Analysis of Coalition Soldiers Sustaining Bilateral Traumatic Amputations with Perineal Involvement Secondary to Improvised Explosive Device

Danielle M Herder, MD1, Saldhana Vilas, MD1, Paul Chestovich, MD2, Nichole Ingalls, MD1. 1United States Air Force/University of Nevada School of Medicine, 2University of Nevada School of Medicine

Objectives:  Penetrating blast injury is the primary wounding mechanism in Operation Enduring Freedom (OEF). The traumatic amputation secondary to improvised explosive device is a devastating injury requiring the coordinated efforts of multiple surgical services. Amongst patients with bilateral lower extremity amputations, there is a subset with concomitant perineal injury.  The aim of this study is to compare this subset to the larger population of bilateral lower extremity amputations with regards to morbidity and mortality.

Methods:  A retrospective analysis of the Joint Theater Trauma Registry (JTTR) for coalition soldiers sustaining traumatic amputations from 2009 to 2013 was performed. A cohort of these patients with concominant perineal injuries was identified.  These patients were compared using STATA software and chi square or Wilcoxon rank sum analysis.

Results:  One hundred ninety seven patients were identified with bilateral lower extremity amputations from 2009 to 2013, of which, 135 also sustained perineal injuries.  Amputation combined with perineal injury was associated with lower mean systolic blood pressure upon arrival to ED, 81 vs 111 mmHg (p<0.001).  No significant differences were noted in use of tranexamic acid, use of tourniquet, intubation on arrival, TBI severity, acute renal failure, Acinetobacter infection, DVT, PE, fungal infection, rhabdomyolysis, wound infection, 30 day survival, mortality prior to discharge to home military treatment facility (MTF).  Patients with perineal injuries had higher rates of exploratory laparotomy (36% vs. 8%, p<0.001), bowel resection or repair (38% vs 11%, p<0.001), uni- or bi-lateral orchiectomy (36% vs. 8%, p<0.001).

Conclusions:   Patients sustaining multiple traumatic amputations with associated perineal involvement are more likely to present hypotensive and require abdominal exploration, intestinal repair and orchiectomy.  These data should guide the forward deployed surgeon in developing a treatment algorithm for these complex patients.

 Bilateral lower amputees (n=62)Bilateral lower amputees with perineal injury (n=135)P-value
Initial Presentation
Mean ED systolic blood pressure11181<0.001*
Tranexamic acid use37% (n=23)37.7% (n=51)0.92
Tourniquet use83.9% (n=52)91.9% (n=124)0.092
Intubated on arrival22.8% (n=13)28.7% (n=35)0.41
Severe TBI (GCS 3-8)37.1% (n=23)34.8% (n=47)0.15
Survival and Mortality
30 day survival95.6% (n=59)93.3% (n=126)0.62
Mortality4.8% (n=3)6.7% (n=9)0.62
Surgical Intervention
Exploratory Laparotomy8.1% (n=5)36.3% (n=49)<0.001*
Bowel resection/repair11% (n=7)37.8% (n=51)<0.001*
Uni-, bi-lateral orchiectomy0% (n=0)37.8% (n=51)<0.001*
Vascular repair37.1% (n=23)32.6% (n=44)0.54

* P value <0.05 is statistically significant.


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