O A RIGINAL RTICLE Return to Duty After Type III Open Tibia Fracture Jessica D. Cross, MD,*† Daniel J. Stinner, MD,*† Travis C. Burns, MD,* Joseph C. Wenke, PhD,† Joseph R. Hsu, MD*† and Skeletal Trauma Research Consortium (STReC) measureaftertraumaticinjury,andoutcomedatainamilitary Introduction:Despitethehighincidenceofbattlefieldorthopaedic population are only available for patients with a limb injuries, longterm outcomes and return to duty (RTD) status have amputation ranging from 2.3% to 16.5%.1 Civilian trauma rarelybeenstudied.OurpurposewastodeterminetheRTDratefor patients with severe lower extremity injuries have a well- soldierswhosustainedTypeIIIopentibiafracturesinactivecombat. documented rate of returning to work (49–53%)2, and in the military, the equivalent metric is return to active duty service Methods:Onehundredfifteensoldierswhosustainedbattlerelated aftercombatinjury.Eighty-twopercentofinjuredUSmilitary TypeIIIopentibiafractureswereretrospectivelyreviewed.TheArmy personnelhavesustainedextremityinjuriesduringtheongoing PhysicalEvaluationBoarddatabasewasreviewedtodeterminewhich conflictsinAfghanistanandIraq,3andthemajorityofinjuries soldierswereabletoRTDandthedisabilityratingsofthosenotable (79%) are secondary to explosions.4 Fractures sustained to RTD. during the current conflicts are predominantly open fractures Results:TheoverallRTDratewas18%,isolatedopenfractureshad (82%) demonstrating the severity of battlefield injuries.3,5 aRTDrateof22%,salvagedextremitieshadaRTDrateof20.5%, Ouraimwastodeterminethereturntodutyrateforsoldiers andamputeeshadaRTDrateof12.5%.Olderageandhigher rank whosustainedseverelowerextremitytrauma,specificallyGustilo werebothsignificantfactorsinincreasingthelikelihoodofRTDand andAndersonTypeIIIopentibiafractures,andwhounderwent amputees had significantly higher disability ratings than those with either limb salvage or amputation. salvagedextremities. Conclusion:Despitetheseverenatureofcombatextremitywounds, PATIENTS AND METHODS 20%ofpatientswithsalvagedTypeIIIopentibiafracturesand22% After protocol approval by our Institutional Review withisolatedinjurieswereabletoreturntoactiveduty.Theseratesare Board, we identified battle wounded soldiers with Type III similar to those reported for civilian amputees. Amputees in our opentibiafracturesoccurringbetween2003and2007treated cohort werelesslikely toRTD. definitively in a US military medical center. We reviewed Key Words: tibia fracture, return to work, return to duty, Type III patient records to characterize the injuries and outcomes, openfracture,combat injury including limb salvage versus amputation, age, rank, gender, mechanism of injury, injury pattern, associated injuries, and (JOrthopTrauma2012;26:43 47) presence of complications. We queried each patient in the Army Physical Evaluation Board (PEB) database for disposition and disability evaluation. The PEB is a body of military and medical personnel who determine if a service member is unable to return to active duty service.6–8 If INTRODUCTION a soldier’s condition at the time of maximal medical Despite the high incidence of battlefield orthopaedic improvement,asdeterminedbyhisphysicians,isnotsufficient injuries, long-term outcomes after combat injury are scarcely for returntoactiveduty,heorsherequiresaPEBevaluation. reported. Return to work is a commonly reported outcome The PEB results indicate permanent disability retirement, separationwithseverancepay,temporarydisabilityretirement list, or fit for duty. The first three dispositions indicate that AcceptedforpublicationMarch23,2011. asoldierisunabletoreturntodutyandisthereforemedically From*BrookeArmyMedicalCenter,FortSamHouston,TX;andthe†US ArmyInstituteofSurgicalResearch,FortSamHouston,TX. retiredorseparated(MRS).Asoldiermayalsoreturntoactive Nofundingwasreceivedforthiswork. duty with a disposition of continuation on active duty This study was conducted under a protocol reviewed and approved by the (COAD), which allows an individual to return to active duty Brooke Army Medical Center Institutional Review Board and in after a PEB appeal process and a change in job status.9 We accordancewithgoodclinicalpractice. Theopinionsorassertionscontainedhereinaretheprivateviewsoftheauthor surveyed each patient’s electronic medical record for and are not the construed as official or as reflecting the views of the documentation of COAD status because the PEB database DepartmentoftheArmyortheDepartmentofDefense. doesnotcaptureCOADstatusasonemethodofreturntoduty. Reprints: CPT Jessica D. Cross, MD, Brooke Army Medical Center DOR, Eachsoldierwhoisnotfitforduty,asdeterminedbythe 3851RogerBrookeDrive,FortSamHouston,TX78234(e-mail:jessica. PEB,hasalistof‘‘unfittingconditions,’’indicatingpersistent [email protected]). Copyright(cid:2)2012byLippincottWilliams&Wilkins disability.‘‘Unfittingconditions’’arecodedusingtheVeterans JOrthopTrauma (cid:2)Volume 26,Number1,January 2012 www.jorthotrauma.com | 43 Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302 Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number 1. REPORT DATE 2. REPORT TYPE 3. DATES COVERED 01 JAN 2012 N/A - 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Return to Duty After Type III Open Tibia Fracture 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER Cross J. D., Stinner D. J., Burns T. C., Wenke J. C., Hsu J. R., 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER Houston, TX 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release, distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a REPORT b ABSTRACT c THIS PAGE UU 5 unclassified unclassified unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 Crossetal JOrthopTrauma (cid:2)Volume 26,Number1,January 2012 Affairs System of Rating Disabilities and are assigned a percent disability.10 We calculated each soldier’s overall dis- TABLE 2. Injury Characteristics, RTDRatesand Percentages ofThoseWithLimb SalvageVersus Amputation ability rating using this system when they were unable to return to duty (RTD). No. MRS RTD LimbSalvage Amputees WecalculatedtheRTDratebycombingthesoldierswho Mechanismof injury werefitfordutybyrecovery(noPEB),thosewhowerefound Explosion 90 82% 18% 79% 88% fit for duty at the PEB, and those who returned to duty on Motorvehiclecollision 17 76% 24% 7% 9% COAD. We compared the demographics, injury character- Gunshotwound 8 88% 13% 14% 3% istics, and disability ratings between soldiers whowere MRS GustiloandAnderson and thosewho RTD and also performed separate analyses on TypeIIIA 74 84% 16% 64% 50% salvaged versus amputated extremities. Each RTD group and TypeIIIB 47 81% 19% 32% 39% ‘‘medically retired’’ group was compared using two-tailed TypeIIIC 6 100% 0% 4% 11% Fisher exact test for categorical data or t tests for continuous Segmentinjured data. Statistical significance was assessed with P # 0.05. Proximal 30 83% 17% 29% 25% Middle 54 80% 20% 41% 22% Distal 43 88% 12% 30% 53% RESULTS Nerveinjury 45 89% 11% 26% 50% One hundred twenty-three soldiers with 138 tibia Vascularinjury 6 100% 0% 4% 11% fracturesmetourinclusioncriteria.Sixsoldierswereexcluded Bilateralfractures 12 100% 0% 9% 16% fromfinalanalysisasaresultofanincompletemedicalrecord RTD,returntoduty;MRS,medicalretiredorseparated. andtwosoldiersweredead.Theremaining115subjectswith 127 tibia fractures comprised the study cohort. The cohort demographicsarelistedinTable1.Amajorityofsoldierswere injured by explosions (Table 2), and no soldiers with Gustilo amputeeswas12.5%.Ofthesoldierswithsalvagedlimbswho and Anderson Type IIIC fractures or with bilateral open tibia wereabletoRTD,94%werebyrecovery(noPEB)orbybeing fractures returned to duty (Table 3). The RTD group was found fit for duty at the PEB (Table 4). In contrast, all 6yearsolder(P,0.0001)andheldranksthreepositionshigher amputees required a PEB appeal for COAD status and each (E-8vsE-5)thanthosewhodidnotreturntoduty(P,0.05). haddocumentationofvocationaltrainingorjobreassignment, Theaverage Injury SeverityScorewas13.4 (range, 4–43) and indicatingthatatruechangeinjobstatusoccurredforthemto Abbreviated Injury Scorewas3.5 (range,0–9) andshowedno RTD on COAD. The COAD exception was therefore used statistical difference between the twogroups. significantly more by amputee soldiers than subjects with Twenty-onesoldierswithintheentirecohortwereableto salvaged limbs (P , 0.05). RTD (18.3%). Fourteen of those achieved osseous union and PEBresultsfortheMRSgroupincluded208‘‘unfitting were able to return to duty by recovery without requiring conditions’’ and an average disability rating of 50%. One aPEB,whereastwowhosalvagedtheirlimbsrequiredaPEB hundredforty-threeoftheunfittingconditions(69%)resulted and were found fit for duty. Five soldiers were medically directly from the soldiers’ open tibia fractures (Fig. 2). retiredbythePEBbutappealedtheirdispositionandremained Psychiatric conditions (including posttraumatic stress disor- on active duty on COAD status (Fig. 1). The remaining der) and traumatic brain injury were present in 17% and 6%, 94 Soldiers were MRS. One soldier had bilateral injuries, a respectively,ofMRSsoldiers.Thedisabilityratingsassociated Type IIIB open tibia fracture and contralateral traumatic amputation,RTDwithCOAD.SoldierswhoRTDexperienced significantlymorerevisionsurgeriesandgreatertimetounion comparedwiththosewhowereMRS(P,0.05).Eighty-three soldierssalvagedtheirfracturedlimbs andhada RTDrateof TABLE 3. Treatment/Outcome and RTDRates 20.5%,76soldierswithisolatedfracturessalvagedtheirlimbs No. MRS RTD and had a RTD rate of 22.4%, and the he RTD rate for Irrigationsandde´bridements(average) 6.15 6.14 Revisions(average) 1.38 2.05* Coverage TABLE 1. Demographics Nonerequired 42 88% 12% Entire Limb Split-thicknessskingraft 29 79% 21% Cohort MRS RTD Salvage Amputees Flap 32 72% 28% Age* 27 25 31 26 26 Unknown 25 96% 4% Medianrank† E-5 E-5 E-8 E-5 E-5 Tibiaunion 105 83% 17% Percentmale 94% 94% 95% 94% 94% Timetounion(months) 8.9 13.2* InjurySeverityScore 13.4 14.1 11.8 14.3 14.6 Malunion 13 85% 15% AbbreviatedInjuryScore 3.5 3.6 3.1 3.6 3.9 Osteomyelitis 25 92% 8% *P,0.0001;†P,0.05betweenthosemedicalretiredorseparated(MRS)and *P,0.05. returntoduty(RTD). RTD,returntoduty;MRS,medicalretiredorseparated. 44 | www.jorthotrauma.com q2012LippincottWilliams&Wilkins JOrthopTrauma (cid:2)Volume 26,Number1,January 2012 Returnto DutyAfterOpenTibiaFracture FIGURE 1. One hundred fifteen subjects met inclusion criteria. Each subset may have return to duty (RTD)byrecoveryofthelimb,being found fit for duty at the Physical Evaluation Board (PEB), or by con- tinuation on active duty (COAD). RTD by COAD required a true change in job status in this cohort asindicatednewvocationaltraining orreassignment. with a salvaged limb averaged approximately two thirds of a transtibial amputation (nine of 130) with our cohort of those with an amputation (P , 0.05) (Tables 5 and 6). isolatedsalvagedtibiafractureswhoeitherRTDbyrecoveryor were found fit for duty (16 of 76), our cohort RTD at a significantly higher rate. DISCUSSION Our study demonstrated a lower return to duty rate Althoughreturntoworkdataforciviliantraumapatients compared with what is available in the civilian literature for are well established, this is among the first evaluations of unilateral and bilateral lower extremity injuries. Civilian military personnel with severe lower extremity injuries.11–15 trauma patients are most often injured in motor vehicle Stinner et al demonstrated RTD rates during the current collisionsandfalls,whereasexplosionsarethemostcommon conflicts,reportinganoverallrateof16.5%foramputeesand mechanism of injury for today’swounded soldier.2,4 Combat- 20% for those with a single extremity amputation.7 This is injuredsoldiershavesustainedanaverageof4.2woundsatthe muchhigherthanwhatwaspreviouslyreportedbyKishbaugh timeofmedicalevacuation,3anditislikelythatthesoldiersin et al during the 1980s.1 Our overall RTD rate for salvaged our cohort have more severe injuries compared with the limbswas20%,itwas22%forisolatedsalvagedinjuries,and average civilian trauma population. This difference may also 12.5%foramputees.AlthoughourRTDrateforamputeeswas beexplainedbythephysicaldemandsassociatedwithmilitary lower than that reported by Stinner et al, this was not service compared with less physically demanding civilian significantly different than the rate for our salvaged limbs jobs. One factor that the LEAP study group identified as resulting from the small number of amputees in our study. a negative predictor for return to work was a subject’s Amajority(14of17)ofthesoldierswhodidRTDinthelimb involvementindisability compensationlitigation.14Although salvagegroupdidsowithoutrequiringaPEBevaluation,and suchsystemsdonotexistinthemilitary,receivingadisability this did not occur for any soldiers with an amputation. This rating and retiring or separating from the military does have finding is similar to the Stinner et al publication, which implicationsforlong-termdisabilitypaymentsandhealthcare demonstrated that soldiers with amputations require the benefits. Return to work rates in the civilian work force for COAD program to RTD a majority of the time.5 When we combat veterans have not been reported. compare the Stinner cohort whowere found fit for duty after Our study suggests that a soldier’s age and rank may potentially be used to help predict whether or not he or she mayRTDafteracombatinjury.Thiscohort’sdataonageand rankareconsistentwiththatfoundbyStinneretal.Soldiersof TABLE 4. RTDRatesforComparisonGroups higher enlisted ranks generally have more administrative job PercentRTD descriptions compared with younger enlisted soldiers who RTD WithRecovery PercentRTD Rate orFitforDuty WithCOAD performamajorityofthephysicallydemandingjobs.Itisnot surprising, therefore, that the younger soldiers of lower rank Entirecohort 18.3% 81.0% 19.0% are not able to return to the physically demanding positions Retainedfracturedlimbs 20.5% 94.1% 5.9% they typically hold on active duty, whereas the older senior Amputatedfracturelimbs 17.6% 0.0% 100.0%* enlisted soldiers can more easily transition back to adminis- Retained,isolatedinjury 22.4% 94.1% 5.9% trativework, even if disability persists. Amputated,isolatedinjury 27.3% 0.0% 100.0%* Disability within our cohort was substantial with the Allsubjectswithoutamputation 20.5% 94.1%* 5.9% MRS group rated, on average, 50% disabled. Those with Allsubjectswithanamputation 12.5% 0.0% 100.0%* amputationwereratedsignificantlyhigherthanboththecohort *P,0.05. as awhole and thosewith salvaged limbs, and this finding is RTD,returntoduty;COAD,continuationonactiveduty. contrarytoLEAPdatathatsuggestssubjectswithamputations q2012LippincottWilliams&Wilkins www.jorthotrauma.com | 45 Crossetal JOrthopTrauma (cid:2)Volume 26,Number1,January 2012 TABLE6. CharacteristicsofBilateralLowerExtremityInjuries No. AveragePercentDisability Bilaterallowerextremityinjuries 28 69% Bilateraltibiafractureswith Bothsalvaged 7 53% Onesalvaged 3 63% Bothamputated 2 100% Tibiafracturepluscontralateral Traumaticamputationwith Tibiasalvaged 12 63% Tibiaamputated 4 100% because soldiers are able to appeal their disposition or disability rating. Although these data may provide valuable information to the treating physicians counseling patients on limb salvage versus amputation, our findings do not suggest that limb salvage should be attempted for every person sustaining severe lower extremity trauma. In addition, it is FIGURE 2. Sixty-nine percent of unfitting conditions in this possiblethattherewerefactorsnotdocumentedinthemedical cohort are directly related to the subjects’ Type III open tibia records that led to the decision to amputate, thus potentially fracture. selecting higher energy injuries into the amputation group. Despite the severe nature of combat extremity wounds, 18%ofpatientswithTypeIIIopentibiafracturesand22%of and subjects with limb salvage are equally disabled. It is these with isolated injuries and salvaged limbs were able to possiblethatthestatisticallysignificantdifferenceindisability return to active duty. For those not returned to duty, their ratings reflects the perceptions and bias of the PEB. orthopaedicsinjuriescausedthegreatestamountofpermanent Psychiatricconditions,includingposttraumaticstressdisorder, disability, and patients with an amputation were rated as occurred in 17% of our retired cohort, and although significantly more disabled than those with salvaged limbs. psychologicdistressmaybeprevalent,thelong-termdisability Future studies are required to determine how often the impact relates mostly to orthopaedic injuries. Although the medically retired woundedsoldier isemployedinthe civilian actual incidence of posttraumatic stress disorder and other workforce and why there is a discrepancy between amputees psychiatric conditions may be higher than reported in our and limb salvage in the civilian and military populations. cohort, the frequency at which these conditions cause permanentdisabilityislowerthanexpectedwhenconsidering rates reported inthecivilian trauma literature.16Furthermore, REFERENCES orthopaedic conditions directly resulting from the open tibia 1. KishbaughD,DillinghamTR,HowardRS,etal.Amputeesoldiersand injury cause the largest percentage of permanent disability in theirreturntoactiveduty.MilMed.1995;160:82 84. our study. 2. 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