Short-term physical and mental health outcomes for combat amputee and nonamputee extremity injury patients.

OBJECTIVES: The present study: (1) reports the early physical health complications, mental health outcomes, and outpatient health care utilization of patients with serious extremity injuries sustained during the Iraq or Afghanistan wars and (2) compares clinical outcomes between amputee and nonamputee extremity injury groups. METHOD: This was a retrospective review of clinical records in military health databases for patients injured in the Iraq and Afghanistan wars. Health outcomes of amputee (n = 382, injured 2001-2005) and nonamputee patients (n = 274, injured 2001-2007) with serious extremity injuries (abbreviated injury score ≥ 3) were followed up to 24 months post injury. This study was performed at Naval Health Research Center, San Diego. RESULTS: Amputee and nonamputee groups had similar injury severity scores. Amputees had nearly double the risk of certain adverse complications (infections, anemia, septicemia, and thromboembolic disease), but other complications (osteomyelitis and nonhealing wound) were similar between the 2 groups. Amputees had significantly greater odds of certain mental health disorders including mood, sleep, pain, and postconcussion syndrome. However, amputees had significantly reduced odds of posttraumatic stress disorder compared with nonamputees. Amputees used various outpatient clinics significantly more than nonamputees. CONCLUSIONS: Patients with serious combat extremity injuries showed high rates of adverse health outcomes in the short term. Amputees had higher rates of many but not all clinically important physical and mental health outcomes compared to nonamputees. These results are important for military orthopaedic surgeons and allied providers who care for and counsel these patients and clinicians and researchers who seek to understand and improve health outcomes in patients with extremity war injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic ossification in combat amputees from Afghanistan and Iraq wars: five case histories and results from a small series of patients.

Heterotopic ossification (HO) is excess bone growth in soft tissues that frequently occurs in the residual limbs of combat amputees injured in Operation Iraqi Freedom and Operation Enduring Freedom, or Iraq and Afghanistan wars, respectively. HO can interfere with prosthetic use and walking and delay patient rehabilitation. This article describes symptomatic and/or radiographic evidence of HO in a patient series of combat amputees rehabilitating at a military amputee care clinic (27 patients/33 limbs). We conducted a retrospective review of patient records and physician interviews to document evidence of HO symptoms in these limbs (e.g., pain during prosthetic use, skin breakdown). Results showed HO-related symptoms in 10 of the 33 residual limbs. Radiographs were available for 25 of the 33 limbs, and a physician identified at least moderate HO in 15 of the radiographs. However, 5 of the 15 patients who showed at least moderate radiographic HO did not report adverse symptoms. Five individual patient histories described HO onset, symptoms, treatments, and outcomes. These case histories illustrated how HO location relative to pressure-sensitive/pressure-tolerant areas of the residual limb may determine whether patients experienced symptoms. These histories revealed the uncommon but novel finding of potential benefits of HO for prosthetic suspension.

Predeployment and in-theater diagnoses of American military personnel serving in Iraq.

OBJECTIVE: This purpose of this study was to determine the incidence and types of preexisting mental disorders among military personnel who received mental health services in an Iraqi war zone. METHODS: The study examined psychiatric histories of 1,078 American military personnel (Marines, 65%; Army, 23%; Navy, 11%; and Air Force, <1%) deployed to Iraq and seen by in-theater mental health providers between January 2006 and February 2007. RESULTS: Among the 1,078 patients, the most frequent in-theater diagnoses were anxiety (24%), adjustment (23%), and mood (19%) disorders. Twenty-nine percent of the sample (N=308) had a psychiatric diagnosis in their medical records before their first encounter with mental health services in Iraq (Navy patients, 42%; Army patients, 39%; and Marine Corps patients, 23%). The mean time between last predeployment diagnosis and first in-theater mental health encounter was 21 months. For patients with a prior diagnosis, the highest rate of relapse (receipt of the same diagnosis in theater) was for attention-deficit hyperactivity disorder (57%), followed by anxiety disorders (44%)--especially posttraumatic stress disorder (PTSD) (55%)--mood disorders (38%), and adjustment disorders (32%). CONCLUSIONS: A significant proportion of military personnel who experienced mental health problems in a combat zone had preexisting psychiatric conditions. Because more than half of predeployment diagnoses were received in the nine months before the in-theater mental health encounter, further study may be advisable to determine whether a time-based algorithm for deployability is needed, particularly for PTSD, for which a high rate of repeat diagnosis in theater was found.

Midterm health and personnel outcomes of recent combat amputees.

OBJECTIVE: Warfighters who sustained combat amputations in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) have unique challenges during rehabilitation. This study followed their outcomes. METHODS: Subjects were 382 U.S. warfighters with major limb amputations after combat injury in OEF/OIF between 2001 and 2005. Outcome measures were diagnoses, treatment codes, and personnel events captured by health and personnel databases during 24 months postinjury. RESULTS: Most patients had multiple complications generally within 30 days postinjury (e.g., infections, anemia), with important exceptions (e.g., heterotopic ossification). Lower limb amputees had 50% more complications than upper limb amputees. Two-thirds of patients had a mental health disorder (e.g., adjustment, post-traumatic stress disorder), with rates of major disorder categories between 18% and 25%. Over 80% of patients used physical and occupational therapy, prosthetic/orthotic services, and psychiatric care. CONCLUSIONS: Combat amputees had a complex set of outcomes supporting the continued need for military amputee care programs.

Determining medical staffing requirements for humanitarian assistance missions.

OBJECTIVE: The primary mission of hospital ships is to provide acute medical and surgical services to U.S. forces during military operations. Hospital ships also provide a hospital asset in support of disaster relief and humanitarian assistance (HA) operations. HA missions afford medical care to populations with vastly different sets of medical conditions from combat casualty care, which affects staffing requirements. METHODS: Information from a variety of sources was reviewed to better understand hospital ship HA missions. Factors such as time on-site and location shape the mission and underlying goals. RESULTS: Patient encounter data from previous HA missions were used to determine expected patient conditions encountered in various HA operations. These data points were used to project the medical staffing required for future missions. CONCLUSIONS: Further data collection, along with goal setting, must be performed to accomplish successful future HA missions. Refining staffing requirements allows deployments to accomplish needed HA and effectively reach underserved areas.

The Navy-Marine Corps Combat Trauma Registry.

The U.S. military services, drawing on the experiences of civilian trauma systems in monitoring trauma care delivery, have begun to implement their own registries, emphasizing injury incidence and severity in a combat environment. This article introduces and describes the development of the U.S. Navy-Marine Corps Combat Trauma Registry and presents several preliminary inquiries of its database regarding combat injury patterns and casualty management during Operation Iraqi Freedom. The Navy-Marine Corps Combat Trauma Registry is composed of data sets describing events that occur from the point of injury through the medical chain of evacuation and on to long-term rehabilitative outcomes. Data were collected from Navy-Marine Corps level 1B, 2, and 3 medical treatment facilities. Data from the official combat period were analyzed to present a variety of preliminary findings that indicate, among other things, how many and for what type of injury casualties were evacuated, specific mechanisms of injury, and types of injuries treated at the medical treatment facilities.

Identifying clinical supply requirements for Marine Corps dental capability.

The Naval Health Research Center developed and used a systematic process to review Marine Corps dental supply requirements. The approach (1) identified the dental procedures required to treat patients with dental conditions and (2) determined the consumable supplies and equipment needed to complete each procedure. By establishing the clinical requirement for each item pushed forward, the Naval Health Research Center model significantly reduced weight, cubic volume, and cost while enhancing far-forward dental capability. This effort produced a database that clarifies the relationship among dental conditions, dental procedures, consumables, and equipment when conducting authorized dental allowance list reviews, determining training requirements, and configuring supplies for future deployments.