Cover: Limb Salvage and Recovery After Severe Blast Injury

Limb Salvage and Recovery After Severe Blast Injury

Literature Review for the Eighth Department of Defense International State-of-the-Science Meeting on Blast Injury Research

Published Jul 6, 2020

by Charles C. Engel, Molly M. Simmons, Sara E. Heins, Mimi Shen, Gulrez Shah Azhar, Tepring Piquado


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Research Questions

  1. What are the outcomes and epidemiology of limb salvage after severe blast-related limb injury?
  2. What does the evidence about the decision to salvage versus amputate a limb after severe blast-related limb injury say?
  3. What can be learned from the evidence and innovations about restoration and reconstruction after limb salvage for severe blast-related limb injury?
  4. What do the evidence and innovations about rehabilitation, reintegration, and recovery after limb salvage for severe blast-related limb injury say?

During the conflicts in Iraq and Afghanistan, there have been changes in the mechanism, severity, and complexity of injuries from improvised explosive devices⁠—changes that have resulted in a higher incidence of combat-related traumatic injuries. Battlefield medical advances and improvements in protective equipment have resulted in a greater proportion of blast-exposed service members surviving their severe injuries, and progress in surgical reconstruction and rehabilitation has resulted in an increased medical capacity to salvage limbs. Collectively, these developments have led to important questions about when to emphasize limb salvage over other treatment options, most notably amputation, for individuals with severe blast-related limb injuries.

To better understand limb salvage and recovery after severe blast-related injury, the authors conducted a literature review of recent research on the topic. They considered completed research addressing one or more of four objectives: (1) injury epidemiology and outcomes; (2) the clinical decision to salvage the limb; (3) the process of limb restoration and reconstruction; and (4) rehabilitation, reintegration, and recovery strategies. They found that although there is a vast literature on limb salvage, there is limited research on military blast-related limb salvage. The authors make several recommendations related to future research into limb salvage and recovery after severe blast injury.

Key Findings

There is a very limited body of empirical research on blast-related injuries to extremities and subsequent limb salvage—much more research is needed

  • An important gap is the absence of completed prospective, longitudinal studies with follow-up longer than one year.
  • There is limited evidence on the outcomes of amputation versus limb salvage overall and in clinically relevant subgroups.
  • Current evidence comparing various surgical approaches to limb salvage for blast-related limb injury is limited.
  • The most underdeveloped area of empirical research pertains to rehabilitative approaches in caring for blast-injured patients with severe limb injuries. Promising programs have been identified, but codification and empirical evaluation are needed.

Severe limb injuries are common among combat-injured service members

  • Persistent and disabling pain, sleep disturbance, depression and anxiety, and general loss of functioning are common after these injuries.
  • Most service members with severe combat-related limb injury are significantly disabled.

There is no one-size-fits-all intervention for severe blast-related limb injuries

  • To date, prognostic assessment tools have largely failed as decision aids for clinicians and patients.
  • There is a need for ongoing, intensive efforts to share and study decisionmaking with patients, caregivers as appropriate, and a multidisciplinary clinical team.


  • Establish theater-wide medical surveillance systems, coupled with multiyear follow-up studies with military and U.S. Department of Veterans Affairs collaboration.
  • The U.S. Department of Defense should establish and maintain relationships with civilian trauma centers and research platforms to support further research.
  • Future research should explore feasible clinical models of shared decisionmaking, patient-centered treatment planning, and patient-reported outcomes pertaining to limb salvage-related decisions following severe limb trauma.
  • Military hospitals should partner with civilian trauma centers and extremity trauma research platforms to strengthen research ties and investigate the impact of military clinician training in these settings on development and maintenance of limb salvage--related skills among military clinicians.
  • As new salvage techniques are introduced, we recommend that a series of a large, multicenter trials enrolling civilians is instituted.
  • Codify complex rehabilitative interventions for limb-salvage patients and explore the feasibility, important outcomes, and assessments of intervention fidelity that are most appropriate for studying the effectiveness of complex rehabilitative strategies for blast-related limb salvage and recovery.
  • Develop validated outcome measures on limb strength, performance, and function, as well as rehabilitative psychosocial interventions that reduce service members' suffering from chronic pain, persistent sleep disorders, posttraumatic stress disorder, anxiety, and related consequences of these injuries.
  • Develop, perfect, and deploy the dynamic ankle-foot orthosis in caring for severe lower-extremity injuries.

This research was sponsored by the the DoD Blast Injury Research Coordinating Office and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute.

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