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Scientific Articles   |    
The Military Extremity Trauma Amputation/Limb Salvage (METALS) StudyOutcomes of Amputation Versus Limb Salvage Following Major Lower-Extremity Trauma
COL (Ret) William C. Doukas, MD1; COL (Ret) Roman A. Hayda, MD2; H. Michael Frisch, MD3; COL Romney C. Andersen, MD4; CDR Michael T. Mazurek, MD5; COL James R. Ficke, MD6; CDR John J. Keeling, MD7; COL Paul F. Pasquina, MD8; Harold J. Wain, PhD9; Anthony R. Carlini, MS10; Ellen J. MacKenzie, PhD11
1 UHC Orthopedics, 527 Medical Park Drive, Suite 400, Bridgeport, WV 26330. E-mail address: wcdoukas@ma.rr.com
2 Rhode Island Hospital, Brown University, 2 Dudley Street, Suite 200, Providence, RI 02905. E-mail address: Roman_Hayda@brown.edu
3 Orthopaedic Trauma Service, Mission Hospital, 509 Biltmore Avenue, Asheville, NC 28801. E-mail address: pdrhmf@msj.org
4 Walter Reed National Military Medical Center, 6900 Georgia Avenue, N.W., Building 2, Orthopaedic Clinic 5A, Washington, DC 20307. E-mail address: Romney.andersen@us.army.mil
5 Deceased
6 Department of Orthopaedics & Rehabilitation, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. E-mail address:james.ficke@amedd.army.mil
7 Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 8, 2nd Floor, Bethesda, MD 20889. E-mail address: john.keeling@med.navy.mil
8 Walter Reed National Military Medical Center, 6900 Georgia Avenue, N.W., #77, Washington, DC 20307. E-mail address: Paul.Pasquina@na.amedd.army.mil
9 Walter Reed National Military Medical Center, 6900 Georgia Avenue, N.W., 6th Floor, Washington, DC 20307-5001. E-mail address: Harold.wain@na.amedd.army.mil
10 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 502, Baltimore, MD 21205. E-mail address: acarlini@jhsph.edu
11 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 482, Baltimore, MD 21205. E-mail address: emackenz@jhsph.edu
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  • Disclosure statement for author(s): PDF

A commentary by Michael S. Pinzur, MD, is linked to the online version of this article at jbjs.org.

Investigation performed at Walter Reed National Military Medical Center, Washington, DC; San Antonio Military Medical Center, Fort Sam Houston, Texas; Naval Medical Center, San Diego, California; and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Army, Department of the Navy, Department of Defense, or the U.S. Government.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jan 16;95(2):138-145. doi: 10.2106/JBJS.K.00734
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Abstract

Background: 

The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage.

Methods: 

This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences.

Results: 

Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status.

Conclusions: 

Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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