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MILITARY
MEDICINE

Long-term outcomes of
extremity injuries from the
Iraq and Afghanistan wars

By Paula K. Shireman, Jessica Rivera, Mary Jo Pugh

Vascular injuries are present in 12 percent of tions, and 38 percent screened positive for depressive symptoms,
wounded soldiers from Afghanistan and Iraq (Opera- with 34 percent not working or in school. However, service mem-
tions Enduring Freedom/ Iraqi Freedom/New Dawn; bers with amputations experienced better functional outcomes com-
OEF/OIF/OND) and extremity injuries comprise 50 pared to limb reconstruction patients as well as lower rates of
to 60 percent of casualties. The rate of vascular injury post-traumatic stress disorder.4 The DoD responded to these find-
is five times higher than in previous wars, and multiple ings by developing more support and rehabilitation programs for
injuries with open fractures are common due to the in- limb salvage patients, such as the Return to Run Clinical Pathway5
creased use of rocket-propelled grenades and improvised and the Intrepid Dynamic Exoskeletal Orthosis (IDEO).6 METALS
explosive devices (IED). In parallel, improvements in II is performing 10 year outcomes for the original METALS cohort
body armor as well as medical and surgical care have in- and establishing a second cohort that may have benefited from the
creased survival.1 Meeting the complex needs of these improvements in limb salvage care.
veterans poses a critical challenge demanding greater
understanding of the long-term medical and psychoso- Our university/VA/DoD team and presence in San Antonio
cial needs of veterans with injured extremities. uniquely position us to identify service members/veterans with extrem-
ity injuries to determine long-term care and outcomes. The results of
While the care of service members with vascular injuries these studies will help the VA and DoD to identify areas where specialty
has been studied in every war, the OEF/OIF/OND con- care or tele-health options are lacking, thus allowing for better planning
flict established the Department of Defense Trauma Reg- and resource utilization within VA and DoD systems, improving DoD
istry (DoDTR) database to capture information on injury to VA care transitions, and providing data that can inform current
demographics. Approximately 86 percent of service mem- management and/or guide development of new approaches for PACT
bers with an extremity vascular injury that was repaired remain free
of amputation five years post-injury.2 Long-term outcomes of ex-
tremity vascular repairs are not available in the civilian or military
trauma literature in regards to limb function and repair patency.
Our ongoing Veterans Administration (VA) Vascular Injury Study
(VAVIS)3 used the DoDTR to identify service members with ex-
tremity vascular injuries, and we are determining long-term repair
patency, limb function and limb salvage using VA medical records
and surveys to define the outcomes and needs of our veterans.

Our team, along with with our colleagues at Johns Hopkins Uni-
versity, is also performing a DoD funded, follow-up study on ex-
tremity orthopedic injuries in OEF/OIF/OND, the Military
Extremity Trauma and Amputation/Limb Salvage II (METALS II).
The first METALS was a retrospective cross-sectional study that in-
cluded 324 U.S. service members who had sustained major lower
limb trauma as a result of high-energy blast and ordnance-related
mechanisms. Both unilateral and bilateral lower limb traumatic in-
juries were included. Patients in the limb salvage and amputation
groups reported significant disability compared to normal popula-

24 San Antonio Medicine • August 2017