Military Extremity Trauma and Amputation/Limb Salvage II (METALS II)

Many service members suffered from major limb trauma obtained during combat operations in Iraq and Afghanistan. Treating the wounded must occur at a rapid rate. The treatment strategies for major limb trauma come down to amputation versus reconstruction. In order to develop treatment guidelines and avoid prolonged, costly and fruitless salvage procedures, several investigations have compared outcomes under amputation versus limb salvage. 

The Military Extremity Trauma and Amputation/Limb Salvage(METALS) Study, retrospectively examined the differences between amputation and limb salvage. The study was conducted with service members deployed to Afghanistan or Iraq between 2003-2007. The service members had also sustained major limb trauma to the upper and/or lower limbs (n=429). Interviews were conducted and medical records were examined. Results showed that major limb trauma led to significant physical and psychosocial disability. The results demonstrated that these disabilities were greater in Veteran populations than in the civilian U.S. population (see LEAP study below). However, patients with lower limb trauma who underwent amputation experienced significantly better outcomes than those undergoing limb salvage.  

The Lower Extremity Assessment Project (LEAP), prospectively studied civilian adults with leg injuries (n=545) similar to those studied in METALS. After adjusting for differences in patient and injury characteristics, the LEAP study found no differences in outcomes following amputation versus limb salvage. As with the METALS study, however, outcomes were generally poor across both groups. Only 51% of participants returned to work at 2 years. In addition, 42% of participants suffered from depression and/or anxiety.

Differences in the METALS and LEAP study results may be due to greater access to state-of-the art prostheses and prosthetic care for Military versus civilian amputees. In addition, amputees in the Military may have benefitted from more focused rehabilitation and support services compared to both Military limb salvage patients and civilian amputees. Rehabilitation protocols for amputees, including an emphasis on peer support, have been well established through the Military Amputee Care Programs.

The METALS II study extends the original METALS study to examine longer-term outcomes in service members. The METALS II study also enrolled a new group of METALS patients injured in later years of OIF/OEF/OND. These patients may have benefited from improvements in limb salvage care. Our SLC team has been tasked to analysis de-identified electronic health records. We are investigating complications and use of services between amputees and limb salvage patients and variations in utilization over time. For a subset of eligible individuals who provide consent to be interviewed, their outcome data will also be linked with data on the long-term use of services provided by the military and VA. 

This study will provide a comprehensive longitudinal assessment of the consequences of major limb trauma. We will examine clinical, functional, and mental health consequences. It will add to our understanding of the long-term benefits of reconstruction versus amputation for the most severely injured. This could provide the basis for targeting interventions and developing more focused research on selected aspects of long-term recovery. Developing a better understanding of these consequences will be critical in designing and appropriately targeting interventions that improve outcome in both the civilian and military populations. 

The study will also provide important information on the health care services used by service members injured in OIF/OEF/OND. In addition, we will examine their perception of unmet need for services and some insight into barriers to obtaining necessary care.