Deployment after limb salvage for high-energy lower-extremity trauma

BACKGROUND Many wounded warriors experienced high-energy lower-extremity trauma (HELET) that may be limb threatening. Volumetric muscle loss, posttraumatic osteoarthritis, nerve injuries, and pain may severely limit physical function. Several wounded warriors express a strong desire to return to their units and be deployed in their original military occupational specialty. We began the return-to-run (RTR) clinical pathway at our institution 2 years ago to facilitate high-performance goals such as these. It involves an energy storing ankle foot orthosis, the intrepid dynamic exoskeletal orthosis in combination with high-intensity, progression-oriented rehabilitation. We sought to determine the rate of deployment or predeployment training after participation in this noninvasive intervention. METHODS A retrospective analysis of the RTR database was performed to determine the rate of deployment or predeployment training among those service members who began participation in the RTR between November of 2009 and March of 2011. Medical records were reviewed for demographics, injury, surgical data, and major complications. Requests for delayed amputation were recorded, and charts were reviewed to determine if patients eventually elected to proceed with amputation or if they chose to continue with limb salvage. RESULTS Between November 2009 and March 2011, 87 service members completed the RTR. Of these, 17 (19.5%) have been deployed to combat or are in predeployment training. Sixteen serve in combat arms (nine Special Forces, four infantry/ranger, two combat engineers, and one gunner), and one is a member of the military intelligence community. Fifteen patients sustained their injuries as a result of HELET (four gunshot, five motor vehicle collisions, four explosions, one parachute injury, and one fall from height), one had idiopathic avascular necrosis of the talus, and one had an iatrogenic nerve injury after pelvic surgery. Six of the patients underwent circular external fixation, five received joint fusions (three ankle, two subtalar joint), and nine had major nerve injuries. Four initially desired amputation of their injured limb but have subsequently countermanded their request. CONCLUSION Returning to high-level physical function after HELET is challenging. After implementation of the RTR clinical pathway with the intrepid dynamic exoskeletal orthosis, 19.5% of wounded warriors treated with the RTR have been deployed or will be deployed in the coming year. Level of evidence Therapeutic study, level V.