Injury, Int. J. Care Injured 46 (2015) 1527–1532
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Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients§ Chad A. Krueger a,*, Jessica C. Rivera b, David J. Tennent a, Andrew J. Sheean a, Daniel J. Stinner b, Joseph C. Wenke b a b
San Antonio Military Medical Center, Fort Sam Houston, TX, United States United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 May 2015
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. Published by Elsevier Ltd.
Keywords: Late amputation Limb salvage Limb reconstruction Combat injury PTSD
Introduction §
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of Defense or the US government. This work was prepared as part of the authors’ official duties and, as such, there is no copyright to be transferred. * Corresponding author at: Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States. Tel.: +1 210 916 3410; fax: +1 210 916 7323. E-mail addresses: [email protected], [email protected] (C.A. Krueger). http://dx.doi.org/10.1016/j.injury.2015.05.015 0020–1383/Published by Elsevier Ltd.
The burden of musculoskeletal injuries and, in particular, amputations is well documented [1–5]. In spite of this, there is a relative lack of reporting on the course of those patients that undergo amputation at or after 90 days from their original injury [6–8]. Efforts focused on salvaging severely injured extremities often times involve an intensive, multidisciplinary expenditure of resources that seeks to address complicated clinical scenarios [4,9–12]. This fact, combined with the potential morbidity of
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delayed amputation procedures, continues to compel initiatives to better understand the clinical factors that determine the lasting viability of severely injured extremities [13,14]. Recent literature has shown that both limb salvage patients and late amputees experience short and long-term extremity complications [15–18]. Additionally, it appears that both limb salvage patients and amputees both endure adverse mental health outcomes secondary to their injuries [4,15,19,20]. What remains unknown, however, is the extent to which a late amputation decreases the likelihood of complications encountered in this population. In the setting of a patient who is unsatisfied with his or her salvaged limb, the understanding of late amputation outcomes would be important for orthopaedic surgeons to adequately counsel these patient in order to more appropriately manage their expectations following a late amputation. The purpose of this study was to assess the extent to which late amputation 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. This retrospective case series was conducted under a protocol approved by our institutional review board. Patients and methods A database of all military amputations (Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, TX) was queried to identify all major extremity amputations (MEA) sustained by service members that occurred between October 1, 2001 and July 30, 2011. This database contains demographic information on all US Military amputees injured during recent military conflicts who were treated at military treatment facilities. MEA was defined as an amputation proximal to the carpals or tarsals of a limb and a late amputation was determined to be any amputation that occurred 90 days or more after injury. These names were then cross-referenced within the Department of Defense Trauma Registry ((DoDTR) Fort Sam Houston, TX). This registry contains medical treatment data on service members that is obtained from the battlefield and each treatment facility where they are treated. This generated a potential subject list from the above mentioned period of combat. The final case series was derived from the potential list based on two inclusion criteria. First, the electronic medical records of each subject were evaluated for documentation of pre and post amputation treatment, function, complications and mental health conditions. Subjects were potentially included if the medical documentation was adequate to delineate a treatment and complication timeline. Secondly, subjects with adequate medical records were included if the documentation indicated that a portion of the driving force behind the decision for late amputation was the subject’s dissatisfaction with his or her salvaged limb. This was done in order to exclude patients who underwent amputation solely for a medically indicated reason such as infection in lieu of patients who underwent amputation in an attempt to improve function, pain, and/or limb satisfaction. After accounting for these exclusions, 44 late amputees were further examined. Simple statistics are used to describe the frequency of pre- and post-amputation complications and mental health disorders. Results These amputees were typically young males with a mean age of 26 (SEM 0.84, range 20–42 years old). The majority (70%) of these amputees was injured via explosive device and sustained a penetrating injury (54%). The mean Injury Severity Score (ISS)
Table 1 Demographic information for all patients in this study. Demographic information Injury type Blunt Burn Penetrating
16 5 23
37% 11% 52%
Mechanism of injury GSW/firearm Burn Explosive device Fall MVC
10 1 31 1 1
24% 2% 70% 2% 2%
GSW: gunshot wound; MVC: motor vehicle collision.
for these amputees was 14.8 (SEM 1.4, range 1–50). The injury types and mechanisms are found in Table 1. The mean number of days from injury to amputation was 576 days (SEM 56, range 96– 1696 days). Thirty of the 44 subjects (68%) had entered in the military medical evaluation board process pending medical discharge from the service; the mean number of days from to initiation of the medical board process which reflects the limitation of follow up available in the military electronic medical record was 996 days (SEM 73, range 485–1785 days). The levels of amputation among late amputees is summarised in Fig. 1, and the most common level of late amputation occurred at the transtibial level (33, 75%). The most common reasons documented in the medical record for late amputees desiring amputation were pain associated with their salvaged limb (31 amputees, 69%) and being unsatisfied with their functional ability or range of motion (26 amputees, 58%). There were an average of 2.4 reasons for desiring a late amputation per amputee and a list of all patient reported reasons for wanting to undergo an amputation is presented in Table 2. There were 138 total complications that were documented by health care providers in the late amputees prior to undergoing their amputation (mean 3.2 per amputee, SEM 0.27, range 1–10 complications). The most common complications prior to late amputation were soft tissue infection (24, 17%), joint pain (17, 23%), chronic regional pain syndrome, and nonunion (16, 12% each). The mean number of complications per amputee after undergoing late amputation was 1.8 (SEM 0.13, range 0–5). The most common complications sustained after undergoing their late amputation were soft tissue infection (9, 22%), heterotopic ossification (7, 17%), arthritis/joint pain, osteomyelitis and wound dehiscence (5, 12% each). The complete list of complications reported before and after late amputation is summarised in Table 3. The pre-amputation complications associated with a longer time to prosthesis fitting after amputation were heterotopic ossification (mean 182 days), wound dehiscence (149 days) and soft tissue infection (mean 148 days). Among the eleven patients that required revision amputation, all revisions were undertaken to address infection, with four cases involving the soft tissues (36%) and seven cases of osteomyelitis (64%). Details pertaining to mental health characteristics in this cohort are presented in Table 4. 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 diagnosed after late amputation. The mental health conditions that were present prior to the late amputation were typically not the same as the mental health conditions present after the 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.
[(Fig._1)TD$IG]
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Fig. 1. Distribution of late amputations by level.
Discussion The late amputees evaluated in this study were of a similar demographic compared to previous studies evaluating those service members with combat-related lower extremity trauma [3,13,21]. These data demonstrate that complications in the injured extremity were common before the late amputation and despite undergoing the late amputation. Moreover, mental health disorders persisted following a late amputation. Table 2 Documented reasons of why the limb salvage patients wanted a late amputation. Reasons for desired late amputation
n
%
Pain Not satisfied with functional level Nerve dysfunction Nounion/malunion of fractures Chronic infection Lack of joint motion Lack of strength Skin coverage or flap failure CRPS
30 26 13 11 10 6 4 2 1
68 59 30 25 23 13 9 5 2
CRPS: Chronic Regional Pain Syndrome.
Our data are consistent with prior studies demonstrating that limb salvage patients opting for late amputation continue to experience a difficult clinical course and that late amputation may not necessarily remedy these untoward sequelae [7,9,19,21–24]. This fact would be important to the surgeon counselling a Table 3 Complications present before and after a late amputation. Complication
Before amputation
Soft tissue infection Nonunion/malunion PTOA CRPS Osteomyelitis Loss of motion Heterotopic ossification Wound dehiscence Compartment Syndrome Deep vein Thrombosis Painful hardware Pulmonary Embolism Phantom pain
24 19 17 16 12 11 10 9 6 6 4 3 1
After amputation 55% 43% 39% 36% 27% 25% 23% 20% 14% 14% 9% 7% 2%
9 0 5 2 4 0 7 5 0 1 1 0 1
20% 0% 11% 5% 9% 0% 16% 11% 0% 2% 2% 0% 2%
PTOA: Post traumatic osteoarthritis; CRPS: Chronic regional pain syndrome.
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Table 4 Number of mental health conditions documented for patients before and after undergoing late amputation. Some conditions persisted while some conditions were newly diagnosed following late amputation.. Mental health condition
Before amputation
Persisted
New onset
Anxiety PTSD Depression Insomnia Substance abuse Other
12 14 5 2 1 2
1 2 0 0 0 0
4 11 11 1 1 4
No condition Total
15 52
3 4
17 37
PTSD: Post-traumatic stress disorder.
frustrated patient with a salvaged extremity that may perceive late amputation as a panacea. In contrast, these data suggest that late amputation may not significantly decrease the likelihood of the need for reoperation, the number of post-operative complications, and the prevalence mental health disease. In other words opting for a late amputation does not provide a definitive clinical outcome. While it may not be possible or wise to attempt continued limb salvage on an extremity that continues to have complications or a worsening condition, the decision for amputation is not always driven by medical necessity but by patient desire for a different functional outcome. Advances in limb salvage rehabilitation in combination with our data contributing to the mounting evidence that late amputation does not remedy the burden of severe extremity trauma should shift the perception that some limbs that could continue on the limb salvage pathway [24– 26]. Soft tissue and osseous infections accounted for over 25% and 35% of all complications in the pre-amputation and postamputation time periods, respectively. The high rate of infection is comparable to similar studies evaluating similar patient cohorts and may give pause to surgeons and limb salvage patients who desire an amputation as a means to eradicate infection [7,18,21,27–30]. In fact, Melcer et al. showed that late amputees actually had higher rates of infectious complications and nonhealing wounds compared to limb salvage patients and acute amputees [18]. The rate of complication after amputation within this cohort was very similar to that published by Tintle et al. and the revision rate for late amputation found in this study was similar to the revision rate of more acute amputations completed for combat-related and civilian injuries [30,31]. Other literature such as that by Brown et al., which found an increased risk of infection when patients had undergone a fasciotomy or treated with a tourniquet for their mangled lower extremity, suggest that certain treatment characteristics may be associated with an infectious outcome [27]. While no definitive conclusions can be drawn from this case series on such an association, this study does reiterate the very complex nature of severe lower extremity trauma and the requisite treatments. Therefore, the complexity and severity of the injuries themselves rather than the course of treatment may explain why both limb salvage patients and amputees do relatively poorly after sustaining the high-energy injuries commonly sustained during combat regardless of treatments rendered [[2_TD$IF]4,17,32,33]. These results also seem to suggest that undergoing a late amputation does not change the mental health of limb salvage patients post-operatively. There were no significant differences in the rate of depression, PTSD or other mental conditions pre or post amputation. In one study, Melcer et al. found that late amputees and limb salvage patients had significantly higher rates of PTSD compared to early amputees and that late amputees had
significantly higher rates of most psychological diagnoses than limb salvage patients [18]. Other studies have also shown that limb-salvage patients had significantly higher rates TBI and PTSD than amputees after sustaining lower extremity trauma but that late amputees have the highest number of total mental health conditions [15,34]. As with the presence of complications, this data seem to suggest that it is the injury, and not the treatment, that impacts an injured service member’s mental reaction to his or her injury. Performing a late amputation in hopes of improving a patient’s mental health may at best be misguided and at worse cause a new insult that can negatively impact the patient’s mental health. Persistent and new onset mental health conditions such as PTSD, anxiety and depression may also be indicative of a patient’s function or satisfaction with their extremity declining [35–37]. These mental health conditions may also have a large effect on an amputee’s ability to rehabilitate or change the perception of what they are able to accomplish post amputation [38]. The Lower Extremity Assessment Project (LEAP) study and several other similar research initiatives have demonstrated the impact of intrinsic patient factors such as self-efficacy on outcomes. These results seem to support the notion that those intrinsic factors are predicated on the injury itself and not the treatment [6,19,39]. The LEAP Study Group set a precedent for defining late amputation as an amputation which is performed at 3 months or later following injury [6]. In their analysis, this time point was selected to delineate which subjects had undergone an attempted limb reconstruction as opposed to amputations performed earlier as part of the acute wound and fracture care. We chose to uphold the LEAP precedent to focus our analysis on subjects who had undergone a course of limb reconstruction, differentiating them from ‘‘early’’ amputees who had not endured the time and multiple procedures typical of limb reconstruction. Nevertheless, undergoing an early amputation does not protect patients with severe lower extremity trauma from complications or guarantee a superior outcome. In the LEAP study population, early amputees experienced wound infections in 51 of 149 subjects (34%), wound break down or other stump complication requiring revision in 20 subjects (13%), and chronic pain in 23 subjects (15%) [31]. Metaanalyses by both Busse et al. and Akula et al. conclude that patients with early amputation have similar functional outcomes and quality of life compared to limb salvage patients, though Akula et al. detected that limb salvage was more psychologically acceptable [40,41]. Giannoudis et al. also supported similar, poor outcomes in patients with open tibia fractures and amputations reporting persistent disability in both groups with pain, conduct of usual activities and self-care, and mobility [42]. On counter argument in support of early amputation, other literature supports that delaying amputation in a limb that cannot be reconstructed is associated with high that expected infection rates [43]. The weaknesses of this study are typical of retrospective analyses as these data were collected using a multiple electronic medical records. All of these patients had different follow up periods as some moved out of the military quickly and were not able to be tracked while others continued to have follow up that was easy to follow for years after their amputation. In addition, it contained both upper and lower extremity amputees. While complications associated with late upper extremity amputations have been analysed in a separate paper [22], the main goal of this paper was to evaluate if undergoing a late amputation changed the complications and mental health encountered by the patient. The functional outcomes of the amputees were not evaluated. Therefore, the authors felt it was appropriate to leave the five upper extremity amputees as part of the evaluated cohort. As Melcer et al. have showed, the majority of physical and psychological complications for both late amputees and limb salvage patients occur within the first year after injury, it is entirely
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possible that late amputees experience the majority of their complications within the acute and sub-acute periods following late amputation evaluated by this study [15,18]. In this sense, data extracted from a relatively short interval of follow-up may overstate the impact of complications among late amputees and that the incidence of complications does, in fact, recede with time. However, the LEAP study group suggests that newly observed complications are rare after the first year of follow up, making the follow up available for this study within acceptable limits [39]. It is also important to recognise that some of these patients had more of a choice in electing a late amputation than others. Such decision can be influenced by financial motivations given the high disability payments to which amputees are entitled from the military [23,44]. We are unable to account for financial motivations or other individual decision making processes in this study; and it was not possible for us to stratify this data as such. However, prior to October 2011, only patients who underwent limb amputation were eligible for compensation for their injuries. All of the amputees in this cohort were from prior to that date. We also did not evaluate if certain amputation levels were associated with specific complications as there were not enough amputations to provide meaningful statistical function. Lastly, because of the limited nature of a portion of the available data, this analysis did not incorporate validated functional outcome scores. These scores may have provided further information regarding the overall function of these patients and provided insight towards their conditions that were not otherwise elucidated by the variables we chose to present in the current study. Conclusion Patients with a severe, combat-related lower extremity injury treated initially with limb salvage may not have a reduction in their overall complication rate or a resolution of specific complications after undergoing a late amputation. These results, however, do not appear to differ markedly from those continue with limb salvage. These patients also seem to have mental health conditions that are largely based on their injury sustained and not the treatment received. This study can be used to further counsel patients who are contemplating a late amputation. Conflict of interest None of the authors have any financial or intellectual conflicts of interest to report[1_TD$IF]. References [1] Belmont PJ, Goodman GP, Zacchilli M, Posner M, Evans C, Owens BD. Incidence and epidemiology of combat injuries sustained during ‘‘The Surge’’ portion of Operation Iraqi Freedom by a US Army Brigade Combat Team. J Trauma 2010;68:204–10. [2] Owens BD, Kragh Jr JF, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64(2):295–9. [3] Krueger CA, Wenke JC, Ficke JR. Ten years at war. J Trauma Acute Care Surg 2012;73:S438–44. [4] Doukas WC, Hayda RA, Frisch HM, Anderson RC, Mazurek MT, Ficke JR, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013;95(2):138–45. [5] Reiber GE, McFarland LV, Hubbard S, Maynard C, Blough DK, Gambel JM, et al. Servicemembers and veterans with major traumatic limb loss from Vietnam and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev 2010;47:275–98. [6] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002;347:1924–31. [7] Helgeson MD, Potter BK, Burns TC, Hayda RA, Gajewski DC. Risk factors for and results of late or delayed amputation following combat-related extremity injuries. Orthopaedics 2010;33(9):669.
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Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients§ Chad A. Krueger a,*, Jessica C. Rivera b, David J. Tennent a, Andrew J. Sheean a, Daniel J. Stinner b, Joseph C. Wenke b a b
San Antonio Military Medical Center, Fort Sam Houston, TX, United States United States Army Institute of Surgical Research, Fort Sam Houston, TX, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 May 2015
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. Published by Elsevier Ltd.
Keywords: Late amputation Limb salvage Limb reconstruction Combat injury PTSD
Introduction §
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of Defense or the US government. This work was prepared as part of the authors’ official duties and, as such, there is no copyright to be transferred. * Corresponding author at: Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States. Tel.: +1 210 916 3410; fax: +1 210 916 7323. E-mail addresses: [email protected], [email protected] (C.A. Krueger). http://dx.doi.org/10.1016/j.injury.2015.05.015 0020–1383/Published by Elsevier Ltd.
The burden of musculoskeletal injuries and, in particular, amputations is well documented [1–5]. In spite of this, there is a relative lack of reporting on the course of those patients that undergo amputation at or after 90 days from their original injury [6–8]. Efforts focused on salvaging severely injured extremities often times involve an intensive, multidisciplinary expenditure of resources that seeks to address complicated clinical scenarios [4,9–12]. This fact, combined with the potential morbidity of
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delayed amputation procedures, continues to compel initiatives to better understand the clinical factors that determine the lasting viability of severely injured extremities [13,14]. Recent literature has shown that both limb salvage patients and late amputees experience short and long-term extremity complications [15–18]. Additionally, it appears that both limb salvage patients and amputees both endure adverse mental health outcomes secondary to their injuries [4,15,19,20]. What remains unknown, however, is the extent to which a late amputation decreases the likelihood of complications encountered in this population. In the setting of a patient who is unsatisfied with his or her salvaged limb, the understanding of late amputation outcomes would be important for orthopaedic surgeons to adequately counsel these patient in order to more appropriately manage their expectations following a late amputation. The purpose of this study was to assess the extent to which late amputation 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. This retrospective case series was conducted under a protocol approved by our institutional review board. Patients and methods A database of all military amputations (Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, TX) was queried to identify all major extremity amputations (MEA) sustained by service members that occurred between October 1, 2001 and July 30, 2011. This database contains demographic information on all US Military amputees injured during recent military conflicts who were treated at military treatment facilities. MEA was defined as an amputation proximal to the carpals or tarsals of a limb and a late amputation was determined to be any amputation that occurred 90 days or more after injury. These names were then cross-referenced within the Department of Defense Trauma Registry ((DoDTR) Fort Sam Houston, TX). This registry contains medical treatment data on service members that is obtained from the battlefield and each treatment facility where they are treated. This generated a potential subject list from the above mentioned period of combat. The final case series was derived from the potential list based on two inclusion criteria. First, the electronic medical records of each subject were evaluated for documentation of pre and post amputation treatment, function, complications and mental health conditions. Subjects were potentially included if the medical documentation was adequate to delineate a treatment and complication timeline. Secondly, subjects with adequate medical records were included if the documentation indicated that a portion of the driving force behind the decision for late amputation was the subject’s dissatisfaction with his or her salvaged limb. This was done in order to exclude patients who underwent amputation solely for a medically indicated reason such as infection in lieu of patients who underwent amputation in an attempt to improve function, pain, and/or limb satisfaction. After accounting for these exclusions, 44 late amputees were further examined. Simple statistics are used to describe the frequency of pre- and post-amputation complications and mental health disorders. Results These amputees were typically young males with a mean age of 26 (SEM 0.84, range 20–42 years old). The majority (70%) of these amputees was injured via explosive device and sustained a penetrating injury (54%). The mean Injury Severity Score (ISS)
Table 1 Demographic information for all patients in this study. Demographic information Injury type Blunt Burn Penetrating
16 5 23
37% 11% 52%
Mechanism of injury GSW/firearm Burn Explosive device Fall MVC
10 1 31 1 1
24% 2% 70% 2% 2%
GSW: gunshot wound; MVC: motor vehicle collision.
for these amputees was 14.8 (SEM 1.4, range 1–50). The injury types and mechanisms are found in Table 1. The mean number of days from injury to amputation was 576 days (SEM 56, range 96– 1696 days). Thirty of the 44 subjects (68%) had entered in the military medical evaluation board process pending medical discharge from the service; the mean number of days from to initiation of the medical board process which reflects the limitation of follow up available in the military electronic medical record was 996 days (SEM 73, range 485–1785 days). The levels of amputation among late amputees is summarised in Fig. 1, and the most common level of late amputation occurred at the transtibial level (33, 75%). The most common reasons documented in the medical record for late amputees desiring amputation were pain associated with their salvaged limb (31 amputees, 69%) and being unsatisfied with their functional ability or range of motion (26 amputees, 58%). There were an average of 2.4 reasons for desiring a late amputation per amputee and a list of all patient reported reasons for wanting to undergo an amputation is presented in Table 2. There were 138 total complications that were documented by health care providers in the late amputees prior to undergoing their amputation (mean 3.2 per amputee, SEM 0.27, range 1–10 complications). The most common complications prior to late amputation were soft tissue infection (24, 17%), joint pain (17, 23%), chronic regional pain syndrome, and nonunion (16, 12% each). The mean number of complications per amputee after undergoing late amputation was 1.8 (SEM 0.13, range 0–5). The most common complications sustained after undergoing their late amputation were soft tissue infection (9, 22%), heterotopic ossification (7, 17%), arthritis/joint pain, osteomyelitis and wound dehiscence (5, 12% each). The complete list of complications reported before and after late amputation is summarised in Table 3. The pre-amputation complications associated with a longer time to prosthesis fitting after amputation were heterotopic ossification (mean 182 days), wound dehiscence (149 days) and soft tissue infection (mean 148 days). Among the eleven patients that required revision amputation, all revisions were undertaken to address infection, with four cases involving the soft tissues (36%) and seven cases of osteomyelitis (64%). Details pertaining to mental health characteristics in this cohort are presented in Table 4. 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 diagnosed after late amputation. The mental health conditions that were present prior to the late amputation were typically not the same as the mental health conditions present after the 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.
[(Fig._1)TD$IG]
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Fig. 1. Distribution of late amputations by level.
Discussion The late amputees evaluated in this study were of a similar demographic compared to previous studies evaluating those service members with combat-related lower extremity trauma [3,13,21]. These data demonstrate that complications in the injured extremity were common before the late amputation and despite undergoing the late amputation. Moreover, mental health disorders persisted following a late amputation. Table 2 Documented reasons of why the limb salvage patients wanted a late amputation. Reasons for desired late amputation
n
%
Pain Not satisfied with functional level Nerve dysfunction Nounion/malunion of fractures Chronic infection Lack of joint motion Lack of strength Skin coverage or flap failure CRPS
30 26 13 11 10 6 4 2 1
68 59 30 25 23 13 9 5 2
CRPS: Chronic Regional Pain Syndrome.
Our data are consistent with prior studies demonstrating that limb salvage patients opting for late amputation continue to experience a difficult clinical course and that late amputation may not necessarily remedy these untoward sequelae [7,9,19,21–24]. This fact would be important to the surgeon counselling a Table 3 Complications present before and after a late amputation. Complication
Before amputation
Soft tissue infection Nonunion/malunion PTOA CRPS Osteomyelitis Loss of motion Heterotopic ossification Wound dehiscence Compartment Syndrome Deep vein Thrombosis Painful hardware Pulmonary Embolism Phantom pain
24 19 17 16 12 11 10 9 6 6 4 3 1
After amputation 55% 43% 39% 36% 27% 25% 23% 20% 14% 14% 9% 7% 2%
9 0 5 2 4 0 7 5 0 1 1 0 1
20% 0% 11% 5% 9% 0% 16% 11% 0% 2% 2% 0% 2%
PTOA: Post traumatic osteoarthritis; CRPS: Chronic regional pain syndrome.
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Table 4 Number of mental health conditions documented for patients before and after undergoing late amputation. Some conditions persisted while some conditions were newly diagnosed following late amputation.. Mental health condition
Before amputation
Persisted
New onset
Anxiety PTSD Depression Insomnia Substance abuse Other
12 14 5 2 1 2
1 2 0 0 0 0
4 11 11 1 1 4
No condition Total
15 52
3 4
17 37
PTSD: Post-traumatic stress disorder.
frustrated patient with a salvaged extremity that may perceive late amputation as a panacea. In contrast, these data suggest that late amputation may not significantly decrease the likelihood of the need for reoperation, the number of post-operative complications, and the prevalence mental health disease. In other words opting for a late amputation does not provide a definitive clinical outcome. While it may not be possible or wise to attempt continued limb salvage on an extremity that continues to have complications or a worsening condition, the decision for amputation is not always driven by medical necessity but by patient desire for a different functional outcome. Advances in limb salvage rehabilitation in combination with our data contributing to the mounting evidence that late amputation does not remedy the burden of severe extremity trauma should shift the perception that some limbs that could continue on the limb salvage pathway [24– 26]. Soft tissue and osseous infections accounted for over 25% and 35% of all complications in the pre-amputation and postamputation time periods, respectively. The high rate of infection is comparable to similar studies evaluating similar patient cohorts and may give pause to surgeons and limb salvage patients who desire an amputation as a means to eradicate infection [7,18,21,27–30]. In fact, Melcer et al. showed that late amputees actually had higher rates of infectious complications and nonhealing wounds compared to limb salvage patients and acute amputees [18]. The rate of complication after amputation within this cohort was very similar to that published by Tintle et al. and the revision rate for late amputation found in this study was similar to the revision rate of more acute amputations completed for combat-related and civilian injuries [30,31]. Other literature such as that by Brown et al., which found an increased risk of infection when patients had undergone a fasciotomy or treated with a tourniquet for their mangled lower extremity, suggest that certain treatment characteristics may be associated with an infectious outcome [27]. While no definitive conclusions can be drawn from this case series on such an association, this study does reiterate the very complex nature of severe lower extremity trauma and the requisite treatments. Therefore, the complexity and severity of the injuries themselves rather than the course of treatment may explain why both limb salvage patients and amputees do relatively poorly after sustaining the high-energy injuries commonly sustained during combat regardless of treatments rendered [[2_TD$IF]4,17,32,33]. These results also seem to suggest that undergoing a late amputation does not change the mental health of limb salvage patients post-operatively. There were no significant differences in the rate of depression, PTSD or other mental conditions pre or post amputation. In one study, Melcer et al. found that late amputees and limb salvage patients had significantly higher rates of PTSD compared to early amputees and that late amputees had
significantly higher rates of most psychological diagnoses than limb salvage patients [18]. Other studies have also shown that limb-salvage patients had significantly higher rates TBI and PTSD than amputees after sustaining lower extremity trauma but that late amputees have the highest number of total mental health conditions [15,34]. As with the presence of complications, this data seem to suggest that it is the injury, and not the treatment, that impacts an injured service member’s mental reaction to his or her injury. Performing a late amputation in hopes of improving a patient’s mental health may at best be misguided and at worse cause a new insult that can negatively impact the patient’s mental health. Persistent and new onset mental health conditions such as PTSD, anxiety and depression may also be indicative of a patient’s function or satisfaction with their extremity declining [35–37]. These mental health conditions may also have a large effect on an amputee’s ability to rehabilitate or change the perception of what they are able to accomplish post amputation [38]. The Lower Extremity Assessment Project (LEAP) study and several other similar research initiatives have demonstrated the impact of intrinsic patient factors such as self-efficacy on outcomes. These results seem to support the notion that those intrinsic factors are predicated on the injury itself and not the treatment [6,19,39]. The LEAP Study Group set a precedent for defining late amputation as an amputation which is performed at 3 months or later following injury [6]. In their analysis, this time point was selected to delineate which subjects had undergone an attempted limb reconstruction as opposed to amputations performed earlier as part of the acute wound and fracture care. We chose to uphold the LEAP precedent to focus our analysis on subjects who had undergone a course of limb reconstruction, differentiating them from ‘‘early’’ amputees who had not endured the time and multiple procedures typical of limb reconstruction. Nevertheless, undergoing an early amputation does not protect patients with severe lower extremity trauma from complications or guarantee a superior outcome. In the LEAP study population, early amputees experienced wound infections in 51 of 149 subjects (34%), wound break down or other stump complication requiring revision in 20 subjects (13%), and chronic pain in 23 subjects (15%) [31]. Metaanalyses by both Busse et al. and Akula et al. conclude that patients with early amputation have similar functional outcomes and quality of life compared to limb salvage patients, though Akula et al. detected that limb salvage was more psychologically acceptable [40,41]. Giannoudis et al. also supported similar, poor outcomes in patients with open tibia fractures and amputations reporting persistent disability in both groups with pain, conduct of usual activities and self-care, and mobility [42]. On counter argument in support of early amputation, other literature supports that delaying amputation in a limb that cannot be reconstructed is associated with high that expected infection rates [43]. The weaknesses of this study are typical of retrospective analyses as these data were collected using a multiple electronic medical records. All of these patients had different follow up periods as some moved out of the military quickly and were not able to be tracked while others continued to have follow up that was easy to follow for years after their amputation. In addition, it contained both upper and lower extremity amputees. While complications associated with late upper extremity amputations have been analysed in a separate paper [22], the main goal of this paper was to evaluate if undergoing a late amputation changed the complications and mental health encountered by the patient. The functional outcomes of the amputees were not evaluated. Therefore, the authors felt it was appropriate to leave the five upper extremity amputees as part of the evaluated cohort. As Melcer et al. have showed, the majority of physical and psychological complications for both late amputees and limb salvage patients occur within the first year after injury, it is entirely
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possible that late amputees experience the majority of their complications within the acute and sub-acute periods following late amputation evaluated by this study [15,18]. In this sense, data extracted from a relatively short interval of follow-up may overstate the impact of complications among late amputees and that the incidence of complications does, in fact, recede with time. However, the LEAP study group suggests that newly observed complications are rare after the first year of follow up, making the follow up available for this study within acceptable limits [39]. It is also important to recognise that some of these patients had more of a choice in electing a late amputation than others. Such decision can be influenced by financial motivations given the high disability payments to which amputees are entitled from the military [23,44]. We are unable to account for financial motivations or other individual decision making processes in this study; and it was not possible for us to stratify this data as such. However, prior to October 2011, only patients who underwent limb amputation were eligible for compensation for their injuries. All of the amputees in this cohort were from prior to that date. We also did not evaluate if certain amputation levels were associated with specific complications as there were not enough amputations to provide meaningful statistical function. Lastly, because of the limited nature of a portion of the available data, this analysis did not incorporate validated functional outcome scores. These scores may have provided further information regarding the overall function of these patients and provided insight towards their conditions that were not otherwise elucidated by the variables we chose to present in the current study. Conclusion Patients with a severe, combat-related lower extremity injury treated initially with limb salvage may not have a reduction in their overall complication rate or a resolution of specific complications after undergoing a late amputation. These results, however, do not appear to differ markedly from those continue with limb salvage. These patients also seem to have mental health conditions that are largely based on their injury sustained and not the treatment received. This study can be used to further counsel patients who are contemplating a late amputation. Conflict of interest None of the authors have any financial or intellectual conflicts of interest to report[1_TD$IF]. References [1] Belmont PJ, Goodman GP, Zacchilli M, Posner M, Evans C, Owens BD. Incidence and epidemiology of combat injuries sustained during ‘‘The Surge’’ portion of Operation Iraqi Freedom by a US Army Brigade Combat Team. J Trauma 2010;68:204–10. [2] Owens BD, Kragh Jr JF, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008;64(2):295–9. [3] Krueger CA, Wenke JC, Ficke JR. Ten years at war. J Trauma Acute Care Surg 2012;73:S438–44. [4] Doukas WC, Hayda RA, Frisch HM, Anderson RC, Mazurek MT, Ficke JR, et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013;95(2):138–45. [5] Reiber GE, McFarland LV, Hubbard S, Maynard C, Blough DK, Gambel JM, et al. Servicemembers and veterans with major traumatic limb loss from Vietnam and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev 2010;47:275–98. [6] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002;347:1924–31. [7] Helgeson MD, Potter BK, Burns TC, Hayda RA, Gajewski DC. Risk factors for and results of late or delayed amputation following combat-related extremity injuries. Orthopaedics 2010;33(9):669.
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