JBJS | Transtibial Amputees from the Vietnam War : Twenty-eight-Year Follow-up

The Journal of Bone & Joint Surgery, Volume 83, Issue 3

Articles | March 01, 2001

Transtibial Amputees from the Vietnam War : Twenty-eight-Year Follow-up

Paul J. Dougherty, Lieutenant Colonel, United States Army Medical Corps

Investigation performed at the University of Louisville, Louisville, Kentucky
LTC Paul J. Dougherty, United States Army Medical Corps William Beaumont Army Medical Center, 5005 North Piedras, El Paso, TX 79920. E-mail address: paul.dougherty@amedd.army.mil
The views expressed herein are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the United States Government.
Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received, but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the United States Army Medical Research and Material Command, Fort Detrick, Maryland. Funding number DAMD 17-97-1-7148.

The Journal of Bone & Joint Surgery. 2001; 83:383-383

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Abstract

Background: The long-term functional outcome following lower-extremity amputation is not well documented. I ascertained the functional outcome and health status of patients who had sustained a unilateral transtibial amputation as a result of a battlefield injury.

Methods: The records of 123 patients who had been treated at Valley Forge Army General Hospital during the Vietnam War for a diagnosis of isolated transtibial amputation due to a battlefield injury were reviewed. Group 1 had an isolated transtibial amputation, and Group 2 had at least one other major injury (another major long-bone fracture of the lower extremity, burns covering >20% of the body surface area, or a chest, abdominal, face, or head wound) in addition to the transtibial amputation. Seventy-two (59%) of the patients were enrolled in the study: twenty-eight were in Group 1 and forty-four, in Group 2. Data were collected about employment status, marital status, whether the patient had children, and use of psychological support services. The Short Form-36 (SF-36) health survey was used to compare Group 1 and Group 2, individually and combined, with age and gender-matched controls. Scaled scores for the two groups (control and amputation) were compared with use of the Student t test (two-tailed).

Results: Tripping a land mine or booby trap caused 65% of the injuries. The average age at the time of follow-up was forty-eight years. The average time to follow-up was twenty-eight years. Only the prevalence of the use of psychological support services differed significantly between Groups 1 and 2 (21% compared with 50%; p = 0.015). The results of the SF-36 health survey for Groups 1 and 2 were 81.6 and 58.2, respectively, for physical function, 82.7 and 33.1 for role physical, 81.4 and 50.9 for bodily pain, 74.1 and 58.7 for general health, 67.1 and 51.5 for vitality, 89.1 and 70.4 for social function, 88.1 and 56.0 for role emotional, and 79.5 and 64.0 for mental health. The average scaled scores for Group 1 were similar to those for the age and gender-matched controls, but the scores for Group 2 were significantly lower (p £ 0.001) than those for the age and gender-matched controls in all categories.

Conclusions: Group-1 patients led relatively normal lives after sustaining a transtibial amputation in battle. The addition of another major injury (Group 2) appears to have significant long-term consequences with regard to SF-36 scores and the need for psychological care.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Transtibial amputation is the most common type of major amputation seen in war and peace. Wartime amputations in battle usually occur as the result of trauma in young, healthy individuals and thus differ from those seen in civilian life^1-27.

Since World War II, explosive munitions such as land mines, artillery, mortars, grenades, and bombs have been the most common cause of transtibial amputations (Fig. 1)^{1,4-11,13,14,19,21,25,26,28-30}. Currently, antipersonnel land mines are of much concern throughout the world because vast tracts of mines remain planted in Asia, Africa, and the Balkans^1,13,28. Although the exact number of land mines remaining in place is unknown, estimates range between ninety and 110 million^1,13,28. Amputations resulting from land-mine injuries remain a problem for those who live in these areas as well as for peacekeepers assigned to the region^{1,10,13,28,30}.

In previous conflicts, the United States Army and Navy designated hospitals as amputee centers to ensure consistency of care^{4-6,11,12,16-19,23,24,27,31}. During the Vietnam War, members of the United States Army who had sustained an amputation were given care at other general hospitals, but only Valley Forge Army General Hospital in Phoenixville, Pennsylvania, provided a designated amputee service for the Army. This service was established on February 1, 1969, to consolidate the efforts of therapists, nurses, prosthetists, and surgeons to provide more consistent and structured care^5-7,14,19. The surgeons also explored the use of the Ertl osteoplasty, in which a synostosis is created between the distal aspects of the tibia and fibula^11,32.

There have been few long-term follow-up studies concerning individuals who sustained a battlefield amputation. The outcome when these injuries are sustained at a young age remains in question. The present study involved the long-term follow-up of patients who had been treated for a transtibial amputation at Valley Forge Army General Hospital during the Vietnam War.

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Fig. 1:: Explosive munitions may cause injury proximal to the amputation site, which can increase the difficulty of fitting a prosthesis.

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Fig. 2:: Walking with a pylon and an open wound.

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TABLE I: Comparison of Injury Groups with Regard to Work, Family, and Psychological Care*

*The values are given as the number of patients. †There was a significant between-group difference (p = 0.015; chi-square test).

	?Employed	Married	Children	Psychological Care†
Group 1 (n = 28)	?28 (100%)	26 (93%)	23 (82%)	?6 (21%)
Group 2 (n = 44)	43 (98%)	43 (98%)	37 (84%)	22 (50%)

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TABLE I: Comparison of Injury Groups with Regard to Work, Family, and Psychological Care*

*The values are given as the number of patients. †There was a significant between-group difference (p = 0.015; chi-square test).

	?Employed	Married	Children	Psychological Care†
Group 1 (n = 28)	?28 (100%)	26 (93%)	23 (82%)	?6 (21%)
Group 2 (n = 44)	43 (98%)	43 (98%)	37 (84%)	22 (50%)

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TABLE II: Comparison of Injury Groups with Regard to Treatment, Rehabilitation, and Prosthetic Wear

*There was a significant between-group difference (p < 0.05; Mann-Whitney U test).

	Group 1 (n = 28)	Group 2 (n = 44)	Average	?P Value
Surgery on residual limb (no. of ops.)	?1.36	?2.32	?1.94	?0.048*
Time to pylon use (wk)	3.48 (n = 26)	5.32 (n = 41)	?4.58	?0.009*
Time to fitting of permanent prosthesis (mo)	5.85 (n = 25)	7.07 (n = 41)	?6.57	0.102
Prosthetic wear (hr/day)	16.21	15.73	15.91	0.279
Change in prescription (no. of patients)	22	32		0.577
No. of prostheses since original	?7.89	8.84 (n = 43)	?8.34	0.584

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TABLE II: Comparison of Injury Groups with Regard to Treatment, Rehabilitation, and Prosthetic Wear

*There was a significant between-group difference (p < 0.05; Mann-Whitney U test).

	Group 1 (n = 28)	Group 2 (n = 44)	Average	?P Value
Surgery on residual limb (no. of ops.)	?1.36	?2.32	?1.94	?0.048*
Time to pylon use (wk)	3.48 (n = 26)	5.32 (n = 41)	?4.58	?0.009*
Time to fitting of permanent prosthesis (mo)	5.85 (n = 25)	7.07 (n = 41)	?6.57	0.102
Prosthetic wear (hr/day)	16.21	15.73	15.91	0.279
Change in prescription (no. of patients)	22	32		0.577
No. of prostheses since original	?7.89	8.84 (n = 43)	?8.34	0.584

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TABLE III: Comparison of Each Injury Group with the Control Group with Regard to Short Form-36 Scores

*The p values were derived from comparison of Group 1 or Group 2 with the control group. †There was a significant between-group difference in all categories.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.5	74.2	73.2	63	85.5	85.4	76.4
Group 1	81.6	82.7	81.4	74.1	67.1	89.1	88.1	79.5
P value*	?0.240	?0.642	?0.157	?0.807	?0.352	?0.440	?0.660	?0.375
Group 2	58.2	33.1	50.9	58.7	51.5	70.4	56.0	64.0
P value*†	<0.001	<0.001	<0.001	<0.001	0.001	<0.001	<0.001	<0.001

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TABLE III: Comparison of Each Injury Group with the Control Group with Regard to Short Form-36 Scores

*The p values were derived from comparison of Group 1 or Group 2 with the control group. †There was a significant between-group difference in all categories.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.5	74.2	73.2	63	85.5	85.4	76.4
Group 1	81.6	82.7	81.4	74.1	67.1	89.1	88.1	79.5
P value*	?0.240	?0.642	?0.157	?0.807	?0.352	?0.440	?0.660	?0.375
Group 2	58.2	33.1	50.9	58.7	51.5	70.4	56.0	64.0
P value*†	<0.001	<0.001	<0.001	<0.001	0.001	<0.001	<0.001	<0.001

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TABLE IV: Comparison of Both Injury Groups Combined with the Control Group with Regard to Short Form-36 Scores

*There was a significant between-group difference.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.6	74.2	73.2	63.1	85.5	85.4	76.4
All amputations	66.9	52.6	62.9	64.7	57.7	77.7	69.2	68.3
P value	<0.001*	<0.001*	?0.002*	?0.003*	?0.077	?0.274	?0.001*	?0.005*

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TABLE IV: Comparison of Both Injury Groups Combined with the Control Group with Regard to Short Form-36 Scores

*There was a significant between-group difference.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.6	74.2	73.2	63.1	85.5	85.4	76.4
All amputations	66.9	52.6	62.9	64.7	57.7	77.7	69.2	68.3
P value	<0.001*	<0.001*	?0.002*	?0.003*	?0.077	?0.274	?0.001*	?0.005*

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TABLE V: Comparison of Individuals Treated with and without Ertl Transtibial Amputation with Regard to Short Form-36 Scores

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Ertl (n = 42)	70.4	56.3	64	69	60.3	82.6	75	73.4
No Ertl (n = 30)	63.1	47	61	60.6	54.5	72.0	64.4	66
P value	?0.184	?0.347	?0.644	?0.124	?0.265	?0.104	?0.317	?0.161

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TABLE V: Comparison of Individuals Treated with and without Ertl Transtibial Amputation with Regard to Short Form-36 Scores

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Ertl (n = 42)	70.4	56.3	64	69	60.3	82.6	75	73.4
No Ertl (n = 30)	63.1	47	61	60.6	54.5	72.0	64.4	66
P value	?0.184	?0.347	?0.644	?0.124	?0.265	?0.104	?0.317	?0.161

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

During the late 1960s, some physicians at Valley Forge Army General Hospital gradually started a program of early walking for the treatment of patients who had a lower-extremity amputation. All patients in this study were part of that program. The program of early walking compressed or overlapped the stages of care so that walking could begin before the open wound had healed. As soon as the patient arrived, the limb was placed in skin traction; daily local wound care and dressing changes were performed. The extremity was fitted with a plaster pylon, and the patient walked intermittently (Fig. 2). As wound-healing progressed, the patient walked with the pylon on for longer periods and spent less time with the limb in skin traction^14,19.

The medical records of patients with a transtibial amputation treated at Valley Forge Army General Hospital during the Vietnam War were reviewed for information regarding the mechanism of injury, the indications for surgery, the specific procedure performed, the time from the injury to arrival at Valley Forge Army General Hospital, the time from the injury to fitting of the pylon, and the time from the injury to fitting of a permanent prosthesis. Patients were then contacted by mail at their last known address. If there was no response, attempts were made to contact them by telephone. After obtaining informed consent, a questionnaire consisting of two parts was administered. One part obtained information about how the initial injury occurred, the number and type of subsequent surgical procedures, other medical problems, marital status, number of children, employment status, and use of psychological support services (seeing a psychologist or psychiatrist; receiving counseling, including marriage counseling; and/or participating in Alcoholics Anonymous). Also, information was obtained about current use of a prosthesis (the type of prosthesis, the number of hours it was worn each day, and whether the design of the current prosthesis differed from that of the original prosthesis). The present study was approved by the Human Use Committees at the organization that provided the funding (the United States Army Medical Research and Material Command, Fort Detrick, Maryland) and the institution where the research was conducted (the University of Louisville, Louisville, Kentucky).

The second part of the questionnaire was the Short Form-36 (SF-36) health survey. The SF-36 is a standardized test, which is divided into eight areas (physical function, role physical, bodily pain, general health, vitality, social function, role emotional, and mental health)³³. The SF-36 responses of the individuals with a transtibial amputation were compared with those of a control group consisting of men aged forty-five to fifty-four years. The control group was thought to represent a cross section of the United States population. The norms were generated on the basis of responses to the National Survey of Functional Health Status in 1990 (The Health Institute, New England Medical Center, Boston, Massachusetts)³³.

The individuals with an amputation were assigned to one of two groups: Group 1 included those with no other major injury, and Group 2 included those with at least one other major injury (long-bone fracture of the lower extremity, chest wound, abdominal wound, burns involving >20% of the body surface area, and/or face or head wound) in addition to the transtibial amputation. Each patient’s responses in each of the eight areas of the SF-36 health survey were given a value between zero and 100 (a scaled score). Average scaled scores were calculated for each group. The Student t test (two-tailed) was used to compare the scores in Group 1 and Group 2 with the scores in the control group. The responses of the patients in Groups 1 and 2 were compared with use of the chi-square test for the categories of marital status, whether the patient had children, employment status, and use of psychological support services. Data on the number of prostheses used since the first permanent prosthesis, the number of hours the prosthesis was worn each day, and the number of additional surgical procedures on the residual limb after the initial amputation were compared between Groups 1 and 2 with use of the Mann-Whitney U test^33-35. The functional outcomes, as measured with the SF-36 health survey, were also used to compare the patients who had undergone the Ertl procedure with those who had not.

Results

Introduction | Materials and Methods | Results | Discussion | References

The records of 484 patients who had sustained an amputation on the battlefield and were treated at Valley Forge General Hospital during the Vietnam War were retrospectively reviewed. Of those patients, 183 (37.8%) were identified as having sustained a unilateral transtibial amputation. To match the control group, only 141 patients who were forty-five to fifty-four years old at the time of follow-up were selected for possible inclusion in the follow-up study. According to Veterans Administration records, eighteen of these patients were known to have died. Seventy-two (59%) of the 123 remaining individuals with a transtibial amputation could be contacted and agreed to participate in the study. The other fifty-one were lost to follow-up.

Review of the records of the seventy-two individuals showed that forty-seven (65%) of the injuries could be attributed to tripping a land mine or booby trap; fifteen (21%), to mortar or artillery fragments; six (8%), to small-arms fire; two (3%), to the person’s vehicle striking a land mine; and two, to a rocket-propelled grenade. Sixty-one patients (85%) had an amputation of the limb due directly to the severity of the injury—a partial or complete traumatic amputation. Discrete wounds did not cause these amputations; rather, the whole limb was involved. The explosive munitions causing these injuries severely damaged the soft tissues, making replantation unlikely even with current technology. Seven patients (10%) underwent an amputation because of infection one to six weeks after the injury. Four patients (6%) had a vascular injury after a failed repair: three of the vascular injuries involved the superficial femoral artery and one, the popliteal artery. Three of the four patients with a vascular injury also had a femoral fracture. The evacuation time from the point of injury to the arrival at Valley Forge Army General Hospital averaged 3.4 weeks (range, one to eleven weeks).

Twenty-eight (39%) of the seventy-two patients were included in Group 1 and forty-four (61%), in Group 2. The average age at the time of injury was 21.7 years. Most patients (86%) electively underwent a second procedure to obtain closure of the stump. This closure was performed between the time of the initial training with use of the pylon and the fitting of the permanent prosthesis. As noted above, at that time surgeons at Valley Forge Army General Hospital were also investigating the use of the Ertl osteoplastic amputation technique^11,32. It was performed on nineteen (68%) of the twenty-eight patients in Group 1 and on twenty-three (52%) of the forty-four patients in Group 2. There was no significant between-group difference in the number of patients who received the Ertl procedure (p = 0.190; chi-square test).

The average duration of follow-up of the seventy-two patients was twenty-eight years (range, twenty-five to thirty years) after the injury. At the time of follow-up, the average age was 48.4 years (48.9 years in Group 1 and 48.1 years in Group 2). When the patients with an isolated injury (Group 1) were compared with the patients with multiple injuries (Group 2) with regard to employment status, marital status, whether they had children, and use of psychological support services (Table I), only the prevalence of the use of psychological support services was found to be significantly different (21% compared with 50%) (p = 0.015; chi-square test). There were no significant differences between the two groups with regard to marital status (p = 0.311), whether they had children (p = 0.631), or employment status (p = 0.411).

At the time of follow-up, the patients reported an average of 1.94 operations (range, zero to thirteen operations) on the stump—1.36 in Group 1 and 2.32 in Group 2—since their initial amputation. The difference between the groups was significant (p = 0.048). The patients were fitted with a pylon at an average of 4.58 weeks after the injury (3.48 weeks [range, two to eight weeks] after the injury in Group 1 and 5.32 weeks [range, two to sixteen weeks] after the injury in Group 2; p = 0.009). The average time from the injury to the fitting of the permanent prosthesis was 6.57 months (5.85 months in Group 1 and 7.07 months in Group 2; p = 0.102). The respondents were wearing the prosthesis for an average of 15.91 hours each day (16.21 hours in Group 1 and 15.73 hours in Group 2; p = 0.279). Most patients (twenty-two [79%] in Group 1 and thirty-two [73%] in Group 2) reported that the prosthesis prescription had changed from that for the original prosthesis; the difference between the two groups was not significant (p = 0.577). The average number of prostheses used since the first permanent prosthesis was 8.34 (7.89 [range, three to thirty] in Group 1 and 8.84 [range, four to thirty] in Group 2). There was no significant difference between the two groups in this regard (p = 0.584) (Table II).

Average scaled scores in each SF-36 area were calculated for Group 1 and Group 2, for comparison with the control group. Comparison of the average scaled scores in Group 1 with those in the control group yielded no significant difference in any area. Comparison of Group 2 with the control group showed significantly (p £ 0.001) decreased scores in all SF-36 areas (Table III). In all categories except vitality and social function, the scores of all patients combined were significantly lower than those of the controls (p £ 0.005, Table IV).

The Ertl procedure was performed on forty-two patients. One patient reported that he had the bone block removed because of pain. Given the available numbers, no significant difference was found between the SF-36 scores of the patients who had undergone an Ertl procedure and those who had not (p > 0.05 in all categories of the SF-36) (Table V).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Historically, the knowledge needed to provide effective treatment of battlefield casualties has been relearned by each new generation of surgeons, often at the patient’s expense. Techniques implemented in civilian practice are not usually directly applicable to patients who sustain injuries on the battlefield. Surgeons in World War I, World War II, and the Korean and Vietnam Wars all documented the lack of preparedness that they felt when treating both amputees and battlefield casualties in general. In the future, the military surgeon may be unprepared to care for a large number of battlefield casualties^{2,4-6,8,9,12,14,16-19,23,24,26,27,31}.

Care of battlefield casualties is also a concern for peacekeepers, who must treat not only soldiers but civilian casualties of war as well. Injuries caused by land mines remain a major clinical problem in areas of conflict in Asia, Africa, and the Balkans^{1,10,13,21,28,30}.

Coupland¹⁰, who worked for the International Committee of the Red Cross, recommended that the traumatic amputation stump be treated with delayed primary closure, with flaps fashioned at the first operation to facilitate closure at a later date. He specifically condemned the use of the open circular amputation and described it as sacrificing length, not allowing for complete wound excision, making prosthetic fitting more difficult, and not allowing for swelling of the muscular calf or thigh. These recommendations were based on care provided to a large number of people injured in their own countries and treated by doctors from the International Committee of the Red Cross. Coupland provided little documentation to support his conclusions. A recent report by Simper³⁰ describing the treatment of 111 patients with transtibial amputation at an International Committee of the Red Cross hospital in Pakistan recommended delayed primary closure of a transtibial amputation caused by a war injury yet made no mention of prosthetic fitting.

Atesalp et al.¹ compared delayed primary closure with primary closure of the residual limb in a retrospective study of 474 patients with transtibial amputation caused by a land mine. Primary closure after "radical debridement" was performed within six hours after the injury in 392 patients. The level of amputation was revised to a transfemoral level in eleven patients in this group. The authors concluded that this is an acceptable complication rate for land-mine amputations; nevertheless, revision to the transfemoral level was not performed in any of the eighty-two patients who had had delayed primary closure. Attempts at prosthetic fitting resulted in revision of the amputation of forty-three patients (11%) who had had primary closure and sixteen (20%) of those who had had delayed primary closure. The authors did not comment on how many patients eventually had successful fitting of a prosthesis.

Surgeons in the former Soviet Union gained considerable clinical experience with land-mine injuries as a by-product of the war in Afghanistan. Nechaev et al.²¹ concluded that it is difficult to determine at the time of the initial surgery whether tissue in this area will or will not survive. As a consequence, they recommended that a "sparing" amputation initially be performed by qualified personnel and that the wound be left open. They recommended amputation at a level of tissue with reversible injury—that is, an area that has muscle contraction, moderate traumatic edema, and an absence of "confluent hemorrhages." They also recommended that procedures attempting to close the stump should be performed at "the echelon of specialized medical care."

Earlier, LaNoue¹⁹ made similar observations in a study of patients who had sustained an amputation during the Vietnam War. He recommended amputation at the most distal level possible because some of the injured tissue will survive. LaNoue thought that skin traction was essential to preserve stump length and to prevent infection^14,19.

Furthermore, LaNoue¹⁹ previously reported on the group of individuals with transtibial amputation in the present study; he compared amputations that were closed in the theater of operations with those that were left open and maintained in skin traction. He evaluated 230 patients with a transtibial stump, some of whom had had multiple amputations. He found that 41% of the stumps had been closed in the theater of operations and 59% had been left open. Of those closed in the theater of operations, 56% failed because of gross infection. The time to permanent prosthetic fitting was also longer for wounds that had been closed in the theater of operations (thirteen months) than it was for stumps that had been left open (eleven months).

The results of patients seen at International Committee of the Red Cross hospitals are not directly comparable with those in the present series. First, patients treated at International Committee of the Red Cross hospitals are not expected to be moved after surgery, unlike soldiers who are evacuated from overseas. LaNoue specifically commented on the deleterious effects of the long airplane ride back to the United States and stated that the goal of surgery is to enable the safest transport of a patient. In a more stable environment, this would not be a consideration. Second, patients seen at International Committee of the Red Cross hospitals have, in general, a longer time lag before they arrive at the hospital. (The average time in Simper’s series³⁰ was fourteen hours.) Some of the severely wounded patients seen at Valley Forge Army General Hospital in our series would not have survived such a delay.

There have been few long-term follow-up studies of patients with amputation due to trauma. Lerner et al.²⁰ followed three categories of patients who had sustained a lower-limb injury: those with nonunion, followed for an average of 6.7 years after injury; those with posttraumatic osteomyelitis, followed for an average of ten years after onset; and those with lower-extremity amputation, followed for an average of five years after amputation. Two scales, the Arthritis Impact Measurement Scale (AIMS) and the Psychosocial Adjustment to Illness Scale (PAIS), were used to evaluate the patients. A statistical comparison showed significantly worse PAIS scores among patients with chronic osteomyelitis. Patients with nonunion and those with osteomyelitis who had persistent pain reported poorer psychosocial adjustment than patients who had no pain. Overall, analysis of the AIMS scores showed no significant differences among the three groups.

In a recent study, Smith et al.³⁶ studied twenty individuals at an average of 5.5 years (a minimum of four years) after a unilateral, traumatic, transtibial amputation. They found that six individuals remained unemployed and one had retired. The patients stated that it took about one and one-half years to achieve their maximum walking ability. The patients had a wide range of ages (nineteen to fifty-eight years), and two were female. Compared with controls, the patients had significantly decreased scores in the SF-36 areas of physical function, role physical, and bodily pain.

In 1983, Hoaglund et al.¹⁵ reviewed the cases of individuals who had had a transtibial amputation treated at one of two Veterans Administration Hospitals in the San Francisco Bay Area. Demographic data were available for seventy-four patients, with an average age of fifty years (range, thirty to seventy years), who were seen at an average of seventeen years (range, one to thirty years) after the amputation. All amputations were due to trauma, but not all were due to a battlefield injury. The initial amputations and rehabilitation took place at a variety of military hospitals and probably spanned both the Korean and the Vietnam Wars. Thirty-five (47%) of these patients reported their prosthesis training to be "inadequate." Information on pain was available for seventy-seven patients; thirty-seven (48%) reported "none-mild" pain, twenty-six (34%) reported moderate pain, and fourteen (18%) reported severe pain. Pain frequency was rated as "seldom-never" by forty-four (57%) of the patients. Of sixty-five patients, thirty (46%) reported pain with walking and forty-four (68%), phantom pain.

Patients at Valley Forge Army General Hospital had the benefits of a rehabilitation program that consolidated the skills of physicians, nurses, prosthetists, and therapists on a team to provide the best overall care. Early walking after transtibial amputation is not a new idea, but walking on an open stump had not been as well documented previously as it was in that program^14,19,27.

This approach had several benefits. First, edema decreased with bearing weight on the hard plaster cast. Second, patients relearned proprioception earlier than they would have with conventional therapy. Third, patients became upright faster and obtained independence more quickly than they would have had they waited for the wound to heal before being fitted with a pylon^7,14,19,27.

Treatment on a service that specifically treats amputees has proven beneficial for both patients and providers. The patient has the benefit of being with individuals who have similar medical problems. Most patients contacted in this study lauded such informal group therapy. An amputee center allows for the concentration of surgeons, nurses, prosthetists, and physical therapists to provide consistent care for the patients^{5-7,16-19,24,27,31,37}.

This study suggests that patients who sustain an isolated transtibial amputation on the battlefield and who are treated at an amputee center can lead a relatively normal, productive life with regard to work and family. However, in this study a major injury in addition to the amputation significantly increased the prevalence of psychological intervention and significantly decreased the average scaled scores on the SF-36.

Today, the Department of Defense has no amputee centers. The amputee-focused clinical skills needed by nurses, therapists, surgeons, and prosthetists require training that is not part of the routine clinical load at a military hospital. Active-duty military personnel can gain experience by becoming involved in the care of patients at specified Veterans Administration amputee centers. Gaining experience in the care of patients who have sustained an amputation during battle is essential. Unless orthopaedic surgeons maintain this knowledge and skill, they are vulnerable to being caught unprepared in future conflicts.

Note: The author thanks A.M. LaNoue, MD, P.A. Deffer, MD, J.H. Herndon, MD, and M.I. Levine, MD, for help in clarifying aspects of patient care rendered at Valley Forge Army General Hospital; Susan E. Siefert, ELS, CBC, for aid in the preparation of this manuscript; and Gavin Gregory, MA, for assistance with the statistical analyses.

References

Introduction | Materials and Methods | Results | Discussion | References

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Burkhalter WE. Penetrating wounds of the leg with associated fractures of the tibia. In: Burkhalter WE, editor. Surgery in Vietnam. Orthopedic surgery. Washington DC: Office of the Surgeon General and Center of Military History, United States Army, United States Government Printing Office; 1994. p 39-53

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Fig. 1:: Explosive munitions may cause injury proximal to the amputation site, which can increase the difficulty of fitting a prosthesis.

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Fig. 2:: Walking with a pylon and an open wound.

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TABLE I: Comparison of Injury Groups with Regard to Work, Family, and Psychological Care*

*The values are given as the number of patients. †There was a significant between-group difference (p = 0.015; chi-square test).

	?Employed	Married	Children	Psychological Care†
Group 1 (n = 28)	?28 (100%)	26 (93%)	23 (82%)	?6 (21%)
Group 2 (n = 44)	43 (98%)	43 (98%)	37 (84%)	22 (50%)

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TABLE I: Comparison of Injury Groups with Regard to Work, Family, and Psychological Care*

*The values are given as the number of patients. †There was a significant between-group difference (p = 0.015; chi-square test).

	?Employed	Married	Children	Psychological Care†
Group 1 (n = 28)	?28 (100%)	26 (93%)	23 (82%)	?6 (21%)
Group 2 (n = 44)	43 (98%)	43 (98%)	37 (84%)	22 (50%)

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TABLE II: Comparison of Injury Groups with Regard to Treatment, Rehabilitation, and Prosthetic Wear

*There was a significant between-group difference (p < 0.05; Mann-Whitney U test).

	Group 1 (n = 28)	Group 2 (n = 44)	Average	?P Value
Surgery on residual limb (no. of ops.)	?1.36	?2.32	?1.94	?0.048*
Time to pylon use (wk)	3.48 (n = 26)	5.32 (n = 41)	?4.58	?0.009*
Time to fitting of permanent prosthesis (mo)	5.85 (n = 25)	7.07 (n = 41)	?6.57	0.102
Prosthetic wear (hr/day)	16.21	15.73	15.91	0.279
Change in prescription (no. of patients)	22	32		0.577
No. of prostheses since original	?7.89	8.84 (n = 43)	?8.34	0.584

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TABLE II: Comparison of Injury Groups with Regard to Treatment, Rehabilitation, and Prosthetic Wear

*There was a significant between-group difference (p < 0.05; Mann-Whitney U test).

	Group 1 (n = 28)	Group 2 (n = 44)	Average	?P Value
Surgery on residual limb (no. of ops.)	?1.36	?2.32	?1.94	?0.048*
Time to pylon use (wk)	3.48 (n = 26)	5.32 (n = 41)	?4.58	?0.009*
Time to fitting of permanent prosthesis (mo)	5.85 (n = 25)	7.07 (n = 41)	?6.57	0.102
Prosthetic wear (hr/day)	16.21	15.73	15.91	0.279
Change in prescription (no. of patients)	22	32		0.577
No. of prostheses since original	?7.89	8.84 (n = 43)	?8.34	0.584

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TABLE III: Comparison of Each Injury Group with the Control Group with Regard to Short Form-36 Scores

*The p values were derived from comparison of Group 1 or Group 2 with the control group. †There was a significant between-group difference in all categories.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.5	74.2	73.2	63	85.5	85.4	76.4
Group 1	81.6	82.7	81.4	74.1	67.1	89.1	88.1	79.5
P value*	?0.240	?0.642	?0.157	?0.807	?0.352	?0.440	?0.660	?0.375
Group 2	58.2	33.1	50.9	58.7	51.5	70.4	56.0	64.0
P value*†	<0.001	<0.001	<0.001	<0.001	0.001	<0.001	<0.001	<0.001

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TABLE III: Comparison of Each Injury Group with the Control Group with Regard to Short Form-36 Scores

*The p values were derived from comparison of Group 1 or Group 2 with the control group. †There was a significant between-group difference in all categories.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.5	74.2	73.2	63	85.5	85.4	76.4
Group 1	81.6	82.7	81.4	74.1	67.1	89.1	88.1	79.5
P value*	?0.240	?0.642	?0.157	?0.807	?0.352	?0.440	?0.660	?0.375
Group 2	58.2	33.1	50.9	58.7	51.5	70.4	56.0	64.0
P value*†	<0.001	<0.001	<0.001	<0.001	0.001	<0.001	<0.001	<0.001

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TABLE IV: Comparison of Both Injury Groups Combined with the Control Group with Regard to Short Form-36 Scores

*There was a significant between-group difference.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.6	74.2	73.2	63.1	85.5	85.4	76.4
All amputations	66.9	52.6	62.9	64.7	57.7	77.7	69.2	68.3
P value	<0.001*	<0.001*	?0.002*	?0.003*	?0.077	?0.274	?0.001*	?0.005*

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TABLE IV: Comparison of Both Injury Groups Combined with the Control Group with Regard to Short Form-36 Scores

*There was a significant between-group difference.

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Control group	86.5	85.6	74.2	73.2	63.1	85.5	85.4	76.4
All amputations	66.9	52.6	62.9	64.7	57.7	77.7	69.2	68.3
P value	<0.001*	<0.001*	?0.002*	?0.003*	?0.077	?0.274	?0.001*	?0.005*

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TABLE V: Comparison of Individuals Treated with and without Ertl Transtibial Amputation with Regard to Short Form-36 Scores

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Ertl (n = 42)	70.4	56.3	64	69	60.3	82.6	75	73.4
No Ertl (n = 30)	63.1	47	61	60.6	54.5	72.0	64.4	66
P value	?0.184	?0.347	?0.644	?0.124	?0.265	?0.104	?0.317	?0.161

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TABLE V: Comparison of Individuals Treated with and without Ertl Transtibial Amputation with Regard to Short Form-36 Scores

	Physical Function	Role Physical	Bodily Pain	General Health	Vitality	Social Function	Role Emotional	Mental Health
Ertl (n = 42)	70.4	56.3	64	69	60.3	82.6	75	73.4
No Ertl (n = 30)	63.1	47	61	60.6	54.5	72.0	64.4	66
P value	?0.184	?0.347	?0.644	?0.124	?0.265	?0.104	?0.317	?0.161