Date Published: January 25, 2017
Publisher: Public Library of Science
Author(s): Ted Melcer, Jay Walker, Vibha Bhatnagar, Erin Richard, V. Franklin Sechriest, Michael Galarneau, Steven Allen Gard.
Little research has described the long-term health outcomes of patients who had combat-related amputations or leg-threatening injuries. We conducted retrospective analysis of Department of Defense and Department of Veterans Affairs health data for lower extremity combat-injured patients with (1) unilateral amputation within 90 days postinjury (early amputation, n = 440), (2) unilateral amputation more than 90 days postinjury (late amputation, n = 78), or (3) leg-threatening injuries without amputation (limb salvage, n = 107). Patient medical records were analyzed for four years postinjury. After adjusting for group differences, early amputation was generally associated with a lower or similar prevalence for adverse physical and psychological diagnoses (e.g., pain, osteoarthritis, posttraumatic stress disorder) versus late amputation and/or limb salvage. By contrast, early amputation was associated with an increased likelihood of osteoporosis during the first year postinjury. The prevalence of posttraumatic stress disorder increased for all patient groups over four years postinjury, particularly in the second year. The different clinical outcomes among combat extremity injured patients treated with early amputation, late amputation, or limb salvage highlight their different healthcare requirements. These findings can inform and optimize the specific treatment pathways that address the physical and psychological healthcare needs of such patients over time.
Previous studies indicated that extremity injuries accounted for approximately half of combat wounds sustained by US service members in Iraq and Afghanistan conflicts [1,2]. For patients with the most severe leg injuries, treatment required either amputation or leg-threatening injuries without amputation (hereafter referred to as limb salvage) through reconstructive surgeries . Patients with combat-related amputation and limb salvage continue to present new treatment and rehabilitation challenges to healthcare providers at both military and Department of Veterans Affairs (VA) facilities [4–8].
Table 1 shows the demographic and injury characteristics for the study sample. The subjects were relatively young males with moderate to serious ISSs. The early amputation group had more severe injuries in comparison to the late amputation or limb salvage groups. Specifically, the early amputation group had significantly higher ISSs compared to the late amputation or limb salvage groups (p’s < 0.05) and a higher percentage of patients with blast injuries than the two comparison groups (p’s < 0.05). The early amputation group had a higher prevalence of above knee amputations (37%) compared to the late amputation (12%) and limb salvage (23%) patients (p’s < 0.05).There were no statistically significant differences in the prevalence of TBI or preinjury psychological diagnoses among the three groups. The present study shows differences in the adverse physical and psychological health outcomes for combat-injured patients treated with early amputation, late amputation, and limb salvage over the first four years postinjury. This study also provides initial results to inform and optimize clinical treatment and rehabilitation pathways specific to the needs of these different patient groups. Early amputation was generally associated with similar or reduced physical and psychological disorders relative to successful limb salvage or late amputation. A notable exception was an increased likelihood of osteoporosis following early amputation. Most evident was that late amputation (>90 days postinjury) was significantly associated with relatively high prevalence of physical and psychological disorders. Over time, all groups showed relatively high rates of complications including musculoskeletal disorders, pain, tobacco use disorder, mood disorders, and PTSD. The present results indicate that some musculoskeletal and psychological disorders persist for at least four years postinjury and may increase in the long-term as these patients age. Patients with severe combat extremity injuries typically require prolonged rehabilitation and, in the case of individuals with amputation and many limb salvage, lifelong prosthetic or orthotic care [31,46]. Future research should continue to track their military and VA health data outcomes over the long-term.