The US War on Diabetic Limb Amputation
Wound care clinicians are keenly aware that diabetes is a leading risk factor for amputations of the lower extremities. Fortunately, we are winning some battles in that regard. According to the Centers for Disease Control and Prevention, the rate of leg and foot amputations among US adults 40 years or older with diagnosed diabetes declined by 65% between 1996 and 2008.1 The age-adjusted rate of nontraumatic lower-limb amputations was 3.9 per 1000 persons with diabetes in 2008, compared with 11.2 per 1000 in 1996.1 Adults 75 years or older had the highest rate-6.2 per 1000.1
Varying estimates indicate that 300 to 500 amputations are performed in the United States daily, and more than 147,000 surgical amputations were performed in 2010.2,3 Currently, nearly 2 million persons are believed to be living with limb loss in the United States. Authors differ in their estimates of traumatic amputees, which points to the need for a unified registry.2-4 Estimates are that about 30,000 traumatic amputations occur in this country every year.2-4
Innately traumatic amputees account for a much younger cohort than diabetic amputees. Therefore, opportunities exist now and the future for population health measures in that cohort,2-4 such as smoking cessation, blood pressure management, and body mass index control and rehabilitation. Diabetes education and cardiovascular fitness are indispensable in this group as they age because of the increasing cardiovascular demand from ambulating with an amputation and prosthesis. In juxtaposition to the civilian traumatic amputee cohort, our young men and women in uniform incur traumatic amputations as a result of war.
The US Military: Current Wars and Amputations
Unfortunately, during 15 years of war in Southwest Asia, the use of improvised explosive devices, as well as conventional weapons, resulted in more than 5300 military deaths and 52,000 combat-wounded US Service Members (SMs).5 The vast majority of SMs sustained orthopedic injuries and other chronic wounds.5 According to the 2013 report6 of the Extremity Trauma and Amputation Center of Excellence (EACE), during the period October 1, 2012, through September 30, 2013, 68 SMs sustained limb loss, 16 of whom lost multiple limbs, bringing the 11-year total to 1628 SMs who have sustained a major amputation in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn.6 Of the 1628 injured, 504 have lost 2 or more limbs, including 5 SMs with the loss of all 4 limbs. Because of policy changes, survivability, advances in combat medical care, orthotics/prosthetics, and the resiliency of this group of warriors, 456 amputees have been retained on active duty, and 68 have redeployed.6
Knowledge and Technology Transfer
Durable incremental and transitional lessons are learned during times of war. Many of the advancements in amputee care, prosthetics, and other technologies are truly transformative, including carbon-fiber energy-storing orthotics-intrepid dynamic exoskeletal orthosis (http://www.prioriti-mtf.org), and microprocessor prosthetic knees, mimicking the normal gait cycle and allowing a mechanical proprioceptive adaptability when ascending and descending stairs (http://www.ottobockus.com/C-Leg.html). On the near horizon, options that use brain myoelectric signals to move robotic prostheses will be available (http://www.extremetech.com/extreme/182202-fda-approves-the-deka-arm-the-first-co). Regenerative medicine and advances in military wound care have and will continue to translate to the civilian sector.
Leveraging the National Resources
The seminal advancements in military rehabilitative care should be leveraged and adapted to advance amputee and wound care in other sectors. The annual US healthcare costs related to amputations are estimated at $8 billion,2 and the 5-year prosthetic costs per person with limb loss are estimated to be as high as $450,000.2 Furthermore, it is projected that the number of people living with the loss of a limb will more than double by 2050.2
The US Department of Defense, the US Department of Veterans Affairs and the EACE6 have set a benchmark for enhancing amputee care. This level of care should be disseminated across the spectrum to include patients who are served by the Centers of Medicare & Medicaid and the Department of Health and Human Services. Opportunities exist to enhance US amputee care, especially through sharing resources, reducing duplication of efforts, and applying clinical translation across systems of care.
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