Session VI - Reconstruction

Long-Term Follow-Up of Unilateral Above-Knee Amputees

Paul J. Dougherty, MD; Lieutenant Colonel, US Army, William Beaumont Army Medical Center, El Paso, TX

Introduction: The long-term consequences of a unilateral above-knee amputation sustained due to battle injuries at a young age are not known. The purpose of this study was to evaluate how well these patients function years after their injury.

Material/Methods: The study consisted of two parts, a retrospective review of records of battle amputees treated in an intensive rehabilitation program at Valley Forge Army General Hospital (VFAGH) during the Vietnam War followed by a survey to compare the current health status and function with a control group matched for age. Of 484 records that were reviewed, 113 (23.3%) patients sustained unilateral above-knee amputations. Records were reviewed to ascertain mechanism of injury, indications for initial surgery in Vietnam, procedure performed, time from injury to arrival at AGH, time to pylon, and time to permanent prosthesis. Patients who were alive at the time of review and aged 45 to 54 years were evaluated. Forty-six of 90 (51%) eligible patients were available for follow up and agreed to answer the questionnaires.

The survey portion consisted of a questionnaire and the SF-36 Health Survey The questionnaire was used to obtain information on mechanism of injury, number and type of subsequent surgeries, other medical problems, marriage, children, employment, prosthetic usage (type of prosthesis, number of hours worn per day, and whether the present prosthesis was a change from the original prescription). Information was also obtained on the incidence of psychological care, including Alcoholics Anonymous and marriage counseling, then compared to below knee amputees matched for age and course of treatment.

The SF-36 Health Survey is divided into eight areas (Physical Function-PF, Role Physical-RP, Bodily Pain-BP, General Health-GH, Vitality-VT, Social Function-SF, Role Emotional-RE, and Mental Health-MH). A control group of 145 male patients aged 45 to54 years from a New England Health Group (The Health Institute, New England Medical Center, Boston Mass) was used to compare SF-36 scores with the amputee group. Mean-scaled scores for the eight areas were compared with the AK/Control group using Student's t-test (two-tailed).

Results: Review of records indicated that 59% of the participants were wounded by land mines and booby traps. Other mechanisms included small arms (15.9%), mortars/grenade/rocket (11.4%), artillery (5.7%), and rocket-propelled grenade (7.9%). Indications for initial surgery were trauma (61.8%), failed vascular repair (29.2%), and infection (8.7%). Time >from initial injury to arrival at AGH averaged 4.4 weeks. Average time to pylon fitting was 7 weeks and time to permanent prosthesis was 7.5 months.

Responses to the questionnaire, taken an average of 28 years after injury, indicated that average age at follow up was 47.9 years, that 91.3% of respondents were employed, 93% were or had been married and 85% had children. After the initial amputation, the average number of operations on the stump averaged 2.4. Average number of prostheses since the initial fitting was 13.8, and the limb was worn an average of 13.5 hours per day. Six patients (13%) did not wear a prosthesis. Twenty patients (43.5%) wore the same prescription as their initial prosthesis, whereas 20 had changed prescriptions. Twenty-four patients (52%) reported psychological care including Alcoholics Anonymous and marriage counseling, which is significantly greater than the previously reported below-knee amputee group (Chi-square P<0.05).

Responses to the SF-36 were significantly lower among the AK amputees than among controls in all areas except mental health. (See table)

Conclusion: A search of the English-language literature revealed no previous studies that assess the long-term (average 28 years) consequences of battle-incurred above knee amputations. Young soldiers who sustain above knee amputations due to battle injuries can lead relatively normal lives if given intensive rehabilitation at a specialty center. When the responses of this group were compared with those of the below-knee amputation group, there were no significant differences in the ability to find employment or to raise families. Compared with data from other groups of amputees who were previously reported, this group described a greater incidence of psychological care, as well as a significant decrease in the SF-36 scores. These findings support early psychological intervention to ensure the best outcome.

SF-36 Scores: Above Knee Amputee versus Control

	PF	RP	BP	GH	VT	SF	RE	MH
AK	46.1	48.4	49.8	56.6	56.0	74.2	62.5	72.3
Control	86.5	85.6	74.2	73.2	63.0	85.5	85.4	74.6
P value	<0.001	<0.001	<0.001	<0.001	<0.05	<0.007	<0.001	0.18