title: Amputation: Not a failure for severe lower extremity combat injury.
abstract: BACKGROUND
  The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life.
  
  
  METHODS
  All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation.
  
  
  RESULTS
  In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery.
  
  
  CONCLUSIONS
  Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.
authors.affiliation: Royal Netherlands Airforce and Department of Trauma, Division of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3585 GA, Utrecht, The Netherlands. Electronic address: t.t.c.vandongen-4@umcutrecht.nl.
authors.forename: Thijs T C F
authors.initials: TT
authors.lastname: van Dongen
authors.affiliation: Department of Surgery, Central Military Hospital, Ministry of Defense, Utrecht, The Netherlands.
authors.forename: Eelco P
authors.initials: EP
authors.lastname: Huizinga
authors.affiliation: Department of Physiatry, Rehabilitation Center de Hoogstraat, Utrecht, The Netherlands.
authors.forename: Loes G M
authors.initials: LG
authors.lastname: de Kruijff
authors.affiliation: Department of Orthopedic Surgery, Central Military Hospital, Ministry of Defense, Utrecht, The Netherlands.
authors.forename: Arie C
authors.initials: AC
authors.lastname: van der Krans
authors.affiliation: Department of Traumatology, Division of Surgery, Haaglanden Medical Center, The Hague, The Netherlands.
authors.forename: Jochem M
authors.initials: JM
authors.lastname: Hoogendoorn
authors.affiliation: Department of Trauma, Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Luke P H
authors.initials: LP
authors.lastname: Leenen
authors.affiliation: Ministry of Defense and Department of Surgery, Alrijne Medical Centre Leiderdorp & Leiden University Medical Centre, Leiden, The Netherlands.
authors.forename: Rigo
authors.initials: R
authors.lastname: Hoencamp
mesh_terms: D000223:Adaptation, Psychological; D055826:Afghan Campaign 2001-; D000671:Amputation, Surgical / Q000523:psychology / Q000534:rehabilitation / Q000706:statistics & numerical data; D001753:Blast Injuries / Q000523:psychology / Q000534:rehabilitation / Q000601:surgery*; D004185:Disability Evaluation; D006233:Persons with Disabilities / 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 / Q000706:statistics & numerical data; D008297:Male; D008887:Military Medicine; D008889:Military Personnel; D009426:Netherlands / Q000453:epidemiology; D011788:Quality of Life; D020127:Recovery of Function; D012189:Retrospective Studies; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology*; D061665:Time-to-Treatment; D016896:Treatment Outcome; D055815:Young Adult
keywords: Afghanistan; Amputation; Combat; Functional outcome; Lower extremity; Quality of life; Trauma