Acute bilateral leg amputation following combat injury in UK servicemen.

BACKGROUND: This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations. METHODS: The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal. RESULTS: There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products. CONCLUSIONS: Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.

Initial predictors associated with outcome in injured multiple traumatic limb amputations: a Kandahar-based combat hospital experience.

INTRODUCTION: Improvised explosive devices (IEDs) are the defining mechanism of injury during Operation Enduring Freedom. This is a retrospective analysis of initial management for IED blast injuries presenting with bilateral, traumatic, lower-extremity (LE) amputations with and without pelvic and perineal involvement. METHODS: A database of trauma admissions presenting to a North Atlantic Treaty Organization (NATO) Role 3 combat hospital in southern Afghanistan over a 7-month period was created to evaluate the care of this particular injury pattern. Patients were included if they were received from point of injury with at least bilateral traumatic LE amputations and had vital signs with initial resuscitation efforts. RESULTS: Thirty-two presented with double LE amputations (36%) and nine with triple amputations (10%). After excluding 10 patients who failed to meet the inclusion criteria, 22 patients were analysed. The mean age was 29 years, and the average ISS and admission haemoglobin were 22 and 11.3mgl(-1), respectively. Patients received an average of 54 units of blood products and underwent 1.6 operations with a mean operative time of 142.5min. The pattern of injury was associated with an increase in the total blood products required for resuscitation (pelvis n=12, p=0.028, gastrointestinal tract (GI) n=14, p=0.02, perineal n=15, p=0.036). There was no relationship between ISS or admission haemoglobin and the need for massive transfusion. Low Glasgow Coma Scale (GCS) was associated with increased 30-day mortality. Hollow viscus injury and operative hemipelvectomy were also associated with mortality. CONCLUSIONS: Early 30-day follow-up demonstrated that IED injuries with bilateral LE amputations with and without pelvic and perineal involvement are survivable injuries. Standard measures of injury and predictors of survival bore little relationship to observed outcomes and may need to be re-evaluated. Long-term follow-up is needed to assess the extent of functional recovery and overall morbidity and mortality.

Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national descriptive study in the Netherlands.

OBJECTIVE: To describe characteristics of hip disarticulation and hemipelvectomy amputees, to assess their level of activities, participation and experienced limitations in mobility and to describe the amputation-related problems. DESIGN: A cross-sectional study. SETTING: Patients were mainly recruited via orthopaedic workshops in the Netherlands. SUBJECTS: Forty-six patients with an acquired unilateral hip disarticulation or hemipelvectomy at least one year post amputation. MAIN OUTCOME MEASURES: Sickness Impact Profile 68 (SIP 68) to assess the level of activity and participation and the questionnaire Rising and Sitting Down, Walking and Climbing Stairs to assess perceived limitations in mobility. RESULTS: The 46 patients (31 with hip disarticulation and 15 with hemipelvectomy) had a mean age of 55.8 years (SD 12.1). In 78% of cases the reason for amputation was a tumour. Mean SIP 68 was low, 10.5 (SD 6.9). Hip disarticulation amputees had significantly poorer emotional stability than the hemipelvectomy amputees (P = 0.04). All amputees experienced considerable limitations in their mobility according to the Rising and Sitting Down, Walking and Climbing Stairs scores. CONCLUSIONS: Hip disarticulation and hemipelvectomy amputees have a relatively high level of activity and participation (SIP scores) but at the same time experience limitations in walking, rising and sitting down and climbing stairs.