Military Amputee Care: Battlefield to Rehabilitation

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Military Amputee Care Battlefield to
Rehabilitation
Robert Granville, MD COL MC USA Director, BAMC
Amputee Services
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Overview

• Impact of recent technological advances
• Surgical management in CONUS
• Early amputee rehabilitation
• Advanced amputee rehabilitation
• Community reintegration
• Problem areas
• The future

• History of military amputee care
• Outcomes in civilian traumatic amputation
• Program development following 9/11
• USAFACP
• NATO Handbook
• Extremity War Surgery
• ATTC
• Surgical management in theater

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History of Military Amputee Care

• WWII
• 7 Amputee Care Centers
• Concentrated expertise
• Grouped patients
• Developed esprit de corps
• Pts. at all stages of recovery
• Activities to foster competence, ease
  reintegration
• Vietnam-Valley Forge

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Civilian Traumatic Amputation Outcomes The LEAP
Study NEJM 3471924

• Prospective, multi-center study comparing limb
  salvage and amputation for severe LE trauma
• Georgiadis, et al Caudle, et al and others
  found poor outcomes from salvage
• Disabled, divorced, addicted, destitute
• Hypothesisearly amputation patients would do
  better than limb salvage patients
• 569 patients
• Principal outcome measurement Sickness Impact
  Profile
• Findingsboth groups did poorly
• Predictors of poor outcome major Cx, low
  education, non-white, poverty, no insurance, poor
  support network, low self-esteem, smoking,
  litigation

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Program Development-AFAPCP

• 9/11 attacks on the Pentagon and World Trade
  Center
• Army Surgeon General directed Orthopaedic
  Consultant to formulate plan for amputee care
• WWII VietnamAmputee Centers maximized outcomes
• Afghanistan
• 73,730 hectares (10,000 m²) uncleared minefields
• ICRC treating 1000 mine casualties/year
• Significant number of amputees anticipated
• Study group of Trauma Foot/Ankle Surgeons
• Amputee Centers
• WRAMC1st CONUS MEDCEN from LRMC
• BAMConce WRAMC at capacity
• Armys Level 1 Trauma Center
• ISRBurn Center

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Doctrine-The NATO Handbook

• Revision of amputee chapter for 3rd Edition
• Concomitant with start of OEF
• Essentially same working group
• 2nd Edition
• Open circular amputation
• Skin traction
• Recent long-term f/u showing good resultsJBJS
  83383
• ICRC
• Western organization with most modern experience
  treating war wounded
• Closure with flaps of opportunityCoupland,
  Amputation for War Wounds, ICRC, 1992
• Preserve all viable soft tissue
• Delayed closure using non-standard flaps
• Outcomeopen, length preserving amputation
  preserving all viable tissue
• 5/12 pages still devoted to technique of skin
  traction

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Training-The Extremity War Surgery Course

• Directed at AD and Reserve General and
  Orthopaedic Surgeons w/o recent trauma experience
  getting ready to deploy
• Focus on initial surgical management of
  penetrating trauma to the extremities
• Didactic and cadaver lab
• Debridementcolor, consistency, contractility,
  capacity to bleed
• Stabilizationplaster and external fixation
• FasciotomyUE and LE
• Amputationopen length preserving technique
• Companion DVD

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Training-Army Trauma Training Center

• Jackson Memorial Hospital, Miami, FL
• 4 weeks
• Surgeons, anesthetists, nurses, techs train
  together in Level 1 civilian trauma center
• Team building
• All deploying FSTs
• All deploying reserve CSHs
• Similar Navy and Air Force centers

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Surgical Management in Theater

• Soft tissue, not osseous, injury determines level
  of amputation

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Surgical Management in Theater

• Decisions regarding ultimate level left to CONUS
  surgeon
• Allows patient to give informed consent
• egTTA vs Symes
• Allows use of viable distal tissues to treat
  other injuries
• Reassures patient that amputation was not done
  for field expediency

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Surgical Management in Theater

• ATLS Principles!
• Traumatic amputation is dramatic
• Focusing on amputation easily allows the tension
  pneumothorax to be missed
• Penetrating, over pressure and blunt trauma
  frequently coexist in blast attacks
• Triage
• Mass casualty is the rule
• Isolated amputation is rarely Immediate once
  tourniquet is applied

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Amputation is a Tool in the Armamentarium

• LMTV driver struck by stacked ATMs
• IIIC tib/fib fx
• Severely contaminated buttock wound
• Closed subtroch femur
• Multiple other open and closed injuries
• Cold and coagulopathic after 3 hr of surgery

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KISS

• Complex procedures should not be attempted in
  theater

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Guillotine Amputations Should Be Avoided Whenever
Possible

• Prolonged skin traction required to close wound
  isolates patient and interferes with initiation
  of rehab

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Impact of Recent Technological Advances

• Case Fatality Ratepercentage of wounded who
  dieincludes RTDs
• WWII19.1
• Vietnam15.8
• OIF/OEF9.4
• Proposed reasons for improvement
• Better medic/corpsman training
• Ceramic/Kevlar armor
• Early tourniquet application
• Hemostatic dressings
• Far-forward surgery

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Far-Forward Surgery

• Traditionally, Echelon IIIfirst surgical
  services
• Norman Bethune
• Spanish Civil War
• Damage Control
• Surgical resuscitation
• Hemorrhage
• Contamination
• Physiologic homeostasis
• Reversing acidosis, hypothermia, coagulopathy
• Croatian Special Police
• 274th FST
• Desert Storm
• Now doctrine for all three MCs

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Evacuation of the Unstable Patient

• Traditionally, the ventilated, hypotensive, or
  otherwise unstable patient remained in theater
  until stable for transport
• Vietnam45 day evac
• Desert Storm
• 8th Evac held pt 13 d prior to evac to Mercy

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Evacuation of the Unstable Patient

• CCATTs, ISR Burn Teams, and ad hoc teams now
  enable fixed wing evacuation of ventilated
  patients
• OIF?Echelon V
• 36-96 hr

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Need for Skin Traction Obviated by Short
Evacuation Times

• Skin traction makes transport and hygiene more
  difficult
• Isolates patient on return to CONUS
• Jacobs ladder /- VAC effective in pulling
  wound margins closed as edema decreases

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Amptee Patient Care Requires Multidisciplinary
Team Approach

• Trauma Surgery
• Orthopaedic Surgery
• Physiatry
• Physical Therapy
• Occupational Therapy
• Case Management
• Anesthesia
• Prosthetics
• Behavioral Medicine
• Peer visitors

• Chaplain
• Nutrition Care
• VA benefits advisor
• Vocational counseling
• PEBLO
• Med Hold Cdr
• USMC Liason
• Family

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Surgical Management in CONUS

• Fracture treatment once soft tissue envelope
  appropriate
• Intramedullary, submuscular reduce bone stripping
  with loss of blood supply

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Surgical Management in CONUS

• Serial debridements until wound clean
• ? Do cultures need to be negative
• Closure using non-standard flaps preserves length
  and improves function

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New Prosthetic Materials Allow Use of STSG,
Insensate Free Tissue, Etc.

• Silicone liners decrease shear
• Anatomic socket design can accommodate unusual
  residual limb shape
• CAD/CAM allows rapid fabrication of test sockets

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Early Rehabilitation

• Pre-prosthetic
• Core strengthening
• Aerobic conditioning
• Hand cycle
• Wound care
• Edema control, shaping
• Tilt table

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Early Rehabilitation

• Prosthetic training
• Core strengthening
• Aerobic conditioning
• Gait training in parallel bars
• Gait with assistive devices
• Stairs, ramps
• Pool

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Advanced Rehabilitation

• Advanced skills
• Core strengthening
• Aerobic conditioning
• Pool
• Agility drills
• Track
• Gait analysis
• Sport-specific training
• Device-specific training

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Community Reintegration

• Goalreturn the soldier to his/her maximum
  functional level
• Individual and group therapy
• Vocational counseling
• Tripslocal and distant

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Problem Areas

• Contrilateral limb injury
• Non-union
• Insensate
• Painful
• Stiff joints

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Problem Areas

• Heterotopic Ossification (HO)
• Mesenchymal stem cells differentiate into
  osteoblasts, not fibroblasts
• 40 incidence
• Not seen in Vietnam
• Crush, burn, TBI
• ? Acineterbacter, ? BMPs from VAC, etc.

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Problem Areas

• Recurrent infection
• Resistant organisms
• Acineterbacter
• Klebsiella
• MRSA
• VRE
• Prophyllactic antibiotic recommendations have
  not changed

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Center for the IntrepidThe National Armed
Forces Physical Rehabilitation Center

• 4 Story
• 65,000 ft²
• Ribbon Cutting 5/07
• 30M
• Capabilities
• Running gait analysis
• Dual force plate treadmill
• Uneven terrain modeling
• Virtual reality
• Poolkayaking, scuba, surfing skills
• Climbing wall
• Weapons simulator
• Prosthetics lab w/self-service training stations
• Benefits counseling
• Behavioral health

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The Future

• The Power Knee
• Active knee extension for transfemoral pts.
• Prototype
• 3hr per charge
• Allows reciprocal gait up stairs

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The Future

• Osseointegration
• Attachment of prosthesis directly to bone
• 80 patients over last 20 years
• Osseoperception
• Problem areaskin/prosthesis interface
• Salt Lake City VA/U. of Utah/AFAPCP collaboration

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The Future

• Neural Engineering
• Peripheral nerve transplanted to chest wall
  muscle to generate signal large enough for
  myoelectric sensor
• Integrated shoulder, elbow, wrist motion to
  position hand in space w/o conscious effort
• Will proceed to generating signal at motor cortex
• Will proceed to SENSATE PROSTHESIS!

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EL FIN

• ?