title: Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military.
abstract: BACKGROUND
  Medical practitioners face difficult decisions over whether to amputate or to salvage a lower limb that has undergone trauma. To our knowledge, there has been little evidence reporting the impact of different surgical decisions on functional and mental health outcomes following intensive rehabilitation that might inform decision-making.
  
  
  METHODS
  This study is a retrospective, independent-group comparison of rehabilitation outcomes from a U.K. military complex trauma rehabilitation center. There were 100 procedures examined: 36 unilateral amputations (11 immediate-below-the-knee amputations, 15 delayed below-the-knee amputations, and 10 immediate above-the-knee amputations), 43 bilateral amputations, and 21 single-limb salvages (including 13 below-the-knee limb salvages); the patients had a mean age (and standard deviation) of 29 ± 6 years and a mean New Injury Severity Score of 34 ± 15 points. The outcome measures at completion of rehabilitation included a 6-minute walk test (6MWT), Defence Medical Rehabilitation Centre mobility and activities of daily living scores, screening for depression (Patient Health Questionnaire [PHQ-9]) and general anxiety disorder (General Anxiety Disorder 7-item scale [GAD-7]), mental health support, and pain scores.
  
  
  RESULTS
  On completion of their rehabilitation, the unilateral amputation group walked significantly farther in 6 minutes (564 ± 92 m) than the limb-salvage group (483 ± 108 m; p < 0.05) and the bilateral amputation group (409 ± 106 m; p < 0.001). The delayed below-the-knee amputation group (595 ± 89 m) walked significantly farther than the group with limb salvage below the knee (472 ± 110 m; p < 0.05), and there was no significant difference between the group with delayed below-the-knee amputation and the group with immediate below-the-knee amputation (598 ± 63 m; p > 0.05). The limb-salvage group was less capable of running independently compared with all amputee groups. No significant differences (p > 0.05) were reported in mean mental health outcomes between the below-the-knee injury groups, and depression and anxiety scores were comparable with population norms. At discharge, 97% of all patients were able to control their pain.
  
  
  CONCLUSIONS
  After completing a U.K. military interdisciplinary rehabilitation program, the unilateral amputation group demonstrated a significant functional advantage over the limb-salvage and bilateral amputation groups. We found that patients electing for delayed amputation below the knee after attempted limb salvage achieved superior functional gains in mobility compared with patients who underwent limb salvage below the knee and experienced no functional disadvantage compared with patients who underwent immediate amputation. The mental health outcomes were comparable with general population norms, optimizing the prospect of full integration back into society.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: 1Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Headley Court, Surrey, United Kingdom 2Department for Health, University of Bath, Bath, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: Ladlow
authors.forename: Rhodri
authors.initials: R
authors.lastname: Phillip
authors.forename: Russell
authors.initials: R
authors.lastname: Coppack
authors.forename: John
authors.initials: J
authors.lastname: Etherington
authors.forename: James
authors.initials: J
authors.lastname: Bilzon
authors.forename: M Polly
authors.initials: MP
authors.lastname: McGuigan
authors.forename: Alexander N
authors.initials: AN
authors.lastname: Bennett
mesh_terms: D000203:Activities of Daily Living / Q000523:psychology; D000328:Adult; D000671:Amputation, Surgical / Q000523:psychology / Q000534:rehabilitation*; D000674:Amputees / Q000523:psychology / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000523:psychology / Q000534:rehabilitation* / Q000601:surgery; D023821:Limb Salvage / Q000523:psychology / Q000534:rehabilitation*; D035002:Lower Extremity / Q000293:injuries / Q000601:surgery*; D008297:Male; D008603:Mental Health; D008889:Military Personnel / Q000523:psychology*; D020127:Recovery of Function; D012189:Retrospective Studies; D016896:Treatment Outcome; D006113:United Kingdom; D016138:Walking; D055815:Young Adult