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The Journal of Bone and Joint Surgery 81:1384-90 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.

Long-Term Follow-up Study of Bilateral Above-the-Knee Amputees from the Vietnam War*{dagger}

PAUL J. DOUGHERTY, {ddagger}, LIEUTENANT COLONEL, UNITED STATES ARMY MEDICAL CORPS

Investigation performed at the University of Louisville, Louisville, Kentucky


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Because caring for patients who have combat-related amputations is a discontinuous practice, military surgeons must relearn treatment techniques during each conflict. Methods: The purpose of the present long-term study (average duration of follow-up, 27.5 years) was to document the status of patients who had sustained a bilateral above-the-knee amputation in Vietnam and had been managed by the only separate amputee service in the United States Army. A review of the records of 484 battle amputees identified thirty individuals (6 percent) who had a bilateral above-the-knee amputation. Twenty-six (87 percent) of the thirty patients had been injured by a land mine or a booby trap. Fifty-three (88 percent) of the sixty limbs were amputated because of trauma, and the other seven (12 percent) were amputated secondarily because of infection. Data regarding education, employment, marriage and family life, prosthetic use, and psychological care were collected by mail or telephone for twenty-three (85 percent) of the twenty-seven surviving patients. Respondents also completed the Short Form-36 (SF-36) Health Survey. Results: At the time of the study, five (22 percent) of the twenty-three respondents used prostheses for walking; the devices were used for an average of 7.7 hours per day. Sixteen respondents (70 percent) were or had been employed outside of the home since the time of discharge. The physical functioning score on the SF-36 questionnaire was significantly lower for the study group than it was for a group of age and gender-matched controls (p < 0.001; Student two-tailed t test). With the numbers available, no significant differences could be detected between the groups with regard to physical role functioning (p = 0.377), bodily pain (p = 0.603), general health (p = 0.407), vitality (p = 0.949), social functioning (p = 0.460), emotional role functioning (p = 0.029), or mental health (p = 0.102). Conclusions: The patients in the present study have led relatively normal, productive lives within the context of their physical limitations.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
No injury that is commonly seen in civilian practice can be readily compared with a bilateral above-the-knee amputation due to explosive munitions1,3,6,7,16,25. Because bilateral traumatic amputation at the thigh is one of the most massive injuries seen in battle16 (Fig. 1), it presents some of the most formidable challenges during both the acute and the long-term phase of recovery.



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  		Fig. 1 Photograph of a patient who sustained a traumatic bilateral above-the-knee amputation that was caused by a command-detonated cannon shell. Note the widespread contamination by dirt and straw. The patient had so-called air hunger and required forty-three units of blood for resuscitation. (This patient was not a member of the study group.)

 
The goal of initial care is to ensure the survival of the patient. Thus, the initial focus is on resuscitation in the broadest sense of the word. This effort requires coordination among the general surgeon, the orthopaedic surgeon, and the anesthetist, who must assess all of the patient's injuries and provide the necessary treatment, including operative débridement, fluid replacement, and administration of antibiotics. Once the task of providing initial care has been met, the medical team focuses on rehabilitation and the patient's quality of life1,3,6,7,16,20,21,25.

Amputation is carried out in two stages, an aspect of caring for battle amputees that is not commonly discussed. The goal of the first stage is to prepare the patient for safe transportation by removing dead tissue, allowing for wide drainage of the stump, and preserving length. The goal of the second stage is to prepare the stump for a prosthesis of the appropriate length and shape5-7,9,18,19,21,24,25.

During the Vietnam War, amputees received initial rehabilitative treatment and prosthetic fitting at the general hospital to which they were assigned when they arrived in the United States after having been injured. Treatment and rehabilitative services were not necessarily consistent among all facilities. At most hospitals, amputees were assigned to a general orthopaedic service that managed all categories of orthopaedic patients6,7,19,21.

Recognizing the need to provide consistent treatment and rehabilitative services to amputees from the Vietnam War, the personnel at Valley Forge General Hospital in Phoenixville, Pennsylvania, organized the only separate amputee service in the United States Army. Before the formation of this service, the care of amputees had been uncoordinated, fragmented, and nonstandardized. Treatment had been directed by a physician and had followed four sequential phases: wound-healing, preprosthetic therapy administered by a physical therapist, and pylon and prosthetic fittings performed by a prosthetist. With the advent of the amputee service, the entire team evaluated the patient at the time of admission and followed the patient until the time of discharge. The stages of care often overlapped, and patients received rehabilitation and were fitted sooner than had been the case under the previous arrangement19. In addition to emphasizing stump-healing and physical therapy, the administrators, physicians, and staff focused attention on the psychological and social aspects of care. As a result, the amputee service created a milieu that fostered camaraderie and teamwork among the amputees6,7,11,19,21.

Although the popular literature has often portrayed Vietnam-era veterans who sustained a bilateral above-the-knee amputation as individuals with insurmountable emotional and physical scars25, the accuracy of this portrayal can be questioned. As far as I know, the present study is the first to document the long-term outcome for patients who sustained a bilateral above-the-knee amputation during battle and were managed for this unusual injury at an Army General Hospital that provided specialty care for amputees. To the best of my knowledge, it is also the largest series of bilateral above-the-knee amputations that has been documented in the English-language literature.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
A review of the records of 484 battle amputees who were patients at Valley Forge General Hospital during the Vietnam War identified thirty patients (6 percent) who had sustained a bilateral above-the-knee amputation. The records were reviewed to determine (1) the mechanism of injury (land mine or booby trap, or artillery, mortar, or small-arms fire), (2) the indications for operative treatment (partial or complete traumatic amputation, vascular injury, or infection), (3) the presence of other major injuries, (4) the evidence of shock at the time of arrival at the initial surgical hospital in Vietnam, (5) the number of units of blood transfused, and (6) the level of success in the use of prostheses before discharge from the Army General Hospital.

After informed consent had been obtained either over the telephone or through the mail, a survey consisting of a questionnaire (specifically designed for this study) and the Short Form-36 (SF-36) Health Survey31 was administered. The surveys were mailed to patients according to the guidelines for the administration of the SF-36. Patients who did not return the survey were contacted by telephone. The questionnaire was administered first in order to collect data on education, employment, marriage and family life, prosthetic use, and psychological care (including Alcoholics Anonymous and marriage counseling).

The SF-36 survey31 was administered second. The guidelines for the administration of the SF-36 include a script designed to preclude prodding by the surveyor. These guidelines also discourage asking health-related questions before administering the SF-36, but, because of an oversight, the questionnaire that had been designed for the present study was administered first. The responses of the patients were compared with those of a group of age and gender-matched controls who had completed the SF-36 as part of the National Survey of Functional Health Status in 199031. The 145 individuals in the control group were thought to represent a cross section of the population of American men who were between forty-five and fifty-four years old. Average scaled scores on the SF-36 were calculated for the control group for physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning, and mental health. The average scaled scores for the control group were compared with the average scaled scores for the study group with use of the Student two-tailed t test8.

The present study was approved by the Human Use Committees at the organization that provided the funding (the United States Army Medical Research and Materiel Command, Fort Detrick, Maryland) and the institution where the research was conducted (University of Louisville, Louisville, Kentucky).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 

Review of the Records
A review of the records of 484 battle amputees identified thirty patients (6 percent) who had a bilateral above-the-knee amputation. Twenty-six patients (87 percent) had been injured by an unconventional land mine or booby trap; three (10 percent), by artillery or mortar fire; and one (3 percent), by multiple bullets that had been fired from a machine gun. Fifty-three (88 percent) of the sixty lower extremities had a partial or complete traumatic amputation that was treated with débridement and completion of the stump as the initial operative procedure. The other seven lower extremities (12 percent) were amputated secondarily because of infection. No patient had an amputation because of a failed vascular repair. In most patients, the wound was grossly contaminated with debris, which not only was present on the surface of the tissue but also had been driven up along fascial planes by the explosion. The recommended operative technique was the open circular method, in which maximum length is preserved. Although it is recommended that skin traction be applied at the time of the initial operative treatment and continued throughout the evacuation chain6,7,9,19,25, this protocol was used for only twenty-six (43 percent) of the sixty stumps (Fig. 2). All of the stumps were placed in skin traction once the patients reached the Valley Forge General Hospital.



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  		Fig. 2 Photograph showing the application of skin traction before transportation.

 
As some records did not contain documentation on every aspect of injury and treatment, the data on the patients varied. The documentation regarding the number of units of blood that had been transfused for resuscitation was inconsistent; the fourteen patients who had such documentation received an average of 23.7 units of blood.

Some patients sustained an amputation of another limb in addition to the bilateral above-the-knee amputation. Specifically, three patients sustained a unilateral amputation of the upper extremity. One of them sustained a disarticulation at the wrist; one, a below-the-elbow amputation; and one, an above-the-elbow amputation.

After they had been stabilized, twenty-eight (93 percent) of the thirty patients were transferred to a hospital in Japan for reassessment of their wounds and preparation for the flight back to the United States and the Valley Forge General Hospital, where the definitive care was to be administered. The patients arrived at the Army General Hospital at an average of 4.5 weeks (range, one to twenty weeks) after the injury.

At the time of arrival at the Army General Hospital, the patients were examined and skin traction was either initiated or continued. The patients were fitted for pylons or stubbies as soon as possible so that they could begin gait-training (Fig. 3). The twenty-three patients (77 percent) for whom such data were available were fitted for these devices at an average of 8.3 weeks (range, three to twenty weeks) after the injury. The staff encouraged the patients to bear increasing weight on the extremities. After the wounds had closed and edema had subsided, the patients were fitted for permanent prostheses. The seventeen patients (57 percent) for whom such data were available were fitted for permanent prostheses at an average of 6.4 months (range, six weeks to fourteen months) after the injury.



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  		Fig. 3 Photograph showing the stubbies that are used for gait-training.

 

Results of the Survey
Three (10 percent) of the thirty patients died after discharge from the Army General Hospital. One of these patients died of natural causes; the cause of death was unknown for the other two. Twenty-three (85 percent) of the twenty-seven surviving patients provided consent and completed the survey by telephone or mail. Four patients (15 percent) could not be contacted. The average age at the time of the survey (performed at an average of 27.5 years after the injury) was 47.8 years (range, forty-six to fifty-one years).

Sixteen (70 percent) of the twenty-three respondents were or had been employed outside of the home even though the Veterans Administration provides adequate compensation to support a simple lifestyle. Twenty-one respondents (91 percent) were married, and twenty (87 percent) had children. One respondent had posttraumatic stress disorder, and four others had made use of such services as marriage counseling or Alcoholics Anonymous.

Sixteen respondents (70 percent) were fitted for prostheses at the Valley Forge General Hospital, and six (26 percent) were fitted at Veterans Administration facilities after they had been discharged from the Army General Hospital. The remaining patient, who had had very proximal amputations, was not fitted for prostheses. At the time of the survey, five respondents (22 percent) wore prostheses for various activities, including walking, for an average of 7.7 hours per day. Between the time of the initial fitting and the time of the survey, the individuals in that group had replaced their prostheses an average of 3.8 times. Four other respondents (17 percent) used prostheses when going outside of the home. Ten respondents (43 percent) reported that they had continued to walk with use of prostheses for an average of 12.9 years (range, 0.5 to twenty-nine years) after discharge. Although most patients had achieved a limited ability to walk with use of prostheses before they were discharged, eighteen (78 percent) of the twenty-three respondents reported that they used a wheelchair as the primary means of moving from one place to another at the time of the survey.

The amputees' average scaled scores on the SF-36 questionnaire were compared with those of the age and gender-matched controls (Table I). The physical functioning score was significantly lower for the study group than it was for the control group (p < 0.001, Student two-tailed t test). With the numbers available, no significant differences could be detected with regard to the other parameters that were assessed. The data from the present study are archived in Excel for Windows (Microsoft, Redmond, Washington) at the funding organization.


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  		TABLE I RESULTS OF THE SHORT FORM-36 (SF-36) HEALTH SURVEY31 FOR PATIENTS AND CONTROLS

 


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Previous conflicts demonstrated that amputee centers were needed in order to consolidate the skills of surgeons, prosthetists, nurses, and therapists. During World War I, about 2600 patients with major amputations were evacuated to the United States. Eleven (0.42 percent) of those patients had a bilateral above-the-knee amputation5. Because the United States entered the conflict late, military physicians relied on the advice and experience of British physicians who had been involved with the management of such patients for some time. To gain experience in caring for combat casualties, including amputees, twenty American orthopaedic surgeons worked in British military hospitals in England before the United States had sustained a large number of casualties23,24. Earlier in the war, some Americans had gone to France to gain similar experience4.

Philip D. Wilson, who served as President of the American Academy of Orthopaedic Surgeons during the 1930s, was one of the first orthopaedic surgeons to go to Europe during World War I. He took over amputee care at a hospital center in Savenay, France, and prepared patients for the long cruise back to the continental United States. Aware that confining amputees to bed until they reached the United States would provide less-than-optimum results, he began a program of early walking on pylons as well as physical therapy. The rehabilitation program reduced edema and swelling of the stump and also benefited patients psychologically by allowing them to achieve an upright posture well before they arrived in the United States5,13,32.

Seven amputee centers were established at Army General Hospitals across the continental United States to provide the best care for amputees by consolidating the resources of surgeons, prosthetists, nurses, and therapists. The team approach to amputee care that is commonly used in civilian facilities today originated with the Army Medical Department during World War I5,18.

The magnitude of mobilization during World War II is hard to imagine today. In 1945, the number of physicians in the United States Army peaked at about 48,000, and sixty-five named general hospitals in the continental United States provided specialized care for various disorders14. To consolidate resources as had been done during World War I, seven of these hospitals were designated as amputee centers. According to Peterson24, who served as a consultant to the United States Army Surgeon General, 870 (5.9 percent) of the 14,782 amputees from the United States Army who were reported to have been evacuated to the United States at the end of World War II had a bilateral amputation of the lower extremity; this group included an unknown number of patients who also had a bilateral above-the-knee amputation.

The Korean War began five years after World War II ended. Many surgeons who had gained experience in the management of casualties during World War II were still on active duty, and they implemented the lessons that had been learned during the previous conflict. The mortality rate among 1580 patients from the United States Army who had sustained an amputation was 33.5 percent (460 were killed in action and sixty-nine died of wounds)2,26,29,30.

During the Korean War, the Surgical Research Team found that patients who had sustained a bilateral above-the-knee amputation due to explosive munitions were the most severely injured casualties1,16. In an effort to improve the rate of survival among patients with massive open wounds, military trauma teams at Edgewood Arsenal conducted research after the Korean War with use of a goat model20,22. Those studies confirmed that prompt wound débridement, administration of antibiotics, and fluid resuscitation were the most effective means of treating such injuries.

During the Vietnam War, the Wound Data and Munitions Effectiveness Team3 studied approximately 5000 casualties and found that fourteen of nineteen patients who had sustained a bilateral above-the-knee amputation died before hospitalization despite prompt medical care and timely evacuation (unpublished data). In comparison, the mortality rate was 77 percent (286 of 370) among patients who had an isolated head wound, 67 percent (277 of 415) among those who had an isolated chest wound, and 25 percent (seventy-eight of 318) among those who had an isolated abdominal wound.

As previously mentioned, most bilateral above-the-knee amputations in the present study were caused by unconventional land mines and booby traps or by weapons fabricated from locally available materials or from another piece of ordnance, such as a cannon shell. In general, these devices were larger than the antipersonnel land mines that are of concern throughout the world today. For example, the 105-millimeter cannon shell used by United States troops during the Vietnam War had an explosive charge of about two kilograms, whereas the PMA-2 antipersonnel land mine currently in use in the former Republic of Yugoslavia has an explosive charge of about 100 grams10,17.

More than one-third of the respondents in the present study reported that they continued to use prostheses with some regularity, and ten respondents (43 percent) reported that they had used prostheses for walking for an average of 12.9 years after they had been fitted. Walking with use of prostheses may have become more difficult as the patients gained weight or sustained injuries of the shoulder.

Twenty-two (73 percent) of the thirty patients in the present study had been admitted to Valley Forge General Hospital before a psychiatrist was officially added to the staff in January 1971. During that time, patients developed their own group therapy, which was not formally directed but was encouraged by physicians and nurses.

Frank11, a psychiatrist who was assigned to the service, described three phases of treatment: (1) stabilization and wound-healing, during which patients were taught and encouraged to change their own dressings, (2) walking with use of prostheses, and (3) transition to outpatient status. Frank believed that the first phase often included a major component of denial among both patients and staff and suggested that patients were reluctant to display emotion for fear of ridicule. During the second phase, some patients exhibited frustration and hopelessness through self-defeating behavior, but most did not. To learn how to handle social situations such as dating as well as defense against verbal or physical attacks, patients discussed problems in group-therapy sessions. During the third phase, patients were given convalescent leave or passes to test life in the real world for several weeks. Although this approach had evolved before the formal amputee service was established, the addition of a psychiatrist completed the team and provided a continuum of care.

One patient in the present study reported that he had received treatment for posttraumatic stress disorder. Schlenger et al.27 reported that, fifteen years or more after military service, the prevalence of posttraumatic stress disorder was 15.2 percent among 1191 male Vietnam veterans who were in the theater of conflict and 2.5 percent among 419 Vietnam-era veterans who were not in the theater of conflict. In comparison, the prevalence was 1.2 percent among 451 nonveterans who were matched for age and gender.

Because of a lack of practice, it is unlikely that the quality of rehabilitation at Valley Forge General Hospital could be equaled at a military facility today. Caring for patients who have sustained an amputation during battle is a discontinuous practice in the military. Documenting the stages in the rehabilitation process is essential for facilitating the inevitable relearning process that is forced on each generation of orthopaedic surgeons who must care for such patients. The fact that graduate medical education programs in orthopaedic surgery have de-emphasized amputee care further increases the gap in learning.

Two courses of action could help to minimize the learning curve in future conflicts. The first component is the assignment of military medical personnel to Veterans Administration hospitals so that they can gain experience in working with amputees. The second component is the rotation of military medical personnel to hospitals in regions where large numbers of patients are injured by residual land mines, such as Asia, Africa, and the Balkans, so that military surgeons can gain experience in the treatment of amputations.

Future research should be directed toward preventing death on the battlefield by improving local resuscitative measures that can be applied immediately after soldiers are wounded. Recent efforts to develop a field dressing that is impregnated with dry fibrin in order to reduce bleeding have shown promise for both the prehospital and the hospital care of injured patients15. In addition, the use of fibrinolytic agents for the treatment of adult respiratory distress syndrome currently is under investigation and may show promise for future treatment12. Because most patients who have sustained a bilateral above-the-knee amputation use a wheelchair for moving about, prosthetics research should be directed toward providing a more energy-efficient means of locomotion that duplicates normal gait as much as possible.

The present study has some limitations. First, a comparison of the responses of the patients in the study group with those of individuals who were managed for a bilateral above-the-knee amputation at other military hospitals during the Vietnam War would have provided an excellent basis for conclusions. Unfortunately, the program described in the present study was the only one of its kind. The records of amputees who were managed in general orthopaedic services at other military hospitals are not available. Locating these amputees and then identifying the hospitals where they were managed could introduce a selection bias. Consequently, the findings of the present study cannot be compared with those from any other military facility.

The second limitation of this study is related to the image of heroism associated with this type of injury in the military setting. In addition, many of the patients in the present study held leadership roles as officers and noncommissioned officers. The personality, character, and skills that justified the selection of these individuals for leadership roles may well have carried over into the rehabilitation process. Furthermore, the comradeship among service members who have been wounded in similar circumstances is probably not reproducible in the civilian setting. Therefore, the findings of the present study cannot be extrapolated to the amputee population at large.

The third limitation of this study concerns the question of whether the SF-36 is appropriate for the assessment of amputees. If it is, then it appears that the responses of the patients in the study group were comparable with the published age and gender-matched norms31 in all areas except physical functioning. Perhaps the questionnaire that was designed for the present study revealed more valuable information than the SF-36 did.

Wartime amputations remain an important clinical problem for the United States Army Medical Department. Patients who have sustained a bilateral above-the-knee amputation have one of the most challenging types of injuries6,7,28. In my opinion, nothing can compensate these patients for the severe injuries that they sustained in the service of their country. In contrast to the portrayal in the popular media25, the present study provides evidence that those who have sustained a bilateral above-the-knee amputation on the battlefield are not automatically condemned to live with severe physical and emotional difficulties. The patients in this long-term follow-up study have led relatively normal, productive lives within the context of their physical limitations.

NOTE: The author thanks Alcide M. LaNoue, M.D., Chief of the Amputee Service at Valley Forge General Hospital; Phillip A. Deffer, M.D., Commander of Valley Forge General Hospital while the amputee program was in place; Monroe I. Levine, M.D., and James H. Herndon, M.D., staff orthopaedic surgeons, for providing insight into the care of these patients during their treatment; Ronald F. Bellamy, M.D., for information on the Wound Data and Munitions Effectiveness Team database; and Susan E. Siefert, E.L.S., C.B.C., for aid in the preparation of this manuscript.


   Footnotes
 
*Although the author has not received and will not receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received, but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the United States Army Medical Research and Materiel Command, Fort Detrick, Maryland 79920-5001, funding number: DAMD 17-97-1-7148.

{dagger}The views expressed in this article are those of the author and do not reflect the official policy of the Department of Defense or the United States Government.

{ddagger}Orthopaedic and Rehabilitation Service, Department of Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, Texas 79920-5001. E-mail address for Lieutenant Colonel Dougherty: paul.dougherty@cen.amedd.army.mil.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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