reactions to upper extremity limb salvage: A cross-sectional study

STUDY DESIGN

Descriptive cross-sectional survey study.

INTRODUCTION

Limb salvage spares an extremity at risk for amputation after a major traumatic injury. Psychosocial recovery for individuals with lower extremity limb salvage has been discussed in the literature. However, to date, psychosocial reactions for individuals with upper extremity (UE) limb salvage have not been examined.

PURPOSE OF THE STUDY

To determine which factors may influence psychosocial adaptation to UE limb salvage.

METHODS

Participants (n = 30; 28 males) were adults (mean, 30.13; range, 18-61) who sustained an UE limb salvage from a traumatic event. Adaptation was measured using a modified version of the Reactions to Impairment and Disability Inventory.

RESULTS

A linear mixed-effects regression found that worse psychosocial adaptation was associated with having less than a college degree, being less than 6 months post-injury, being older than 23 years, and having more pain. Dominant hand injuries were found to influence poor adaptation on the denial Reactions to Impairment and Disability Inventory subscale only.

DISCUSSION

The results of this study indicate that there is potential for nonadaptive reactions and psychological distress with certain variables in UE limb salvage. Therapists may use these results to anticipate which clients may be at risk for poor psychosocial outcomes.

CONCLUSIONS

This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. However, future research is indicated to better understand the unique psychosocial challenges and needs of these individuals.

LEVEL OF EVIDENCE

4.

Amputees Unanimous: A 12-step program

BACKGROUND

Alongside physical impairment, psychosocial health issues may arise after amputation, impacting quality of life. Traditional psychosocial care models provide services in a linear fashion, with limited supports upon discharge. A novel program entitled Amputees Unanimous is a 12-step program provided for amputees by amputees.

OBJECTIVE

To shape the final content of Amputees Unanimous by identifying personal beliefs and opinions of healthcare professionals and amputees.

STUDY DESIGN

Qualitative design utilizing a phenomenological approach.

METHOD

Five focus groups were held: four with amputees and one with healthcare providers. A phenomenological approach shaped the inquiry of the lived experience of limb loss in relation to the content of Amputees Unanimous.

RESULTS

Three themes emerged: (1) accepting limb loss, (2) peer inspiration, and (3) regaining prior level of function.

CONCLUSION

Limb loss may alter one's self-image, both physically and psychologically, having a profound effect on how an individual copes throughout his or her lifetime. The content and delivery format of Amputees Unanimous could be tested for effectiveness as a program tailored to facilitate coping after limb loss and to provide encouragement, support, and hope for the future of amputees.

CLINICAL RELEVANCE

A dynamic, amputee-led, mutual help program may provide individuals with limb loss a place for encouragement, support, and optimism for the future.

Comparing life satisfaction and functioning 15 years after September 11, 2001 among survivors with and without injuries: a mixed-method study

PURPOSE

This study compares life satisfaction and limited activity days among 9/11 survivors with and without physical injuries using quantitative and qualitative approaches.

METHODS

The study population included World Trade Center Health Registry enrollees who reported being injured on 9/11 in 2003-2004 and a sample of non-injured enrollees who participated in a cross-sectional substudy. We used multivariable logistic regression to examine differences in life satisfaction and number of limited activity days in the last 30 days between those with and without injuries. The free-response section of the survey was analyzed qualitatively to compare themes of those with and without injuries.

RESULTS

The final sample consisted of 2821 adult enrollees. Compared to those who were not injured, those who were injured on 9/11 were more likely to report being unsatisfied with their life (adjusted odds ratio (AOR): 1.5, 95% confidence intervals (CI) 1.1-2.0) and have 14 or more limited activity days in the last 30 days (AOR: 1.4, 95% CI 1.0-1.9). Among those who were injured, being partially or completely prevented from working increased the odds of being unsatisfied with life and having 14 or more limited activity days. In qualitative analysis, the emotional trauma experienced from 9/11 was a major and common theme, regardless of injury status. Those with injuries were more likely to express anger/lack of recognition/appreciation, describe substance use/abuse, and have financial/health care access issues.

CONCLUSIONS

More than 15 years after 9/11, those who were injured continue to be impacted, reporting lower life satisfaction and more functional impairment.

Evaluation of Three Postal Invitational Strategies to Increase Survey Response Rates in a Combat-Injured U.S. Military Population: Findings From the Wounded Warrior Recovery Project

The survival rate of those injured in combat in overseas contingency operations is higher than in previous conflicts. There is a need to assess the long-term psychosocial and quality of life outcomes of those injured in combat, yet surveying this population presents inherent challenges. As part of a large-scale, longitudinal examination of patient-reported outcomes of service members injured on deployment, the present manuscript evaluated the effectiveness of three postal strategies on response rates: (1) mailing a study prenotification postcard, (2) mailing the survey invitation in a larger envelope, and (3) including a small cash preincentive ($2). Evaluation of these strategies yielded mixed results in this population. Neither the prenotification postcard nor inclusion of a $2 cash preincentive significantly increased response rates. However, use of a larger envelope to mail the survey invitation significantly increased the response rate by 53.1%. Researchers interested in collecting patient-reported outcomes among military populations, including those with combat-related injuries, may find that increasing the visibility of recruitment materials is more effective for improving response rates than attempting to cognitively prime or offer prospective participants preincentives.

Life after conflict-related amputation trauma: a clinical study from the Gaza Strip

Background

More than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip.

Methods

We included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history.

Results

The amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family’s sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt.

Conclusions

The most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.

Combat amputees' health-related quality of life and psychological outcomes: A brief report from the wounded warrior recovery project

BACKGROUND

This study extends what is known about long-term health-related quality of life (HrQoL) and other psychosocial outcomes (i.e., depression, posttraumatic stress disorder [PTSD]) among US military combat amputees serving in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.

METHODS

A total of 63 combat amputees were identified from the Wounded Warrior Recovery Project, a study assessing long-term self-reported HrQoL and psychological outcomes among those wounded during military service. Another 477 service members from the Wounded Warrior Recovery Project were identified as a comparison group (i.e., nonamputees with moderate to severe extremity injuries).

RESULTS

After adjusting for age, time since injury, overall injury severity, and traumatic brain injury, amputees had poorer functional HrQoL than those in the nonamputee comparison group overall and in the specific area related to performance of usual activities, and, to some degree, chronic and acute symptoms, and mobility/self-care. On the other hand, depression and PTSD symptoms were not different for the two groups.

CONCLUSION

Results suggest that when assessed over 5 years postinjury, on average, amputees have unique physical and functional limitations, yet do not report greater depression or PTSD symptoms than others seriously injured in combat. It may be that state-of-the-art integrated amputee care that includes support networks and emphasis on adjustment and psychological health may increase successful coping and adjustment, at least to a level that is on par with other types of serious combat injury.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

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.

Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients

INTRODUCTION

Following severe lower extremity trauma, patients who undergo limb reconstruction and amputations both endure frequent complications and mental health sequelae. The purpose of this study is to assess the extent to which late amputation following a period of limb salvage impacts the evolution of the clinical variables that can affect the patient's perception of his or her limb: ongoing limb associated complications and mental health conditions.

PATIENTS AND METHODS

A case series of US service members who sustained a late major extremity amputation from September 2001 through July 2011 were analysed. Pre- and post-amputation complications, mental health conditions, and reason(s) for desiring amputation were recorded.

RESULTS

Forty-four amputees with detailed demographic, injury and treatment data were identified. The most common reasons for desiring a late amputation were pain and being dissatisfied with the function of the salvage limb. An average of 3.2 (range 1-10) complications were reported per amputee prior to undergoing late amputation and an average of 1.8 (range 0-5) complications reported afterwards. The most common complication prior to and after late amputation was soft tissue infection (24 (17%) and 9 (22%), respectively). Twenty-nine (64%) late amputees were diagnosed with a mental health condition prior to undergoing their amputation and 27 (61%) late amputees were diagnosed with mental conditions after late amputation. Only three of the 15 patients who did not have a mental health condition documented prior to their late amputation remained free of a documented mental health condition after the amputation.

DISCUSSION

Ongoing complications and mental health conditions can affect how a patient perceives and copes with his or her limb following severe trauma. Patient dissatisfaction following limb reconstruction can influence the decision to undergo a late amputation. Patients with a severe, combat related lower extremity injury that are undergoing limb salvage may not have a reduction in their overall complication rate, a resolution of specific complications or an improvement of their mental health after undergoing late amputation.

CONCLUSION

Surgeons caring for limb salvage patients should counsel appropriately when managing expectations for a patient who desires a late amputation.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review

BACKGROUND

Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment.

METHOD

Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)).

RESULTS

25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%).

CONCLUSIONS

Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Anxiety and depression following traumatic limb amputation: a systematic review

BACKGROUND

Traumatic amputation can result in multiple physical, psychological and socio-economic sequalae. While there has been a significant increase in investment and public profile of the rehabilitation of patients who have experienced traumatic limb amputation, little is known about the prevalence of anxiety and depression, especially in the long term.

OBJECTIVE

To determine the association between traumatic limb amputation and anxiety and depression.

DATA SOURCES

A literature search of available databases including Cochrane, Medline, Embase, and PsycINFO was performed for relevant studies since 2002. Secondary outcomes included the effect on employment, substance misuse, relationships and quality of life.

SELECTION CRITERIA

Randomised control trials, observational studies or reviews which met the inclusion, exclusion and quality criteria.

RESULTS

Levels of anxiety and depression are significantly higher than in the general population. Significant heterogeneity exists between studies making meta-analyses inappropriate. Improved rehabilitation is having a positive effect on employment rates. There appears to be no significant effect on substance abuse and relationships.

CONCLUSIONS

All studies demonstrated high prevalence of anxiety and depression in post-traumatic amputees. No good prospective data exists for levels of anxiety and depression beyond two years of follow up and this should be an area of future study.

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.

Glasgow Coma Scores, early opioids, and posttraumatic stress disorder among combat amputees

A recent study found that combat amputees had a reduced prevalence of posttraumatic stress disorder (PTSD) compared with nonamputees with serious extremity injuries. We hypothesized that an extended period of impaired consciousness or early treatment with morphine could prevent consolidation of traumatic memory and the development of PTSD. To examine this hypothesis, we retrospectively reviewed 258 combat casualty records from the Iraq or Afghanistan conflicts from 2001-2008 in the Expeditionary Medical Encounter Database, including medications and Glasgow Coma Scale (GCS) scores recorded at in-theater facilities within hours of the index injury. All patients sustained amputations from injuries. Psychological diagnoses were extracted from medical records for 24 months postinjury. None of 20 patients (0%) with GCS scores of 12 or lower had PTSD compared to 20% of patients with GCS scores of 12 or greater who did have PTSD. For patients with traumatic brain injury, those treated with intravenous morphine within hours of injury had a significantly lower prevalence of PTSD (6.3%) and mood disorders (15.6%) compared to patients treated with fentanyl only (prevalence of PTSD = 41.2%, prevalence of mood disorder = 47.1%). GCS scores and morphine and fentanyl treatments were not significantly associated with adjustment, anxiety, or substance abuse disorders.

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.

Ectopic bone formation in severely combat-injured orthopedic patients -- a hematopoietic niche

Combat-related heterotopic ossification (HO) has emerged as a common and problematic complication of modern wartime extremity injuries, contributing to substantial patient morbidity and loss of function. We have previously reported that HO-forming patients exhibit a more pronounced systemic and local inflammatory response very early in the wound healing process. Moreover, traumatized muscle-derived mesenchymal progenitor cells from these patients have a skewed differentiation potential toward bone. Here, we demonstrate that HO lesions excised from this patient population contain highly vascularized, mature, cancellous bone containing adipogenic marrow. Histologic analysis showed immature hematopoietic cells located within distinct foci in perivascular regions. The adipogenic marrow often contained low numbers of functional erythroid (BFU-E), myeloid (CFU-GM, CFU-M) and multilineage (CFU-GEMM) colony-forming hematopoietic progenitor cells (HPCs). Conversely, tissue from control muscle and non-HO traumatic wound granulation tissue showed no evidence of hematopoietic progenitor cell activity. In summary, our findings suggest that ectopic bone can provide an appropriate hematopoietic microenvironment for supporting the proliferation and differentiation of HPCs. This reactive and vibrant cell population may help maintain normal hematopoietic function, particularly in those with major extremity amputations who have sustained both massive blood loss, prompting systemic marrow stimulation, as well as loss of available native active marrow space. These findings begin to characterize the functional biology of ectopic bone and elucidate the interactions between HPC and non-hematopoietic cell types within the ectopic intramedullary hematopoietic microenvironmental niche identified.