Abstract
Background
Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War.
Questions/purposes
We compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).
Methods
As part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean age ± SD at followup was 61 ± 2 years and 28 ± 5 years for the Vietnam War and OIF/OEF groups, respectively.
Results
Excellent, very good, and good self-reported health (85% versus 82%; p = 0.85) and QoL (69% versus 72%; p = 0.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (p = 0.018).
Conclusions
Participants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Introduction
Multiple limb loss due to battle injury involves a unique group of servicemembers who are often severely injured [1]. Those who live require intensive rehabilitation and diverse prosthetic and mobility assistive devices. The proportion of servicemembers with multiple limb loss has been increasing since World War I [3, 9], with a more recent report of casualties from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) describing the prevalence of multiple limb loss as 30% of all patients [17, 21].
Individuals with multiple limb loss are often studied as a group, yet there are differing types of multiple limb loss levels. We previously performed a study comparing individuals with multiple limb loss from the Vietnam War and OIF/OEF [13]. While there were 44 distinct types of limb loss noted, the most common was bilateral lower-extremity limb loss, with bilateral transfemoral amputations the most common subgroup and bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (bilateral transfemoral/transtibial or TFTT) the second most common subgroup. Each of these groups was seen to have varying levels of function. While those with multiple limb loss due to battle injury have been documented to constitute between 2% and 16% of all major amputees, a recent report shows that rate may be as high as 30% [17, 21]. Because of their frequency [9, 10, 13, 14, 17, 20] and their more complex care [4, 5, 18], it seems important to characterize the different levels of multiple limb loss for both treatment and prognosis.
Recently, self-reported quality-of-life (QoL) questionnaires have been used to study patients with a wide variety of illnesses. A single-item QoL questionnaire has been used to predict mortality and hospital use, and therefore a measure of a person’s overall health, and VAS QoL measures have been used as a tool to assess QoL for patients with cancer, spinal cord injury, and amputation [2, 7, 8, 24].
With this in mind, we completed a separate study protocol to compare only those with bilateral transfemoral amputation from the Vietnam War to those from OIF/OEF. We found that, while QoL was similar between groups, the Vietnam War group showed decreased levels of function when compared to those from OIF/OEF [14].
TFTT amputations have been reported as the second or third most frequent type of injury in patients with combat injuries from either the Vietnam War or the recent conflicts in Iraq and Afghanistan [13, 21]. We therefore compared outcomes between individuals from the Vietnam War and OIF/OEF who sustained TFTT amputations with regard to self-reported (1) health status, (2) QoL, (3) prosthetic use, and (4) level of function.
Patients and Methods
Survey Participants
After receiving institutional and human subject approvals from the Department of Veterans Affairs and the Department of Defense, veterans and servicemembers with major limb loss (amputation proximal to the wrist or ankle) occurring during the Vietnam War (1961–1973) or OIF/OEF (2001–2008) were sent letters requesting participation in a survey concerning their limb loss, use of prosthetics, and other medical conditions [13, 22]. Once consent was obtained, participants took the survey from 2007 to 2008 by mail, telephone interview, or website.
As part of a larger survey, all servicemembers with major limb loss from OIF/OEF, all Vietnam War veterans with unilateral upper limb loss and multiple limb loss, and a sample of Vietnam War veterans with unilateral lower-extremity limb loss were invited to participate. Only those individuals with war theater injury amputations were considered. There were 501 subjects in the Vietnam War group and 541 in the OIF/OEF group. We were able to contact 458 of the 501 veterans from the Vietnam War group. Of these 458, 298 were enrolled (65%) in the study. Similarly, we were able to contact 482 of the 541 servicemembers from the OIF/OEF group, of which 283 (59%) were enrolled in the study. Overall, the response rate was 581 of 940 (62%). For this study, only those with TFTT amputations were considered. TFTT limb loss was reported in 13 of 298 participants (4.3%) in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group [13, 22].
Characteristics of TFTT Amputees
All participants were male. The mean ± SD age at followup was 61 ± 2 years for the Vietnam War group and 28 ± 5 years for the OIF/OEF group. Postamputation employment was reported in 12 of 13 subjects in the Vietnam War group and in four of 11 in the OIF/OEF group. A further three of the OIF/OEF subjects were students. The mean number of surgeries per limb after initial amputation was 1.7 ± 1.9 for the Vietnam War group and 8.4 ± 7.9 for the OIF/OEF group (p < 0.001).
The anatomic distribution of injuries (nonamputation) was similar between groups (Table 1). Head injury was reported to be different when comparing the Vietnam War group to the OIF/OEF group (18% versus 0%), but with the numbers available, this was found to be not significant (p = 0.18). Hearing loss was not greater in the Vietnam War group when compared to the OIF/OEF group (46% versus 27%) (p = 0.34).
Table 1.
Combat-incurred injuries to other anatomic areas
| Anatomic area | Number of participants | p value | |
|---|---|---|---|
| Vietnam War group (n = 13) | OIF/OEF group (n = 11) | ||
| Head | 0 (0%) | 2 (18%) | 0.20 |
| Eye | 3 (23%) | 2 (18%) | 0.77 |
| Hearing loss | 6 (46%) | 3 (27%) | 0.34 |
| Chest | 0 (0%) | 1 (9%) | 0.46 |
| Abdomen | 3 (23%) | 3 (27%) | 0.81 |
| Burns | 1 (8%) | 0 (0%) | 0.54 |
| Extremity (nonamputation) | 4 (31%) | 3 (27%) | 0.85 |
OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
Other health issues were generally similar between groups (Table 2). The presence of phantom limb pain (62% versus 73%, p = 0.56) and residual limb pain (46% versus 73%, p = 0.19) was similar when comparing the Vietnam War and OIF/OEF groups, respectively. The presence of arthritis (p = 0.39) and chronic back pain (p = 0.20) were also similar between groups. Posttraumatic stress disorder was reported in 15% of the Vietnam War group and 36% of the OIF/OEF group (p = 0.23). Traumatic brain injury was less common in the Vietnam War group compared to the OIF/OEF group (0% versus 36%, p = 0.03).
Table 2.
Current health issues
| Variable | Number of participants | p value | |
|---|---|---|---|
| Vietnam War group (n = 13) | OIF/OEF group (n = 11) | ||
| Arthritis | 7 (54%) | 4 (36%) | 0.39 |
| Chronic back pain | 1 (8%) | 3 (27%) | 0.20 |
| Phantom limb pain | 8 (62%) | 8 (73%) | 0.56 |
| Residual limb pain | 6 (46%) | 8 (73%) | 0.19 |
| Migraine headaches | 1 (8%) | 3 (27%) | 0.20 |
| Traumatic brain injury | 0 (0%) | 4 (36%) | 0.03 |
| Depression | 2 (15%) | 3 (27%) | 0.30 |
| Posttraumatic stress disorder | 2 (15%) | 4 (36%) | 0.19 |
OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
Survey Variables
A broad survey was sent to all participants, which was used to collect data on basic demographics, military status, types of combat injuries including current amputation level(s) and their surgical treatment, other medical problems, types of prostheses used, satisfaction with the prostheses, current functional capability, health status, and QoL. For the TFTT groups in this study, we considered the end points of health status, QoL, prosthetic use, and level of function.
Health Status
The use of a single question for self-rated health status has been developed to assess general health in a population. The single-item self-rated health status question is derived from the SF-36 and has been validated to predict mortality in a Veterans Administration population and the general US population [2, 7, 8, 15]. We used the question asking the participant to classify their health as (1) excellent to very good, (2) good, (3) fair, or (4) poor.
Quality of Life
A single-item question to measure of global QoL was used as part of this survey. Survey participants were asked to rate their overall QoL as (1) excellent, (2) very good, (3) good, (4) fair, or (5) poor. This measure has been shown to provide valid assessment for other populations (such as those with cancer and cardiac disease) and a general US population [19, 23, 25]. A VAS is also an effective means to determine patient QoL for those with chronic medical problems and amputation [2, 6, 16, 24]. The participants were asked to respond to a question on how the amputation affected their QoL at the time of the study, answering on a scale from 0 to 10. The descriptors of 0 (does not affect my QoL at all), 5 (moderately affects QoL), and 10 (strongly affects QoL) were used.
Prosthetic Devices
This survey collected data on current prosthetic device and assistive device use (number and type of devices and frequency of daily use). Survey participants were classified into one of three groups: never received any prostheses, current prosthesis user (current use of at least one prosthesis for any length of time during the day), or prosthesis abandoned (received at least one prosthesis in the past and has currently discontinued use of all prostheses).
Retrospective data were collected on the total number (for both limbs) and types of prostheses received for two time periods: during the first 12 months after limb loss because of the first-year variability in rehabilitation as the servicemembers adapt to limb loss and limb volume changes and for Month 13 to 2008.
Survey participants self-reported receipt of any prosthetic device, regardless of whether it was received through military, Veterans Affairs, or private sources, including prototype prosthetic devices. Data were collected on the number of prostheses that wore out and the mean replacement time by type of device. For prostheses that were discontinued due to dissatisfaction, the number and type of device were collected, as well as the reasons why participants discontinued the prosthesis.
Due to the complexity of prosthetic systems, we summarized prosthetic device types into major groups defined by the degree of technology, device use, and level of limb loss. For limb loss at the knee or above (knee, transfemoral, hip, pelvis), the four groups were (1) advanced technology (a microprocessor-type device requiring recharging or a hybrid of electronic and body-powered parts), (2) mechanical (does not require recharging), (3) specialty (recreational, athletic, or high-impact use), or (4) waterproof (shower or swimming leg). Data on assistive technology use (eg, walkers, canes, crutches, car modifications, wheelchairs, terminal upper limb devices) were collected for current use and predicted use in the next 3 years.
Functional Capability
A critical outcome measure for those with lower-extremity limb loss is their degree of self-mobility. Lower-limb functional capability was assessed using seven self-reported levels of function: (1) cannot walk, need assistance to transfer; (2) cannot walk, does not need help to transfer; (3) household walker; (4) community walker; (5) can walk with varying speeds; (6) can perform low-impact activities (such as swimming or golf); and (7) high-impact activities (such as basketball or skiing).
Statistical Analysis
This cross-sectional, descriptive survey compared demographic characteristics, health status, function, prosthetic use, and satisfaction between the Vietnam War group and the OIF/OEF group. Univariate findings were analyzed using Stata® 9.2 (StataCorp, College Station, TX, USA). For univariate analyses, statistical significance was based on chi-square test (categorical data), Mann-Whitney U test (ordinal data), Student’s t-test (continuous data), and Fisher’s exact test (if cell sizes ≤ 5). The level of significance was two-sided p values of 0.05 or less.
Results
The reported single-item self-reported health status was similar between groups, with 85% of the Vietnam War group and 82% of OIF/OEF group reporting good health status or better (p = 0.85) (Table 3).
Table 3.
Self-reported health status and QoL
| Variable | Number of participants | p value | |
|---|---|---|---|
| Vietnam War group (n = 13) | OEF/OIF group (n = 11) | ||
| Health status | |||
| Excellent/very good/good | 11 (85%) | 9 (82%) | 0.85 |
| Fair | 2 (15%) | 1 (9%) | |
| Poor | 0 (0%) | 1 (9%) | |
| QoL | |||
| Excellent/very good/good | 9 (69%) | 8 (73%) | 0.85 |
| Fair | 4 (31%) | 1 (9%) | |
| Poor | 0 (0%) | 2 (18%) | |
| Does the amputation affect your QoL today? (points)* | 7.2 ± 3 | 8.3 ± 2.8 | 0.4 |
* Values are expressed as mean ± SD on a scale from 0 to 10, where 0 = does not affect QoL at all, 5 = moderately affects QoL, and 10 = strongly affects QoL; QoL = quality of life; OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
The single-item self-reported QoL was also similar between groups, with excellent, very good and good QoL reported for 69% of the Vietnam War group and 73% of the OIF/OEF group (p = 0.85) (Table 3). The mean VAS QoL measure was similar in the Vietnam War and OIF/OEF groups (7.2 ± 3 versus 8.3 ± 2.8; p = 0.4), showing the amputations having moderate to strong effects on the TFTT amputees’ life.
All participants in the OIF/OEF group reported using prostheses for some amount of time, whereas one participant in the Vietnam War group abandoned prosthetic use altogether (Table 4). The mean number of prostheses received since 13 months after amputation was 14.8 ± 10.1 for the Vietnam War group (mean 39 years after amputation) and 3.6 ± 4.7 for the OEF/OIF group (mean 3 years after amputation) (p < 0.001). The mean number of prostheses currently used was 2.1 ± 0.9 for the Vietnam War group and 6.1 ± 4.5 for the OIF/OIF group (p = 0.008). All those surveyed in the OIF/OEF group reported using a wheelchair, compared to 10 of 13 in the Vietnam War group (p = 0.085). The Vietnam War group reported a greater number of prostheses replaced over the years (Table 5) when compared to the OIF/OEF group (11.2 ± 9.9 versus 1.1 ± 3.0, p = 0.003).
Table 4.
Reported prosthetic devices
| Variable | Vietnam War group (n = 13) | OIF/OEF group (n = 11) | p value |
|---|---|---|---|
| Number of prostheses ever* | 16.8 ± 10.7 | 9.5 ± 6.9 | 0.06 |
| Number of prostheses received first 12 months* | 2.0 ± 0.9 | 5.9 ± 3.8 | 0.002 |
| Number of prostheses received 13 months to present* | 14.8 ± 10.1 | 3.6 ± 4.7 | < 0.001 |
| Number of prostheses currently using* | 2.1 ± 0.9 | 6.1 ± 4.5 | 0.008 |
| Number of prostheses used per year* | 0.4 ± 0.3 | 3.7 ± 2.2 | |
| Currently using wheelchair (number of participants) | 10 | 11 | 0.085 |
| Not using any prosthesis (number of participants) | 1 | 0 |
* Values are expressed as mean ± SD; OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
Table 5.
Prosthetics replaced, stopped using, or abandoned
| Variable | Vietnam War group (n = 13) | OIF/OEF group (n = 11) | p value |
|---|---|---|---|
| Number of prosthetics replaced (overall) | 11.2 ± 9.9 | 1.1 ± 3.0 | 0.003 |
| Advanced technology/hybrid | 0 | 0.4 ± 1.0 | 0.3 |
| Mechanical | 4.3 ± 4.7 | 1.9 ± 1.9 | 0.14 |
| Specialty/waterproof/cosmetic | 0.5 ± 0.7 | 0.5 ± 1.2 | 0.2 |
| Number of prosthetics stopped using (overall) | 4.4 ± 5.0 | 2.4 ± 2.7 | 0.24 |
| Advanced technology/hybrid | 0.12 ± 0.42 | 0.2 ± 0.42 | 0.7 |
| Mechanical | 4.3 ± 4.7 | 1.9 ± 1.9 | 0.14 |
| Specialty/waterproof/cosmetic | 0.5 ± 0.7 | 0.5 ± 1.2 | 1.0 |
| Number of prosthetics abandoned | 0.3 ± 1.1 | 0 |
* Values are expressed as mean ± SD; OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities versus none in the Vietnam War group (p = 0.018) (Table 6).
Table 6.
Self-reported levels of function
| Level of function | Number of participants | p value | |
|---|---|---|---|
| Vietnam War group (n = 13) | OIF/OEF group (n = 11) | ||
| Cannot walk | |||
| Needs transfer help | 0 (0%) | 0 (0%) | |
| Does not need transfer help | 0 (0%) | 0 (0%) | |
| Household walker | 1 (8%) | 1 (9%) | 0.9 |
| Community walker | 6 (46%) | 3 (27%) | 0.9 |
| Can walk with varying speeds | 4 (31%) | 2 (18%) | 0.5 |
| Low-impact activities | 2 (15%) | 1 (9%) | 0.10 for high and low impact pooled |
| High-impact activities | 0 (0%) | 4 (36%) | 0.018 |
OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom.
Discussion
Those with multiple limb loss have steadily increased as a subgroup of combat-wounded amputees since World War I [9]. Most studies concerning multiple limb loss include all of the differing levels or combinations of limb loss. While studies pooling data of all levels of multiple limb loss allow for greater numbers, the characterization of specific types may be lost. With the increasing frequency of multiple limb loss due to battle injury, there is a realization that characterization of the specific types is important for resource planning of rehabilitation and prosthetics and the ability to predict prognosis. The most frequent types of multiple limb loss are bilateral transfemoral amputations, TFTT amputations as studied in this paper, and bilateral transtibial amputations. We therefore compared outcomes between individuals from the Vietnam War and OIF/OEF who sustained TFTT amputations with regard to self-reported (1) health status, (2) QoL, (3) prosthetic use, and (4) level of function.
There are several limitations to the study. The study design is cross-sectional in nature, so conclusions regarding causality or time sequence of events are limited. Because of this, comparison of veterans of the Vietnam conflict to veterans of the Iraq and Afghanistan conflicts is difficult, given the differing times since limb loss (3-year average for the OIF/OEF group and 39-year average for the Vietnam War group) and ages of the two groups. There are likely age-related changes (such as arthritis), which may influence these outcomes. The use of single-item QoL and health status measures provides less information than using the entire tools (such as the entire SF-36), but using the entire tools would have resulted in surveys quite unlikely to be completed by most patients, given the other data that we believed to be important to gather; moreover, single-item tools as we used them have been used to study other medical problems, such as cancer, spinal cord injury, and cardiac disease [19, 23, 25]. Our findings only apply to those with TFTT from battlefield injury, and these data should be used cautiously with other limb loss groups.
Additionally, there may be differences in prosthetics and rehabilitation that may influence these results, perhaps making comparison of the two groups not valid for all categories. Self-reported prosthetics use was defined as use for any amount of time, which may not reveal some differences in prosthetics use. This is somewhat offset by the self-reported level of function described by the TFTT amputees in both groups. Inherent with self-reported data, there may be bias in reporting from the veterans and servicemembers that may alter the results.
Self-reported health status and QoL are being evaluated more commonly in various areas of medicine, including those who sustain limb loss [2, 7, 8, 15, 16]. Asano et al. [2] surveyed 415 adult patients with a mean age of 61.9 years with either a transtibial or transfemoral level of amputation. Most (53%) of the patients had amputation due to “vascular disease,” with the remaining due to other causes. Predictors for variation included symptoms of depression, prosthetic mobility, social support, comorbidities, daily social activity, prosthetic problems, and age. For our study, a self-reported single-question global QoL was used to assess the patients’ perception of QoL [2, 6, 16, 24]. Reported QoL was similar between groups, with excellent, very good, and good reported for 69% of the Vietnam War group and for 72% of the OIF/OEF group. Additionally, for the VAS QoL instrument, both groups reported moderate to strong effects of the amputation on QoL. This finding is interesting, considering the disparate ages between the two groups.
Activity levels between the Vietnam War and OIF/OEF TFTT groups were different with respect to participation in high- and low-impact activities. This finding is consistent with other studies in other amputee populations reporting decreased activities of young patients who sustain multiple limb loss as they progress throughout life [10–13].
We also compared the TFTT group to a previously published group [14] who sustained bilateral transfemoral limb loss, the most common group of multiple limb loss. There were no significant differences between the two groups with regard to combat injuries to other anatomic areas or other current medical problems. Comparison of the levels of function between bilateral transfemoral amputees and the TFTT amputees from the Vietnam War and OIF/OEF groups pooled together found that 22 of 33 bilateral transfemoral amputees and two of 24 TFTT were household ambulators or nonambulators (p < 0.001). The same comparison between the bilateral transfemoral and TFTT groups from each conflict alone also showed that the bilateral transfemoral group had more household ambulators or nonambulators compared to the TFTT groups (Vietnam War: p = 0.001; OIF/OEF: p = 0.05). This finding implies that the preservation of at least one knee may improve the long-term functional status of those with bilateral lower-extremity limb loss.
In summary, TFTT amputees are a distinct subset of individuals with multiple limb loss. The self-reported health status and QoL of those with TFTT amputation are similar between the Vietnam War and OIF/OEF groups, and both groups reported a moderate to strong impact of the TFTT amputations on their lives. The younger participants from the OIF/OEF group reported higher levels of function and greater prosthetic use when compared to the Vietnam War group. Future areas of research should include longitudinal studies of those with limb loss and assessments of physical function of older patients with limb loss as the demographics shift to where this group of patients becomes more prominent. In addition, further study should focus on specific types of individuals with multiple limb loss in an effort to improve prosthetics and rehabilitation, as well as resource planning.
Footnotes
One of the authors (GER) that she is the recipient of a Veterans Administration Career Scientist Award (RCS 98-353). The remaining authors certify that they, or a member of their immediate family, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at the Veterans Administration Puget Sound Regional Health Care System, Seattle, WA, USA.
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