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The road to recovery and rehabilitation for injured service members with limb loss: a focus on Iraq and Afghanistan.


The early ability to stabilize and transport injured servicemen and women from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) to specialized military centers in the United States has resulted in an approximate 92% survival rate, a higher percentage than any other major military conflict. (1) As a result, service members have been returning from theatre with multiple amputations that require extensive rehabilitation from medical centers within the Department of Defense and the Department of Veterans Affairs. Approximately 2% of injured military personnel returning from OEF and OIF have sustained limb loss. (2) Military databases have indicated that as of April 2010, US medical centers have treated combatants with 992 major limb amputations (822 from OIF and 170 from OEF) and 341 minor amputations (317 from OIF and 24 from OEF). The relative youth and high fitness level of injured service members with ampuations (3) make them an ideal population for aggressive rehabilitation, but have also exposed the limitations of today's existing prosthetic technologies. Military personnel with amputations face unique challenges due to their short residual limbs, (2) unplanned amputations, (4) high incidences of multiple limb loss and accustomed activity levels prior to an amputation.


Debridement, Wound Care & Revision

The use of buried explosive devices such as land mines and improvised explosive devices (IEDs) have been used as a form of weaponry in every military conflict since World War II, (5) and a large portion of severe injuries occurring from military operations in Iraq and Afghanistan have resulted from blasts. (6) The use of explosive armaments generates extensive tissue trauma and disruption of vascular and neurological networks. (7) IED blasts expel the neighboring earth and shrapnel into the wound sites and require rapid wound care strategies. (5,7)

The meticulous debridement of injured tissues has remained of utmost importance in combat wounds as nonviable tissue has been known to create a nidus for infection and may impede the natural healing process. (7) The risk of infection has demanded staged debridement strategies and may result in the decision to delay wound closure. One survey of 230 patients with transtibial amputations conducted during the Vietnam War indicated that 59% of wound closures were left open and 41% were closed in theater. For service members who returned to the United States with closed amputation sites, 56% failed due to gross infection and required urgent surgical revision that reduced residual limb length. (8)

Infection Complications

Traumatic amputations present unique problems for surgeons which may be made more difficult by bacterial colonization. Infections have been a particular concern for combat-related injuries since the disruption of vascular integrity and localized tissue necrosis prevents antibiotics from reaching the wound site. When this occurs, the bacteria in the affected region may become resistant to antibiotics, especially when dosages are below the minimal inhibitory concentration. Studies investigating the infection rate in ischemic lower-extremity amputees report a broad infection range which depends largely on anatomical location. (9) Reports of resilient infections have occurred in over 600 injured service members from OIF and OEF following an extremity amputation (10) and include drug-resistant Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus. (10) Cultures obtained from wound sites of 732 injured service members involved in OIF concluded that a plethora of both gram-negative and gram-positive bacteria cultured were resistant to broad spectrum antibiotic treatments (Figure Additionally, blast injuries from IEDs often generate extensive burns and subsequent nosocomial infections because of multidrug resistant Acinetobacter baumannii. (11) Aggressive debridement and antibiotic usage has remained the standard of care for preventing and treating infections, but multidrug resistant bacterial infections have been a dangerous concern for service members injured in Iraq and Afghanistan. (11)

Residual Limb Problems Skin Breakdown

Successful treatment of an amputation in theatre has been the first phase in a challenging road to recovery and rehabilitation. Residual limb skin breakdown following wound closure has often resulted in superficial infections, the inability to properly wear prostheses, interference with rehabilitation and the need for surgical revisions. The high frequency of skin-related socket complications has occurred from mechanical breakdown, since skin thickness at extremity amputation sites are considerably thinner than the palms and soles which are especially equipped for high load bearing regimens. (12) Previous studies investigating skin breakdown in below-knee amputees revealed that one-third of patients suffered from unhealed wounds or damaged skin, (13) and 40% of lower extremity amputees had at least one skin problem on the lower limb. (14) To prevent breakdown at the skin-prosthetic interface, mechanical forces exerted on newly formed residual limbs must be carefully controlled since excessive skin tension may trigger localized tissue necrosis.


Skin breakdown in sockets has also been known to occur due to scar asymmetry and the suboptimum location of tissue reconstruction relative to weight bearing pressure. The location of the surgical closure scar in traumatic amputations has been commonly dictated by the initial injury and the attempt to retain as much residual limb length as possible. This situation has been further complicated by the dysvascular nature of mature scar tissue and the relative common attachment of scar tissue to the residual bone.

Heterotopic Ossification

Heterotopic ossification (HO) has been a frequent complication following blast-related injuries and traumatic amputations. (15) Ectopic bone has been reported to be variable in nature, (16) metabolically active (16) and results in mature osseous growth in the neighboring soft tissue (17) (Figure 2). While HO has been known to be a consequence of muscle and bone injury, the exact pathological process of HO has not yet been fully understood. (18) The development of HO has been strongly correlated with the presence of head, spine and blast injuries. (15) In fact, the frequency of HO in the residual limb of amputees with blast injuries returning from OIF and OEF has been reported as high as 63% in a study of 213 wounded service members. (15)


Large formations of ectopic bone have been especially disabling for service members who use sockets for prosthetic attachments. Rehabilitation of an amputee with HO may be challenging since wide variations in ectopic bone have been known to occur and may lead to an uncomfortable prosthetic fit. (19) HO may also manifest months after a blast injury and has a maturation rate upwards of 18 months. (20) As a result, poor prosthetic fit may occur and delay the rehabilitation for service members who require socket adjustments to compensate for HO formation. The interface between the residual limb and prosthetic socket overlying a bony prominence may also lead to skin breakdown and significantly restrict mobility of a patient with limb loss. (2,21)

Premature surgical resection of HO often results in more florid ectopic bone than before resection. For this reason, surgical resection of HO has often been delayed until complete HO maturation has occurred, along with the inflammatory stage of "myositis ossificans." Surgical resection of HO may also result in neurovascular damage (22) as these structures may be entwined in the bony deposits. While some studies have demonstrated success after removing HO 8 months from the initial amputation, (15) others have cautioned that 18 months may be a more appropriate timeframe, especially when head injuries or comorbidities have been involved. (16,23)

Phantom Limb Pain

Phantom limb pain (PLP), the painful sensation that an amputated limb is still present, has been known to occur in up to 85% of amputees. (24) Pain has been described as burning, itching, stabbing, cramping, throbbing, or feeling of "pins and needles." (25) While many causal factors have been proposed for PLP, including intrinsic residual limb pain, limb pain that was present prior to amputation, and the presence of neuromas formed after nerve transection, all of these correlations have been both supported and refuted by the literature. (24,26,27) The incidence of PLP has shown to be independent of gender, age (in adults), location, and level of amputation. (28)

It is important to note that congenital amputees have also reported PLP, and it has been speculated that both central and peripheral nervous systems must be active in the pain mechanism. (29) PLP has remained notoriously difficult to treat with few randomized controlled trials demonstrating significant results. Memantine, an oral NMDA receptor antagonist has demonstrated limited success in larger clinical trials for treating acute pain, but may be less effective for long-term established chronic neuropathic pain. (30) Mirror therapy, in which the patient observes the movements of a reflection of their intact limb in a mirror while simultaneously moving their phantom limb has been demonstrated to significantly decrease PLP in a randomized sham-controlled trial. (31)

Rehabilitation--Physical and Occupational Therapy

The severe injuries sustained by OIF and OEF service members have frequently required complex rehabilitation management. Rehabilitation interventions should be designed to maximize functional outcomes and the needs of each individual. Following prosthetic fitting, physical therapy may begin with simple standing and walking activities and slowly progress to higher level balance and mobility training, depending on the individuals' goals and abilities. Specific techniques include strengthening exercises for the residual limb and intact body parts as well as cardiopulmonary conditioning.

Rehabilitation for a service member with an amputation begins immediately following the amputation and includes education and training on skin care, residual limb desensitization, edema control and soft tissue mobilization. (32) Another significant goal of the early stages of rehabilitation has been the use of a prosthetic limb to restore lost function. Management of both postoperative residual limb pain as well as phantom limb pain has remained vital. (33) In order for an individual to return to functional independence, training has included strategies for activities of daily living such as dressing, bathing and other self-care activities.

Prosthesis Fitting and Choices: Options Available for Upper and Lower Limb Amputees

Historically, military conflicts and the associated trauma-related amputations have led to increased attention and advances in prosthetics. (34) Numerous improvements over the past 10 to 20 years in prosthetic design and components have allowed individuals with amputations to achieve functional goals not previously possible. These advances have included improvements in the actual components of the prosthesis as well as artificial limb attachment systems and prosthetic control mechanisms. (35) Newer socket designs utilizing lightweight carbon composites and flexible inner liners have provided better accommodation for fluctuations in residual limb volumes. (35) Various materials including silicone, urethane and copolymer gels have provided an interface between the residual limb and the prosthetic socket to provide cushioning, stability and shear reduction to the skin. (35) Patient specific liners may also be fabricated for residual limbs with unique shapes or pain considerations. Customized options for the suspension of the prosthesis to the residual limb have included various forms of suction and vacuum suspension.


Developments in lower limb prosthetics have led to microprocessor controlled knee and foot devices capable of monitoring gait in real-time and making automatic adjustments based on changes in terrain and angular velocity of the prosthetic component. (35) Targeted muscle reinnervation techniques, which specifically relocate nerves severed in an amputation to alternative muscles to improve control of a myoelectric prosthesis are now being implemented in individuals with upper limb loss. (32) Additionally, newer foot and ankle prosthetic components are capable of energy storage and return during ambulation because of dynamic elastic response properties intrinsic to the materials. (32,35) These foot and ankle components accommodate for uneven terrain, vertical shock absorption and allow service members the ability to return to military deployments.

Recently, transcutaneous osseointegrated implants (TOI) have emerged as a viable option for amputees. Although currently available in Europe, TOI may assist service members in the United States in the near future following FDA approval. (35,36) Osseointegration avoids common socket complications by using direct skeletal attachment of an exoprosthesis to the residual limb (35) and has demonstrated success in transhumeral, transtibial and transfemoral amputations. (37) With osseointegration, a metal fixation is surgically inserted directly into the bone of the residual limb and serves as an attachment system for connecting and suspending a prosthesis to the residual limb. (18) This procedure may reduce skin irritation, enhance osseoperception and better serve individuals with limited residual limb length (Figure 3). (18,38) However, before employing this operative procedure, solutions must be developed to accelerate rehabilitation regimens and prevent periprosthetic infections for future service members. (38)


Servicemen and women have been returning from combat with a higher percentage of amputations compared to other military conflicts (2) and require intensive follow-up care, extensive rehabilitation, and expensive prosthetic services. The primary rehabilitation goal for these individuals has been to provide them with an expedited recovery and progressive reintroduction into the civilian or active duty population. (21) However, in order to continue to provide the best care for wounded service members, novel diagnostic tools and prosthetic devices must continue to be developed to address the many concerns and complications still present today.


This material is based upon work supported by the Veterans Affairs Office of Research and Development, Rehabilitation R&D Service, DVA SLC Health Care System, Salt Lake City, UT; the Albert & Margaret Hoffmann Chair and the Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT.

We thank Gwenevere Shaw for support with manuscript preparation and Dustin Williams for biofilm images.


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Brad M. Isaacson, BS

Sharon R. Weeks, BS

COL Paul F. Pasquina, MC, USA

Joseph B. Webster, MD

James P. Beck, MD

Roy D. Bloebaum, PhD

Mr Isaacson serves as a research assistant for the Bone & Joint Research Laboratory in the Salt Lake City Department of Veterans Affairs, and the Integrated Department of Orthopaedics & Rehabilitation at the Walter Reed Army Medical Center, Washington, DC.

Ms Weeks is a research assistant for the Integrated Department of Orthopaedics & Rehabilitation at the Walter Reed Army Medical Center, Washington, DC.

COL Pasquina is Chief, Integrated Department of Orthopaedics & Rehabilitation, National Naval Medical Center, Silver Spring, MD, and the Walter Reed Army Medical Center, Washington, DC.

Dr Webster is an Associate Professor in Rehabilitation Medicine at the University of Washington, and the Director for Regional Amputation Care for the Veterans Affairs Puget Sound Health Care System.

Dr Beck is Adjunct Professor in the Department of Orthopaedics at the University of Utah, and is a board certified orthopaedic surgeon for the Department of Veterans Affairs.

Dr Bloebaum is a career research scientist with the Department of Veterans Affairs and the Co-Director of the Bone & Joint Research Laboratory. He is also a Research Professor of Biology, Bioengineering, and Orthopaedics at the University of Utah and is the Albert and Margaret Hofmann Chair in Orthopaedics for the University of Utah School of Medicine.
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Author:Isaacson, Brad M.; Weeks, Sharon R.; Pasquina, Paul F.; Webster, Joseph B.; Beck, James P.; Bloebaum
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:7IRAQ
Date:Jul 1, 2010
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