AAOS Now

Published 3/24/2021
|
Brooke C. Hergert; Pedro G. Teixeira, MD; Anthony E. Johnson, MD, FAAOS

Focus on Rehabilitation Needed after Two Decades of Gains in Acute Trauma Care

Acute trauma care has made significant gains since the turn of the 21st century. Many improvements can be attributed to tactical combat casualty care methodologies learned on the battlefields of Iraq and Afghanistan and used in civilian acute trauma care. Best practices such as increased use of tourniquets and hemostatic dressings, improved fluid resuscitation, and emphasis on airway management have vastly advanced acute trauma care in the civilian sector.

Recognizing the military’s trauma care advances, we are now examining other areas of improvement, specifically the rehabilitation of those suffering traumatic amputations. As with battlefield care, civilian acute care trauma teams have been able to resuscitate and save the lives of individuals with more severe injuries than in the past. The question remains whether the post-acute care period has also realized gains comparable to those in trauma care, as patients are surviving with more severe injuries in need of post-acute rehabilitation.

Comparison of injury outcomes: early 2000s versus now

Barmparas et al. analyzed traumatic amputations within the National Trauma Data Bank (NTDB) from 2000 to 2004 (prior). The authors of this article used that study as a benchmark for hospital care of amputees prior to the influence of two decades of war. They first determined whether patients presenting with amputations in the NTDB from 2013 to 2017 (current) were similar in demographics, admission physiology, and injury severity compared to prior data. After a comparison of patient demographics, they then compared outcomes to determine differences in the post-acute period.

To explore differences in patient demographics with amputations from years past, they identified all patients with a limb amputation in the NTDB from 2013 to 2017. Patients with isolated finger and/or toe amputations were considered as minor amputations and excluded from further analysis. They then conducted a descriptive analysis of patients’ demographics, admission physiology, injury severity, and outcomes, and compared the data to the prior NTDB study.

From 2013 to 2017, they identified 37,000 patients undergoing amputation, representing 0.8 percent of trauma patients within the NTDB. This finding aligns with the trend seen in past studies of a decreasing incidence of traumatic amputations. Among the amputees contained within the NTDB, 7,016 (19 percent) had a major limb amputation, which the authors included in their analysis. Men comprised the largest percentage of amputees, as they did in years past (79 percent versus 77 percent; P = 0.013).

Compared to prior amputee data, current amputees were older (mean age, 39.3 ± 18.0 years versus 36 ± 18 years; P < 0.001), with more than 22 percent of current amputees aged older than 55 years compared to only 14 percent of prior data amputees (P < 0.001). Not only are current amputees older, but they are also presenting more severely injured than in the past (mean Injury Severity Score [ISS], 18 ± 12 versus 17 ± 13; P < 0.001). Nearly half (48 percent) of current amputees present with an ISS > 15 compared to 38 percent in the past (P < 0.001), despite similar patterns and mechanisms of injury.

Even as age and injury severity have increased over the years, mortality has significantly decreased. Prior amputee mortality (meaning that they arrived at the hospital alive, but discharge status was listed as deceased or expired) was 13 percent, whereas current amputee mortality was 6 percent (P < 0.001). Despite the significant decrease in mortality among amputees, hospital length of stay (LOS) remained virtually unchanged. Prior mean LOS was 14 ± 17 days, and current mean LOS was 14 ± 15 days (P = 0.184).

As more severely injured patients survive their injuries to hospital discharge, focus must shift to the post-acute care period to affect factors such as LOS and rehabilitation. The post-acute rehabilitation period is crucial to helping those who survive severe, disabling amputations lead healthy and productive lives. The same gains in acute trauma care that have been seen in the civilian sector are possible in post-acute care and rehabilitation, as the military has also made tremendous gains in the post-acute rehabilitation setting.

Although there has been no significant change in how long patients with amputations remain in the hospital, there has been minimal change in where patients are discharged following acute care hospital stay.

In the early 2000s, 25 percent of patients were discharged to a skilled nursing facility, similar rehabilitation program, or long-term acute care facility.

Current data are similar, with 28 percent of patients discharged to those types of facilities. There was a significant decrease in patients being discharged home. In prior years, 60 percent were discharged to their homes, some with home health or hospice, whereas in current years, 33 percent were discharged home. Although fewer patients are discharged home, and with no change in patients discharging to rehabilitation facilities, it is unclear what level of care amputees who do not fall within either of those categories are receiving.

Conclusion

Contemporary NTDB analysis of those with major amputations demonstrates that a greater number of patients are surviving to hospital discharge. Patients with traumatic amputations are surviving with more severe injuries, affirming the gains in acute trauma care that have been made in the past two decades. Many of the gains can be attributed to the military translation of tactical care to the civilian hospital setting. Although there have been substantial gains in acute care, patients are remaining in the hospital for the same amount of time as in years past. The gains in rehabilitation have not similarly translated to the civilian setting. This finding offers an immense opportunity to learn from military rehabilitation of amputees and apply those same principles to civilian amputees so they can regain their highest level of functionality after the acute injury period.

Brooke C. Hergert is a fourth-year medical student at Dell Medical School at the University of Texas in Austin. Following graduation, she hopes to pursue a career in physical medicine and rehabilitation. Prior to medical school, Ms. Hergert served in the U.S. Army and worked as a civil engineer.

Pedro G. Teixeira, MD, is a fellow of the American College of Surgeons and the Society for Vascular Surgery, as well as a member of the American Association for the Surgery of Trauma. He is an associate professor in the Department of Surgery and Perioperative Care at the University of Texas at Austin Dell Medical School.

Anthony E. Johnson, MD, FAAOS, is chair of the AAOS Diversity Advisory Board, which reports to the AAOS Membership Council, and practices in the Department of Surgery and Perioperative Care at the University of Texas at Austin Dell Medical School in Austin, Texas. He is also an AAOS Now Editorial Board member.

References

  1. Butler FK: TCCC updates: two decades of saving lives on the battlefield: tactical combat casualty care turns 20. J Spec Oper Med 2017;17:166-72.
  2. Teixeira PGR, Brown CVR, Emigh B, et al: Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury. J Am Coll Surg 2018;226:769-76.e761.
  3. Pasquina PF: DOD paradigm shift in care of servicemembers with major limb loss. J Rehabil Res Dev 2010;47:xi-xiv.
  4. Barmparas G, Inaba K, Teixeira PG, et al: Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg 2010;76:1214-22.
  5. Dillingham TR, Pezzin LE, MacKenzie EJ: Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil 1998;79:279-87.
  6. Webster JB: Lower limb amputation care across the active duty military and veteran populations. Phys Med Rehabil Clin N Am 2019;30:89-109.