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

Transforming the Anthropomorphic Passive Free-Flow Foot Prosthesis Into a Powered Foot Prosthesis With Intuitive Control and Sensation (Bionic FFF)

INTRODUCTION

Approximately 89% of all service members with amputations do not return to duty. Restoring intuitive neural control with somatosensory sensation is a key to improving the safety and efficacy of prosthetic locomotion. However, natural somatosensory feedback from lower-limb prostheses has not yet been incorporated into any commercial prostheses.

MATERIALS AND METHODS

We developed a neuroprosthesis with intuitive bidirectional control and somatosensation and evoking phase-dependent locomotor reflexes, we aspire to significantly improve the prosthetic rehabilitation and long-term functional outcomes of U.S. amputees. We implanted the skin and bone integrated pylon with peripheral neural interface pylon into the cat distal tibia, electromyographic electrodes into the residual gastrocnemius muscle, and nerve cuff electrodes on the distal tibial and sciatic nerves. Results. The bidirectional neural interface that was developed was integrated into the existing passive Free-Flow Foot and Ankle prosthesis, WillowWood, Mount Sterling, OH. The Free-Flow Foot was chosen because it had the highest Index of Anthropomorphicity among lower-limb prostheses and was the first anthropomorphic prosthesis brought to market. Conclusion. The cats walked on a treadmill with no cutaneous feedback from the foot in the control condition and with their residual distal tibial nerve stimulated during the stance phase of walking.

The Exploration of the GWOT Combat Amputee's Experience With Longitudinal Care: A Qualitative Study

INTRODUCTION

Contemporary advances in combat medicine have allowed greater numbers of wounded service members to survive their injuries. An estimated 1,705 combat veterans sustained major lower or upper extremity amputations between 2001 and 2017 during the Global War on Terror. This study intends to answer the following question utilizing a qualitative study design: What were the common and abnormal experiences of the Global War on Terror combat amputees relative to their mechanism of injury, perception of injury, and systems of care utilized during their recovery and rehabilitation process?.

METHODS

During the months of December 2022 and January 2023, individual semi-structured interviews were conducted with U.S. Marines that served in the Global War on Terror (total n = 10). Deductive and inductive approaches were employed to identify codes, themes, and meta-themes in the data.

RESULTS

All participants deployed to Afghanistan between the years 2010 and 2014 and were assigned to the following military occupational specialties: Explosive Ordnance Disposal technicians (total n = 2); combat engineers (total n = 2); and infantrymen (total n = 6). Analysis of data collected from interviews highlighted these key observations: (1) Themes in the combat amputee experience include support, systems of care, and mindset and (2) the themes synergistically contribute to the meta-themes mental health and pain and vice versa. As all participants were subjected to a blast mechanism of injury, it is difficult to determine if this played a role in deviating rehabilitation and recovery processes. Perception of injury and how well participants adapted to their new lifestyle, meaning how optimistic they were, appeared to play a significant role in recovery. Participants had mixed feelings about the care they had received but generally spoke favorably of military hospitals and were frustrated with the Veteran Affairs, and there was no clear consensus on their relationship with civilian health care, though most participants chose to seek most of their care through the Veteran Affairs.

CONCLUSION

Based on the research question, this study found an intricate relationship between mental health, pain, and the experiences of the participants regarding their care and rehabilitation. However, the nature of qualitative research makes it impossible to determine generalizations that can be used to create meaningful change to address improving combat amputee veteran care. Further research into long-term health outcomes based on hypotheses not evaluated in existing literature would further improve the ability of health care providers to care for this unique patient population.

Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature

Purpose Amputation is a life changing event that can significantly impact an individual's physical and mental well-being. Our objective was to review literature exploring the impact of amputation upon a person's functioning and inclusion in the workplace. Methods Medline, CINAHL, and PsycINFO were searched using keywords related to amputation, employment and community reintegration. Eligible studies were published since 2000 and one of the following study designs: randomized controlled trial, non-randomized controlled trial, retrospective study, prospective study, concurrent cohort study, or cross sectional study. Studies for civilians with amputation as well as service members and Veterans with amputation were considered for inclusion. Results The search identified 995 articles, 25 of which met inclusion/exclusion criteria and were included in the review. While strong evidence for correlations and predictors of outcomes after amputation were limited, multiple factors were identified as contributing to physical functioning and employment after amputation. Conclusions Outcomes after amputation can vary widely with many potentially inter-related factors contributing. The factors identified may also serve to inform the development of interventions aiming to improve functional performance and reintegration after amputation. Furthermore, the review highlights the need for more high quality prospective studies.

Characterization of disability following traumatic through knee and transfemoral amputations

INTRODUCTION

The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries.

METHODS

A retrospective review of all transfemoral and through knee amputations sustained by United States 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, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data.

RESULTS

A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129).

DISCUSSION/CONCLUSION

Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.

What Is New in Trauma-Related Amputations

Traumatic and trauma-related amputations represent unfortunate sequelae of severe injury, but should not be viewed as a treatment failure and may represent the best reconstructive option for some patients. Lessons from recent military conflicts have guided the evolution of modern surgical techniques and rehabilitation management of this challenging patient population, and treatment at a specialty center may improve patient outcomes. Despite appropriate management, however, surgical complications remain common and revision surgery is often necessary. Bridge synostosis procedures remain controversial, and clinical equipoise remains regarding their functional benefits. Based on European experience over the last 3 decades, osseointegration has evolved into a viable clinical alternative for patients unable to achieve acceptable function using conventional sockets, and several devices are being developed or tested in the United States. Targeted muscle reinnervation and advanced pattern recognition may dramatically improve the functional potential of many upper extremity amputees, and the procedure may also relieve neuroma-related pain. Furthermore, exciting new research may eventually facilitate haptic feedback and restore useful sensation for amputees. Natural disasters and global terrorism events, in addition to conventional trauma resulting in limb loss, make a working knowledge of current amputation surgical techniques essential to the practicing orthopaedic trauma surgeon.

Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes

Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.

Rehabilitation and multiple limb amputations: A clinical report of patients injured in combat

This clinical report describes the outpatient rehabilitation program for patients with multiple limb amputations enrolled in the Comprehensive Combat and Complex Casualty Care facility at the Naval Medical Center San Diego. Injury-specific data for 29 of these patients wounded by blast weaponry in Afghanistan in 2010 or 2011 were captured by the Expeditionary Medical Encounter Database at the Naval Health Research Center and were reviewed for this report. Their median Injury Severity Score was 27 (N = 29; range, 11-54). Patients averaged seven moderate to serious injuries (Abbreviated Injury Scale scores ≥2), including multiple injuries to lower limbs and injuries to the torso and/or upper limbs. All patients received care from numerous clinics, particularly physical therapy during the first 6 mo postinjury. Clinic use generally declined after the first 6 mo with the exception of prosthetic devices and repairs. The clinical team implemented the Mayo-Portland Adaptability Inventory, 4th Revision (MPAI-4) to assess functioning at outpatient program initiation and discharge (n = 23). At program discharge, most patients had improved scores for the MPAI-4 items assessing mobility, pain, and transportation, but not employment. Case reports described rehabilitation for two patients with triple amputations and illustrated multispecialty care and contrasting solutions for limb prostheses.