Rehabilitation Protocol Improves Return-to-Duty Outcomes for Limb-Salvage Military

Terry Stanton

Fewer than one in five soldiers who sustain lower limb amputation or type III open tibia fracture return to military duty. To help improve this outcome, staff at the San Antonio Military Medical Center developed a Return to Run clinical pathway (RTR) specifically for severely injured service members pursuing lower extremity limb salvage. The preliminary results of a retrospective cohort study of the results are presented in Scientific Poster P496, “Return to Duty After Integrated Orthotic and Rehabilitation Initiative,” on display in Academy Hall B.

The RTR is an aggressive multidisciplinary rehabilitation program that begins when the patients are still in circular external fixation. It emphasizes strength, plyometrics, power, and agility training with the ultimate goal of return to running, return to sport, or return to military deployment after the healing process is complete.

The researchers found that those who participated in the RTR showed a return-to-duty rate of nearly four times higher than those who did not. Both groups of patients had been fitted with a customized ankle-foot orthosis—an Intrepid Dynamic Exoskeletal Orthosis (IDEO). The IDEO has a footplate that fits into the shoe, a brace that stabilizes the ankle, and carbon fiber rods that run up the back of the calf to a cuff below the knee. It’s designed to support the severely damaged muscles, nerves, and joints of soldiers who do not undergo amputation. It also helps to offload painful ankle, hindfoot, and midfoot joints.

Service members who were enrolled in the RTR had sustained injuries with residual disabilities below the knee, and most considered amputation at some point during the course of their treatment. Injuries typically involved substantial motor and/or nerve deficit, and a large majority occurred secondary to high-energy injuries.

The RTR + IDEO patients (n = 115) began the pathway while they were still in circular external fixation and before they were fitted for an IDEO. More than half (51.3 percent) returned to duty, versus 12.9 percent for those who received the IDEO alone (n = 31) (P = 0.0001). This RTR return rate is higher than what has been previously reported for amputation, Type III open tibia fractures, and other types of routine orthopaedic injuries.

The RTR + IDEO group trended toward an older age and higher seniority in military rank than the IDEO-only group, and those in the RTR + IDEO group who returned to duty were also older and more senior in rank. Across both groups, soldiers whose injuries resulted from explosive mechanisms or gunshot wounds had significantly lower return to duty rates than did those whose injuries involved falls, motor vehicle collisions, and other miscellaneous injuries. Mechanism of injury had significant correlation with return to duty in the RTR group.

“This confirms how devastating explosive injuries can be,” said James A. Blair, MD, one of the study’s authors.

He noted that research into the IDEO is ongoing, and the device is currently available only for a military population. “However, we hope this research begins to show that while the IDEO is revolutionary, it is not magical,” Dr. Blair said. “Our study suggests that it is the rehabilitation that matters the most.”

To view this poster as an iPoster, visit http://aaos.posterview.com/

Co-authors with Dr. Blair are Jeanne C. Patzkowski, MD; Ryan Blanck, Johnny Owens, Joseph R. Hsu, MD; all of the Skeletal Research Consortium (STReC).

Disclosure information: Dr. Hsu—The Geneva Foundation, Combat Casualty Care Research Program, The Major Extremity Trauma Research Consortium, Clinical and Rehabilitative Medicine Research Program. The other authors reported no conflicts.

2013 Annual Meeting News
Tuesday through Friday, February 19 – 23, 2013.
http://www.aaos.org/news/acadnews/2013/AAOS4_3_21.asp