After sustaining an injury to his lower right foot during the initial stages of Operation Iraqi Freedom that resulted in amputation, Cpt. David M. Rozelle later returned to a combat zone, the first amputee to do so. U.S. Army photo by Pfc. Matthew Clifton.
Courtesy of DVIDS


Published 7/1/2011
Peter Pollack

Returning to duty after open tibial fractures

Patients treated with limb salvage or amputation have comparable rates of return

“If you have a severe lower extremity injury, whether you choose to undergo amputation or limb salvage, it is unlikely that you will return to duty,” said LTC Joseph R. Hsu, MD, who presented his paper on “Return to Military Service Following Type III Open Tibia Fracture” at the Limb Lengthening and Reconstruction Society’s Specialty Day at the AAOS Annual Meeting.

“Another group from our institution recently published a paper on return-to-duty (RTD) rates for amputees, and found that the overall rate was about 16.5 percent,” he said. “Although that may seem like a very low number, it is higher than any documented rate for previous military conflicts.

“We didn’t have similar information on limb salvage patients,” he continued, “and there was some concern that limb salvage patients weren’t returning to duty at the same rate. Our aim was to define the return-to-duty rate for military patients with severe open tibia fractures.”

Identical return rates
To examine the issue, Dr. Hsu and his team reviewed the records of 115 wounded military with type III open tibia fractures (127 fractures). Overall, they found that 83 percent of tibias were retained, and the RTD rates for service people with retained limbs was 20 percent. In addition, for service people with no contralateral lower extremity fracture or amputation, the RTD rate was 22 percent. Patients in the RTD group were, on average, significantly older, of higher rank, and tended to have a lower rate of nerve injuries and osteomyelitis, compared with those who did not return.

“Based on information from the amputee study, individuals who went before the Army Physical Evaluation Board (PEB) after an isolated transtibial amputation had an RTD rate of 22 percent. In our study, for those who had type III open tibia fractures, the RTD rate was 22 percent. They were identical.”

The research team had to create an additional category for soldiers who returned to duty “by recovery,” rather than review by the PEB. In essence, 14 individuals who underwent limb salvage simply healed and returned to duty, avoiding the PEB process altogether.

“In comparison, amputees in the current conflicts traditionally go back to duty via PEB,” said Dr. Hsu.

A possible bias?
Dr. Hsu explained that the similar RTD rates did not surprise him or his colleagues.

“We have all had several limb salvage patients who returned to duty,” he said. “Limb salvage patients often serve in anonymity. Amputations are very clear, but limb salvage is much harder to identify.”

According to Dr. Hsu, perhaps the most controversial finding of the study is that the PEB ratings showed that amputees were rated as having a statistically significant greater disability than limb salvage patients—a situation he believes may be indicative of a systemic bias.

“I don’t believe that amputees are, in general, more disabled than limb salvage patients,” he said, “but biases have been found in civilian systems for rating disability. It could be that a parallel bias exists in the military approach, and we may need to review our disability rating systems.”

Dr. Hsu’s coauthors included CPT Jessica D. Cross, MD; CPT Daniel J. Stinner, MD; MAJ Travis C. Burns, MD; Joseph C. Wenke, PhD; and the Skeletal Trauma Research Consortium.

This study has been accepted for publication in the Journal of Orthopaedic Trauma.

Disclosures: Dr. Burns, Dr. Cross, Dr. Stinner—no conflicts; Dr. Hsu—The Geneva Foundation.

Peter Pollack is a staff writer for AAOS Now. He can be reached at

Bottom Line

  • Military amputees are returning to duty at higher rates than during any previous conflict.
  • Military personnel who sustain type III open tibial fractures return to duty at similar rates to military personnel with isolated transtibial amputations.
  • Limb salvage patients who return to duty are often not recognized, because their injury is not as obvious as an amputation.
  • The fact that amputees are rated as having a greater disability may indicate a systemic bias.