Outcomes after Long-Term Follow-Up of Combat-Related Extremity Injuries in a Multidisciplinary Limb Salvage Clinic


      Although the incidence of casualties from the Global War on Terror is decreasing, there remains a focus on the long-term sequelae from injuries sustained in the combat. Patients with prior significant limb injuries remain at risk of future complications. This study examines our institution's experience with a multidisciplinary team approach toward this challenging patient population.


      A retrospective review was performed on all patients treated in a single institution Limb Preservation Clinic over a 2-year period. Those patients who sustained a combat-related injury in theater were examined. Patient demographics, mechanism of injury, amputation rates, time to amputation, and reasons for failure were examined.


      Ninety-four patients were evaluated in our multidisciplinary Limb Preservation Clinic over a 2-year period. Twenty patients (21%) were seen for combat-related injuries. Sixteen patients were evaluated and treated for chronic complications at a median of 13 months from their injury. All 16 patients were male with a median age of 24 years (range, 20–35). Ten patients sustained injuries secondary to a dismounted improvised explosive device (IED). All 16 patients had extensive soft tissue injuries and associated fractures. Only 2 patients sustained a vascular injury. The median number of prior surgeries to the affected limb was 8 (range, 3–19). The limb salvage rate of 37% was lower than our noncombat cohort (47%). The most common reasons for delayed amputation included chronic pain, osteomyelitis, and soft tissue infections.


      The high secondary amputation rates seen in this cohort underscores the need for long-term follow-up. Despite successful initial outcomes, many patients eventually progress to limb loss. Patients who sustain a dismounted IED are at greatest risk for a delayed amputation. Identifying and addressing those factors which lead to delayed amputation should be a priority for returning war veterans and focus of future studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gawande A.
        Casualties of war-military care for the wounded from Iraq and Afghanistan.
        N Engl J Med. 2004; 351: 2471-2475
        • Fox C.J.
        • Gillespie D.L.
        • O’Donnell S.D.
        • et al.
        Contemporary management of wartime vascular trauma.
        J Vasc Surg. 2005; 41: 638-644
        • Starnes B.W.
        • Beekley A.C.
        • Sebesta J.A.
        • et al.
        Extremity vascular injuries on the battlefield: tips for surgeons deploying to war.
        J Trauma. 2006; 60: 432-442
        • Sanders L.J.
        • Robbins J.M.
        • Edmonds M.E.
        History of the team approach to amputation prevention: pioneers and milestones.
        J Vasc Surg. 2010; 52: 3S-16S
        • Rosenblum B.I.
        • Pomposelli Jr., F.B.
        • Giurini J.M.
        • et al.
        Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes. A 5-year experience.
        Diabetes Care. 1994; 17: 983-987
        • Pomposelli F.B.
        • Kansal N.
        • Hamdan A.D.
        • et al.
        A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases.
        J Vasc Surg. 2003; 37: 307-315
        • Champion H.R.
        • Holcomb J.B.
        • Young L.A.
        Injuries from explosions: physics, biophysics, pathology, and required research focus.
        J Trauma. 2009; 66: 1468-1477
        • Scott D.J.
        • Arthurs Z.M.
        • Stannard A.
        • et al.
        Patient-based outcomes and quality of life after salvageable wartime extremity vascular injury.
        J Vasc Surg. 2014; 59: 173-179
        • Dua A.
        • Via K.C.
        • Kreishman P.
        • et al.
        Early management of pediatric vascular injuries through humanitarian surgical care during U.S. military operations.
        J Vasc Surg. 2013; 58: 695-700
        • Eastridge B.J.
        • Mabry R.L.
        • Seguin P.
        • et al.
        Death on the battlefield (2001-2011): implications for the future of combat casualty care.
        J Trauma. 2012; 73: S431-S437
        • Wolf S.J.
        • Bebarta V.S.
        • Bonnett C.J.
        • et al.
        Blast injuries.
        Lancet. 2009; 374: 405-415
        • DePalma R.G.
        • Burris D.G.
        • Champion H.R.
        • et al.
        Blast injuries.
        N Engl J Med. 2005; 352: 1335-1342
        • Gifford S.M.
        • Aidinian G.
        • Clouse W.D.
        • et al.
        Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative.
        J Vasc Surg. 2009; 50: 549-556
        • Burkhardt G.E.
        • Cox M.
        • Clouse W.D.
        • et al.
        Outcomes of selective tibial artery repair following combat-related extremity injury.
        J Vasc Surg. 2010; 52: 91-96
        • Fox C.J.
        • Starnes B.W.
        Vascular surgery in the modern battlefield.
        Surg Clin N Am. 2007; 87: 1193-1211
        • Harris A.M.
        • Althausen P.L.
        • Kellam J.
        • et al.
        Complications following limb-threatening lower extremity trauma.
        J Orthop Trauma. 2009; 23: 1-6
        • Castillo R.C.
        • Mackenzie E.J.
        • Wegener S.T.
        • et al.
        Prevalence of chronic pain seven years following limb threatening lower extremity trauma.
        Pain. 2006; 124: 321-329
        • Bevevino A.J.
        • Lehman R.A.
        • Tintle S.M.
        • et al.
        Incidence and morbidity of concomitant spine fractures in combat related amputees.
        Spine J. 2013; (available online prior to print)
        • Potter B.K.
        • Burns T.C.
        • Lacap A.P.
        • et al.
        Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision.
        J Bone Joint Surg Am. 2007; 89: 476-486
        • Masini B.D.
        • Murray C.K.
        • Wenke J.C.
        • et al.
        Prevention and treatment of infected foot and ankle wounds sustained in the combat environment.
        Foot Ankle Clinics. 2010; 15: 91-112
        • Rush Jr., R.M.
        • Kjorstad R.
        • Starnes B.W.
        • et al.
        Application of the Mangled Extremity Severity Score in a combat setting.
        Mil Med. 2007; 172: 777-781
        • Ly T.V.
        • Travison T.G.
        • Castillo R.C.
        • et al.
        Ability of lower-extremity scores to predict functional outcome after limb salvage.
        J Bone Joint Surg Am. 2008; 90: 1738-1743
        • Scalea T.M.
        • DuBose J.
        • Moore E.E.
        • et al.
        Western Trauma Association critical decisions in trauma: management of the mangled extremity.
        J Trauma Acute Care Surg. 2012; 72: 86-93
        • Swiontkowski M.F.
        • MacKenzie E.J.
        • Bosse M.J.
        • et al.
        Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.
        J Trauma. 2002; 52: 641-649
        • Patzkowski J.C.
        • Blanck R.V.
        • Owens J.G.
        • et al.
        Comparative effect of orthosis design on functional performance.
        J Bone Joint Surg Am. 2012; 94: 507-515
        • O’Toole R.V.
        • Castillo R.C.
        • Pollak A.N.
        • et al.
        Determinants of patient satisfaction after severe lower-extremity injuries.
        J Bone Joint Surg Am. 2008; 90: 1206-1211
        • Ringburg A.N.
        • Polinder S.
        • van Ierland M.C.
        • et al.
        Prevalence and prognostic factors or disability after major trauma.
        J Trauma. 2011; 70: 916-922
        • Melcer T.
        • Sechriest V.F.
        • Walker J.
        • Galarneau M.
        A comparison of health outcomes for combat amputee and limb salvage patients injured in Iraq and Afghanistan wars.
        J Trauma Acute Care Surg. 2013; 75: S247-S254