Session III - Rehabilitation

Twenty-eight Year Follow-up of Below-knee Amputees Injured during the Vietnam War

Paul J. Dougherty, MAJ, MC, William Beaumont Army Medical Center, El Paso, TX, USA

Purpose: To ascertain the physical, social and work-related changes (functional outcome and health status) of patients who sustained unilateral below-knee amputations due to battlefield injuries.

Methods: Records of 484 battlefield amputees who were treated at a US Army General Hospital (AGH) from 1969-1971 were reviewed. Of those patients, one hundred eighty-three (37.8%) were identified as sustaining unilateral below-knee amputations. Only patients whose age at follow up was from 46-54 years were included in the study, leaving 141 patients. Eighteen (12.8%) of the patients are known to have died, six of which were known to be "natural" causes. Sixty-seven of one hundred twenty-three (54.5%) agreed to participate in the study. Average time from initial injury was twenty-eight years. Data was collected on mechanism of injury, indications for surgery, time to the AGH, time to initial pylon fitting and time to permanent prostheses. After obtaining informed consent, information was obtained about marriage, children, employment, prosthetic usage, whether there was a change in prostheses since discharge from AGH, prosthetic type, and psychological care, including marriage counseling and Alcoholics Anonymous. Patients were also evaluated as to whether they had sustained other significant injuries (lower extremity longbone fractures, chest wounds, abdominal wounds, burns>20% BSA, face or head wounds). Twenty-six of sixty-nine (38.8%) patients were classified as having isolated below-knee amputations and forty-one (61.2%) having other significant injuries. The SF-36 health survey was then used to compare the isolated and the multiple-injury group to age- and sex-matched controls (n=145, age range 46-54 years. Mean scaled scores were calculated for each in the following areas: physical function (PF), role-physical (RP), bodily pain(BP), general health(GH), vitality(VT), social functioning (SF), role-emotional(RE), and mental health(MH). Comparison of scaled scores for each group (control/ amputee) was made using the student's t-test (two-tailed).

Results: Land mines and booby traps caused 65.3% of the injuries, mortar/artillery fragments 17%, small arms 8.5%, injuries in vehicles 5.5% and 3.9% rocket-propelled grenades. Indications for surgery were a partial or complete traumatic amputation in 82%, infection 13%, and failed vascular repair 5%. Evacuation time from injury to AGH averaged three and one-half weeks (range 1-11 weeks). Time from injury to pylon fitting was 5.3 weeks (range 2-16), and to permanent prostheses 6.8 months (range 1-14). Comparison of isolated versus multiple injury was then made (see Table 1) with regards to age at follow up, employment, whether they are or were married, whether they had children, psychological care, prosthetic use (hours per day), and what percentage of patients changed their prostheses from the original prescription. Only the incidence of psychological care was significantly different between the two groups using the Chi-squared test (p<0.001). Results of the SF-36 Health Survey (Table 2) show that the mean scaled scores for the isolated below knee patients were similar to age and sex matched controls. The patients who had sustained at least one other significant injury in addition to their below-knee amputation had scores in all categories that were significantly less (p<0.05) than the age- and sex- matched controls using the student's t-test (two tailed).

Table 1

	Age	Work	Marriage	Children	Psych	Prosth use (hrs)	Prosth change
Isolated	48.9	100%	96.4%	82%	21%	17.5hrs	78.5%
Mult	48.1	97.6%	97.6%	90.6%	51%	15.4 hrs	72%

Table 2*

SF-36 Control (45-54yrs)	PF	RP	BP	GH	VT	SF	RE	MH
	86.5	85.5	74.18	73.16	63.05	85.54	85.42	76.38
Isolated	83.5	85.58	84.5	75.9	70.76	90.8	91	80.3
Mult	62.3	31.3	50.5	62	54.1	70.6	55.7	64.1

Conclusion: Patients with battle-incurred below-knee amputations are able to lead relatively normal lives after they have undergone rehabilitation and prosthetic fitting. However, those patients that have other major injuries in addition to the below-knee amputation appear to have significant long-term psychological impact even with no long-term physical disability.

* PF=Physical Function, RP=Role Physical, BP=Bodily Pain, GH=General Health, VT=Vitality, SF=Social Function, RE=Role Emotional, and MH=Mental Health.