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Back to the front lines: Amputees keep fighting

By Peter Pollack

Study looks at factors contributing to soldiers’ return

Damage-control orthopaedic treatment of wounded military personnel often begins on the front line. Military surgeons débride and irrigate open wounds, apply external fixation, and perform fasciotomy and revascularization. As a result, injured patients receive an average of two procedures before arriving at a military hospital in the United States—often within 96 hours of injury.

Cpt. David M. Rozelle stands on a third-floor balcony of Al-Faw Palace, Camp Victory, Iraq, April 1, 2005. Rozelle returned to Iraq after losing his lower right leg during the initial stages of Operation Iraq Freedom. Rozelle is the first amputee to return to a combat zone after suffering such an injury. Courtesy of Multi-National Corps Iraq Public Affairs

Such advances in combat casualty care are not only saving more lives, they are enabling more soldiers to return to active duty. In particular, the percentage of amputees who return to active duty in the U.S. armed forces is higher now than ever before, according to LTC Kevin L. Kirk, DO, who presented his paper, “Return to Duty Rate of Amputee Soldiers in the Current Conflicts in Afghanistan and Iraq,” at the annual meeting of the American Orthopaedic Foot & Ankle Society.

The research team, which included CPT Daniel J. Stinner, MD; CPT Travis C. Burns, MD; and COL James R. Ficke, MD, attempted to identify factors that increase likelihood of return to duty.

Return rates improve over time
According to the U.S. Military, personnel are considered to be unfit for service if they have had a major limb amputation. However, military personnel may petition to remain on active duty if they can obtain recommendations from two medical officers and demonstrate a high level of function with prostheses.

“Overall, 82 percent of casualties in the current conflicts in Afghanistan and Iraq have sustained extremity injuries,” said Dr. Kirk, “with traumatic amputations accounting for 2.3 percent of all battle injuries and 7.4 percent of major limb injuries.”

Dr. Kirk and his colleagues reviewed the cases of all U.S. military personnel who had combat-related amputations from Oct. 1, 2001, through June 1, 2006, as well as the records of personnel who appeared before the Physical Evaluation Board (PEB) during that same time period at a minimum of 2 years post-amputation.

Of the 395 major limb amputees who appeared before the PEB, 65 (16.5 percent) returned to active duty.

A previous, similar study conducted in the 1980s provided the research team an opportunity to compare return rates. In the earlier study, 469 soldiers appeared before the PEB for an amputation sustained while on active duty between 1980 and 1988, but only 11 (2.3 percent) returned to active duty.

According to Dr. Kirk, one reason for the lower return rate in the earlier study may be a lack of designated amputee centers for U.S. personnel during the 1980s and 1990s.

“In addition to state-of-the-art rehabilitation found at these centers, it appears that informal group therapy among amputees may play a beneficial role,” he said.

Officers, elders most likely to return
Those with multiple extremity amputations had the lowest return-to-duty rate (3 percent). The overall return-to-duty rate for single extremity amputees was 20 percent (p<0.0001).

The 130 transtibial amputees comprised the largest single group in the study (32.9 percent). At 22 percent, they also presented one of the highest return-to-duty rates. Hand amputees also returned at a 22 percent rate. Foot amputees, at 25 percent, were most likely to return overall.

In breaking down the demographics of returning warriors, the researchers found that officers (35.3 percent) and senior enlisted personnel (25.5 percent) had a higher return rate than junior enlisted personnel (7.0 percent, p<0.0001). They also learned that older personnel were more likely to return than younger personnel—the average age of returning personnel was 31.4 years; the average age of separating personnel was 27.2 years (p<0.0001).

Gender did not appear to play a role in return to duty, with 63 of 384 male amputees (16.4 percent) returning and 2 of 11 female amputees (18.2 percent) returning.

Although the results were not statistically significant, amputees in combat units trended toward a higher return rate than amputees from support units such as military intelligence, medical, and transportation.

The authors report no relevant conflicts, but state that the opinions or assertions contained in the study are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Related articles:
Trauma care links military, civilian surgeons

War injuries drive orthopaedic advances

A salute to orthopaedics and the military

The ultimate volunteer experience: Serving at LRMC

Iraq: A week ‘in theater’

AAOS Now
November 2009 Issue
http://www.aaos.org/news/aaosnow/nov09/clinical5.asp