Early amputation in combat-injured service members with severe lower extremity injuries is generally associated with lower or similar prevalence for physical and psychological disorders than those treated with late amputation or limb salvage, primarily during the first several years after injury.

According to a new study from the Naval Health Research Center (NHRC), "A Comparison of Four-Year Health Outcomes following Combat Amputation and Limb Salvage," was published online January 25 in PLOS ONE -- a peer-reviewed, open access scientific journal published by the Public Library of Science.

The goal of the study was to investigate the differences in health outcomes between combat-injured patients treated with early amputation (within 90 days of injury), late amputation (more than 90 days after injury), and limb salvage (injury with complex fractures, vascular injuries, and major soft tissue injuries) over the first four years post-injury.

Previous research has shown short-term differences in outcomes between patients with an early unilateral lower extremity amputation and those with limb salvage or late amputation in terms of lower percentages of patients with wound complications and psychological disorders in the first two years after early amputation, but it was unclear whether differences persisted over time.

In NHRC's study, researchers also found that early amputation was associated with the reduced likelihood for wound complications, osteomyelitis, musculoskeletal disorders, and some psychological disorders when compared with the other groups. An important exception was early amputation was associated with an increased likelihood of developing osteoporosis during the first year after injury.

Researchers conducted a retrospective analysis of health records for 625 individuals with lower extremity amputation or limb salvage which resulted from combat injuries sustained in the Iraq or Afghanistan conflicts from 2001 through 2008.

Injury data, including clinical diagnoses four years post-injury, were obtained from the Expeditionary Medical Encounter Database, which provides detailed descriptions of combat-related injuries and associated treatments from point of injury through recovery and rehabilitation.

The study, funded by the Extremity Trauma and Amputation Center of Excellence, was one of the first to integrate Department of Defense (DoD) and Department of Veterans Affairs (VA) national health data, including inpatient and outpatient care over four years post-injury.

Other findings included:

* The early amputation group generally had a lower prevalence of wound complications, pain, musculoskeletal and psychological disorders than the late amputation group during the first several years post-injury.

* Approximately 90 percent of patients in all groups had at least one pain-related diagnosis during the first year post-injury. Approximately 50 percent of patients still had a pain-related diagnosis during the fourth year post-injury.

* The prevalence of most physical and psychological disorders decreased substantially over the four years after injury. The major exception was the prevalence of post-traumatic stress disorder (PTSD) increased significantly over the first several years after injury for all groups.

* Late amputation was significantly associated with a relatively high prevalence of physical and psychological disorders.

* A number of musculoskeletal and psychological disorders including pain and PTSD persisted at relatively high levels (20-50 percent) for at least four years post-injury.

Future directions for research, say study authors, should continue to track service members with combat-related amputations and limb salvage to increase understanding of their long-term health outcomes and inform future care and treatment. Additionally, because this relatively young cohort typically requires prolonged care and rehabilitation, researchers state there is a need to identify this populations' health care use, needs, and associated costs within both the DoD and VA health systems.

Medical Modeling, Simulation, and Mission Support:

Researchers from the Medical Modeling, Simulation, and Mission Support team at NHRC helped author the study. The team collects, analyzes, and interprets health and medical data using databases and tools developed by scientists at NHRC. Their capabilities include injury epidemiology research, medical planning, casualty estimation, operational risk and casualty care assessment, and leveraging medical intelligence for expeditionary medical planning and logistics.

The Publication:

Melcer T, Walker J, Bhatnagar V, Richard E, Sechriest II VF, Galarneau M (2017) Correction: A Comparison of Four-Year Health Outcomes following Combat Amputation and Limb Salvage. PLoS ONE 12(2): e0173214. doi:10.1371/journal.pone.0173214

http://www.ncbi.nlm.nih.gov/pubmed/28122002

About NHRC:

As the DoD's premier deployment health research center, NHRC's cutting-edge research and development is used to optimize the operational health and readiness of the nation's armed forces. In proximity to more than 95,000 active-duty service members, world-class universities, and industry partners, NHRC sets the standard in joint ventures, innovation, and translational research.

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