JAAOS

JAAOS, Volume 14, No. 10


Accelerated fracture healing.

Acceleration of the fracture healing process would have far-reaching benefits for both civilians and military personnel. Decreasing the time to return to complete function would reduce medical costs, enhance quality of life by decreasing pain and increasing mobility, accelerate the return of professional athletes to their sport, and decrease the time for military recruits to enter active duty after injuries incurred in basic training. Moreover, augmenting the healing process may prevent the long-term disability caused by fracture nonunion. Currently available pharmaceutical agents may allow us to realize this goal. However, these agents need to be tested in prospective randomized clinical trials.

    • Keywords:
    • Bone Density Conservation Agents|Fracture Healing|Fractures

    • Bone|Humans|Mesenchymal Stem Cell Transplantation|Parathyroid Hormone

    • Subspecialty:
    • Trauma

    • Clinical Practice Improvement

Amputation is not isolated: an overview of the US Army Amputee Patient Care Program and associated amputee injuries.

Rates of amputation as a percentage of all combat injuries have increased significantly since the Korean War. Following traumatic and combat-related amputation, definitive treatment and rehabilitation require a large, multidisciplinary team to provide comprehensive medical and supportive care. Associated injuries are remarkably frequent, complicating treatment and potentially delaying rehabilitation and/or limiting outcomes. Patient and family psychosocial issues also must be assessed and appropriately addressed. The US Army Amputee Patient Care Program, with the support of numerous other government and private organizations, has been developed to meet the comprehensive medical, rehabilitative, and social needs of amputees injured in the current global war on terrorism, with the goal of maximizing subsequent patient outcomes utilizing a sports medicine approach.

    • Keywords:
    • Amputation|Amputees|Humans|Military Medicine|Military Personnel|Patient Care|United States

    • Subspecialty:
    • Trauma

Antibiotic prophylaxis: current recommendations.

Antibiotic prophylaxis consists of a brief course of antibiotics initiated preoperatively in order to decrease the risk of postoperative wound infection in the patient with a clean wound. The antibiotic should be started within 60 minutes before skin incision and continued for not more than 24 hours. Antibiotic therapy is indicated for the contaminated or dirty wound. In open fractures, antibiotics should be started as soon as possible after injury and continued for 3 days (type I and II fractures) or 5 days (type III). This treatment should be combined with local therapy consisting of antibiotic-impregnated polymethylmethacrylate beads. Although the utility of antibiotics in low-velocity gunshot wounds is controversial, high-velocity gunshot wounds should be treated with 48 to 72 hours of antibiotic therapy.

    • Keywords:
    • Anti-Bacterial Agents|Antibiotic Prophylaxis|Humans|Practice Guidelines as Topic|Preoperative Care|Wound Infection|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • General Orthopaedics

Blast and penetrating fragment injuries to the extremities.

Blast injury to the extremities is the most common form of injury in recent military campaigns and in civilian terror attacks. Most orthopaedic trauma is caused by the secondary effect of blast—penetrating fragment injury. Timely wound débridement and excision of contaminated or avascular tissue, along with prevention of sepsis, are crucial to managing extremity injury. Late reconstruction and functional results are very challenging for the surgical team to achieve.

    • Keywords:
    • Blast Injuries|Extremities|Hand Injuries|Humans|Leg Injuries|Multiple Trauma|Orthopedic Procedures|Wounds

    • Penetrating

    • Subspecialty:
    • Trauma

Combat orthopaedics: a view from the trenches.

Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. Most orthopaedic wounds in Iraq are caused by exploding ordnance—frequently, improvised explosive devices, or IEDs. Because of advances in care, rapid medical evacuation, and modern body armor, many casualties have survived in Iraq who would not have done so in previous wars. Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.

    • Keywords:
    • Humans|Iraq War

    • 2003 -|Military Medicine|Orthopedic Procedures|Orthopedics|United States|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Clinical Practice Improvement

Conversion from external fixation to definitive fixation: periarticular injuries.

Extremity injuries sustained by uniformed service combatants pose a significant challenge to military orthopaedic surgeons. The wounding mechanisms in Operation Iraqi Freedom and Operation Enduring Freedom consist of blasts, penetrating injuries, and blunt injuries. The mortality of warriors has decreased overall because of the improvements in head, neck, and torso body armor. Consequently, the severity of extremity wounds has increased. Because of the far-forward surgical assets (surgeons and advanced equipment), these patients are stabilized rapidly and their injured extremities are treated early (ie, revascularized, débrided, stabilized). However, multiple challenges exist in the timing of definitive reconstructive efforts once these injured service members return to military medical centers in the continental United States.

    • Keywords:
    • External Fixators|Fracture Fixation|Fractures

    • Bone|Hand Injuries|Humans|Joints|Leg Injuries|Treatment Outcome

    • Subspecialty:
    • Trauma

Conversion from temporary external fixation to definitive fixation: shaft fractures.

Temporary external fixation is the most common method of initial stabilization of diaphyseal fractures in forward surgical hospitals. Once the patient arrives at a stable environment, usually the United States, the fracture is managed with intramedullary nailing, small-pin external fixation, or a modified external fixator. Future research should be directed toward improving methods of care. It is not precisely known when is the best time to convert to definitive fixation without increasing the risk of infection. The risk factors leading to infection and nonunion are not well-established, making that determination even more difficult. Clinical studies of a suitable size should provide insight into these problems. Although temporary external fixation is commonly used, an optimal construct has not been determined. Data from studies of in vivo fracture-site motion after application of the temporary external fixator should be compared with biomechanical testing of similar constructs. These data could be used to recommend optimal temporary external fixation constructs of tibia, femur, and humerus fractures using currently available devices as well as to provide groundwork for the next generation of fixators.

    • Keywords:
    • External Fixators|Fracture Fixation|Fractures

    • Bone|Hand Injuries|Humans|Leg Injuries|Treatment Outcome

    • Subspecialty:
    • Trauma

Débridement of extremity war wounds.

The extent of surgery appropriate for limb wounds agreed on at the Inter-Allied Surgical Conference in 1917 included excision of the skin margin, generous extension of the wound, exploration through all layers, and excision of damaged muscle—techniques recognizable by all trauma surgeons today. The criteria for muscle viability (the four C's) include contraction on being pinched, consistency (not waxy or "stewed"), capillary bleeding when cut, and color (red, not pale or brown). Skin is excised with a narrow margin, fascia is generously released, all layers of the wound are explored and gross contamination removed, and nonviable muscle is excised. Some low-energy transfer wounds (eg, civilian handgun injury, military shrapnel wounds) involve little tissue damage and can safely be managed nonsurgically, provided that there is confidence in the assessment of wound severity. Questions remain regarding the safest and most effective way to assess wounds and select patients for surgical versus nonsurgical management.

    • Keywords:
    • Debridement|Extremities|Humans|Treatment Outcome|War|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Definitive treatment of combat casualties at military medical centers.

More than 9,000 casualties have been evacuated during the current conflict, and more than 40,000 orthopaedic surgical procedures have been performed. The most severely injured patients are treated in the United States at military medical centers. Individualized reconstructive plans are developed, and patients are treated with state-of-the-art techniques. Rehabilitation includes the assistance of the physical medicine and rehabilitation, physical therapy, and occupational therapy services, as well as, when necessary, psychiatric or other services. The extreme challenges of treating war-related soft-tissue defects include neurovascular injuries, burns, heterotopic ossification, infection, prolonged recovery, and persistent pain. Such injuries do not allow full restoration of function. Because of such devastating injuries, and despite use of up-to-date methods, outcomes can be less than optimal.

    • Keywords:
    • Adult|Hospitals

    • Military|Humans|Male|Mass Casualty Incidents|Multiple Trauma|Orthopedic Procedures|United States|Wounds and Injuries|Young Adult

    • Subspecialty:
    • Trauma

Distraction osteogenesis.

The treatment of bone loss resulting from acute trauma has traditionally been a complex surgical problem. Numerous procedures have been devised to reconstitute bone stock, obtain fracture union, and provide a stable functional limb. Traditional internal bone transport has been used successfully for bony reconstruction for both acute and reconstructive bone loss. Potential complications are primarily related to the complexity of the external device, prolonged time in the frame, and nonunion of the docking and regenerate segments. Recent advances in fixator and pin design have reduced the complexity of these devices as well as the incidence of pin- and frame-related complications. Gradual shortening, rapid distraction using autodistractors, transporting over intramedullary devices, and using orthobiologic and adjuvant techniques to assist in the consolidation of regenerate and docking sites are now being combined to decrease the morbidity and excessive frame time required to complete these reconstructions.

    • Keywords:
    • Equipment Design|Fractures

    • Bone|Humans|Leg Bones|Leg Length Inequality|Osteogenesis

    • Distraction|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Basic Science

External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft.

External fixation for definitive therapy of closed diaphyseal femur and tibia fractures is the preferred method of treatment only in the pediatric population. In adult injuries, in particular open battle wounds, the timing of conversion of an external fixator to an intramedullary nail is determined by the condition of the soft tissues and the overall stability of the patient. In the tibia, conversion to an intramedullary nail is accomplished as expeditiously as possible. Early (< 2 weeks) conversion to an intramedullary implant may be accomplished safely. Increased infection rates have been documented when conversion is done after 2 weeks of external fixation. In the femur, conversion from external fixation to nailing is done as the patient's overall physical condition and soft tissues allow. Acute conversion to an intramedullary device in a single procedure is preferred in patients without evidence of pin-tract infection. Staged conversion to an intramedullary nail often requires a prolonged period of bed rest with skeletal traction to maintain fracture stability and patient comfort, with the attendant risks of pneumonia, decubiti, and thromboembolic events. Treatment of closed femoral and tibial diaphyseal fractures with external fixation, either definitively or as a bridge to intramedullary nailing, is a viable option in the patient with gross physiologic instability or an ipsilateral dysvascular limb. The decision to use definitive external fixation versus conversion to an intramedullary device should be made on a case-by-case basis. Additional prospective clinical studies are warranted to further delineate risks and benefits of these treatment modalities.

    • Keywords:
    • Bone Nails|External Fixators|Femoral Fractures|Fracture Fixation|Fracture Fixation

    • Intramedullary|Fractures

    • Closed|Humans|Tibial Fractures|Treatment Outcome

    • Subspecialty:
    • Trauma

Extremity injury in war: a brief history.

The complex history of treating traumatic injury in Western warfare consistently included issues such as proximity to surgical care, the organization of medical systems, and the progressive development of technologies and procedures used to treat military service members who are injured in battle. Significant advances have been made in each of these areas, as evidenced in the changes in medical care in conflicts involving US forces. These advances include, among others, organized attempts to improve sanitation; panels of surgeons to assess optimal surgical approaches; the introduction of triage, wound débridement, and delayed wound closure; the development of chemotherapeutics and antibiotics; and increasingly more timely treatment. Perhaps the least recognized historical contribution to military medical care, however, is the compiled medical statistic, which informs bold research and response.

    • Keywords:
    • Extremities|History

    • 15th Century|History

    • 16th Century|History

    • 17th Century|History

    • 18th Century|History

    • 19th Century|History

    • 20th Century|History

    • Ancient|History

    • Medieval|Humans|Orthopedic Procedures|War|Wounds and Injuries

    • Subspecialty:
    • Clinical Practice Improvement

Extremity trauma research in the United States Army.

Extremity wounds compose the burden of injury in the global war on terrorism, and there is a great need for research to improve the treatment of soldiers who incur these devastating injuries. The mission of the United States Army Institute of Surgical Research is to conduct combat casualty care research in several areas, including explosive injury mechanisms, field tourniquet use, external fixator pin coating, wound irrigation optimization, antibiotic-impregnated bone graft substitutes, segmental muscle defects, and outcomes research. Future research directions include development of bone and soft-tissue regenerative technologies, prevention and treatment of heterotopic ossification, and bacteriology of unique pathogens.

    • Keywords:
    • Biomedical Research|Extremities|Humans|Military Medicine|Military Personnel|Orthopedic Procedures|United States|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Basic Science

Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP).

The Lower Extremity Assessment Project (LEAP) is a multicenter study of severe lower extremity trauma in the US civilian population. At 2- and 7-year follow-ups, the LEAP study found no difference in functional outcome between patients who underwent either limb salvage surgery or amputation. However, outcomes on average were poor for both groups. This study and others provide evidence of wide-ranging variations in outcome following major limb trauma, with a substantial proportion of patients experiencing long-term disability. In addition, outcomes often are more affected by the patient's economic, social, and personal resources than by the initial treatment of the injury—specifically, amputation or reconstruction and level of amputation. A conceptual framework for examining outcomes after injury may be used to identify opportunities for interventions that would improve outcomes. Because of essential differences between the civilian and military populations, the findings of the LEAP study may correlate only roughly with combat casualty outcomes.

    • Keywords:
    • Amputation|Disability Evaluation|Humans|Leg Injuries|Outcome Assessment (Health Care)|Risk Factors|Salvage Therapy|Socioeconomic Factors|Trauma Severity Indices

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Far-forward fracture stabilization: external fixation versus splinting.

With improvements in body armor, soldiers often survive previously fatal injuries but incur devastating extremity trauma. Orthopaedic and general surgeons in forward-deployed areas must be well-versed in the selection and application of both external fixation and splinting devices in order to best preserve life and limb of the wounded. The surgeon must consider tactical environment, injury severity, injury location, available resources, and his or her own level of experience. Advantages to using external fixation in the field include preventing future injury to the traumatized soft-tissue envelope, reducing the risk of infection, minimizing fracture hemorrhage, providing pain control, and facilitating medical evacuation. Splinting is reserved for closed, low-energy, stable fractures of either the upper or lower extremity and for unstable fractures that are not amenable to battlefield external fixation; because of the risks of compartment syndrome, casts are avoided.

    • Keywords:
    • Fracture Fixation|Fracture Fixation

    • Internal|Fractures

    • Bone|Hand Injuries|Humans|Leg Injuries|Splints|Treatment Outcome|War

    • Subspecialty:
    • Trauma

    • Basic Science

From the battlefields to the states: the road to recovery. The role of Landstuhl Regional Medical Center in US military casualty care.

The transformation of the modern battlefield with respect to weaponry, modes of transportation, enemy capabilities and location, as well as technological advances, has greatly altered the tactical approach to the mission. Combat casualty care must continually evolve in response to the differences in types of injury, the number and triage of casualties, timing of treatment, and location of care. These battlefield changes have been demonstrated on a large scale in the global war on terrorism, which includes the military operations in Afghanistan and Iraq. The medical response has kept pace with this 21st-century conflict. Even in the new environment of armed conflict and with the advent of new technologies, the principles of managing orthopaedic combat casualties remain clear: preservation of life and limb, skeletal stabilization, and aggressive wound débridement. For United States service members wounded in the current conflicts, Landstuhl Regional Medical Center is a crucial stop along the road to recovery.

    • Keywords:
    • Hospitals

    • Military|Hospitals

    • Special|Humans|Mass Casualty Incidents|United States|Wounds and Injuries

    • Subspecialty:
    • Trauma

Heterotopic ossification in the residual limbs of traumatic and combat-related amputees.

Reports on the occurrence and treatment of heterotopic ossification in amputees are rare. Heterotopic ossification in the residual limbs of amputees may cause pain and skin breakdown and complicate or prevent optimal prosthetic fitting and utilization. Basic science research has shed light on the cellular and molecular basis for this disease process, but many questions remain unanswered. The recent experience of the military amputee centers with traumatic and combat-related amputations has demonstrated a surprisingly high prevalence of heterotopic ossification in residual limbs. Primary prophylactic regimens, such as nonsteroidal anti-inflammatory drugs and local irradiation, which have proved to be effective in preventing and limiting heterotopic ossification in other patient populations, have not been studied in amputees and generally are not feasible in the setting of acute traumatic amputation. When nonsurgical measures such as activity and repeated prosthetic modifications fail to provide relief, surgical excision has provided good early clinical results, with low rates of recurrence and acceptable complication rates in military amputees.

    • Keywords:
    • Amputation Stumps|Amputation

    • Traumatic|Amputees|Extremities|Hand Injuries|Humans|Leg Injuries|Military Personnel|Ossification

    • Heterotopic|Postoperative Complications|War

    • Subspecialty:
    • Trauma

    • Basic Science

Horizons in prosthesis development for the restoration of limb function.

The focus of our research program is the restoration of limb function through a biohybrid approach. We consider the limb conceptually as a biohybrid organ consisting of biological tissue, endoprostheses (including neural devices and joint replacements), and exoprostheses. The biohybrid limb maximizes biological function and functional articulations with optimized human-prosthesis interfaces. Our long-term goals are to create biomimetic prostheses, optimized control systems for prostheses, and optimized human-prosthesis interfaces using both limb lengthening and osseointegration techniques.

    • Keywords:
    • Amputation|Amputees|Artificial Limbs|Humans|Leg|Leg Injuries|Prosthesis Design|Recovery of Function

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

Levels of medical care in the global war on terrorism.

Trauma care for military personnel injured in Iraq has become increasingly sophisticated. There are five levels, or echelons, of care, each progressively more advanced. Level I care provides immediate first aid at the front line. Level II care consists of surgical resuscitation provided by highly mobile forward surgical teams that directly support combatant units in the field. Level III care is provided through combat support hospitals—large facilities that take time to become fully operational but offer much more advanced medical, surgical, and trauma care, similar to a civilian trauma center. Level IV care is the first echelon at which definitive surgical management is provided outside the combat zone. Level V care is the final stage of evacuation to one of the major military centers in the United States, where definitive stabilization, reconstruction, or amputation of the injured extremity is performed.

    • Keywords:
    • Delivery of Health Care|Humans|Military Medicine|Terrorism|Triage|United States|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Clinical Practice Improvement

Management of segmental bony defects: the role of osteoconductive orthobiologics.

Our knowledge about, and the availability of, orthobiologic materials has increased exponentially in the last decade. Although previously confined to the experimental or animal-model realm, several orthobiologics have been shown to be useful in a variety of clinical situations. As surgical techniques in vascular anastomosis, soft-tissue coverage, limb salvage, and fracture stabilization have improved, the size and frequency of bony defects (commensurate with the severity of the initial injury) have increased, as well. Because all methods of managing segmental bony defects have drawbacks, a need remains for a readily available, void-filling, inexpensive bone substitute. Such a bone substitute fulfills a permissive role in allowing new bone to grow into a given defect. Such potential osteoconductive materials include ceramics, calcium sulfate or calcium phosphate compounds, hydroxyapatite, deproteinized bone, corals, and recently developed polymers. Some materials that have osteoinductive properties, such as demineralized bone matrix, also display prominent osteoconductive properties.

    • Keywords:
    • Animals|Bone Regeneration|Bone Substitutes|Bone and Bones|Fractures

    • Bone|Humans|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Basic Science

Missile injuries of the limbs: an Iraqi perspective.

Missiles include pistol or rifle bullets, shell fragments, land mines, and grenades. Medium- and high-velocity missiles produce damage by laceration and crushing, shock waves, and cavitational effects. Low-velocity missiles produce damage by laceration and crushing only. Land mine injuries cause damage by the primary blast effect, secondarily by fragments, and thirdly by the effect induced by whole-body propulsion and by burns. Severity of injuries should be graded according to the degree of soft-tissue damage, bone defect or comminution, and vascular or neural injury. Among other factors, successful management of these injuries requires prompt and vigorous resuscitation, careful wound inspection, aggressive exploration, liberal débridement, and prompt removal of fragments. In addition, in these circumstances, one must stay alert for overlooked injuries and be aware of associated psychological trauma.

    • Keywords:
    • Extremities|Humans|Iraq War

    • 2003 -|Orthopedic Procedures|Trauma Severity Indices|Triage|United States|Wounds

    • Penetrating

    • Subspecialty:
    • Trauma

    • Basic Science

New developments in flap techniques.

Limb reimplantation techniques using composite free-tissue transfer and microsurgical salvage of traumatized extremities have become standard reconstructive methods. Mechanisms for working with free-tissue transfers have advanced, specifically in regard to the use of thin-wire fixators: combining microsurgical techniques and thin-wire fixators helps in salvaging limbs that otherwise might be amputated. Also, combining the Ilizarov method with microsurgical techniques for limb salvage provides a new use for flaps. A further development in the use of flaps is the application of free-tissue transfers to preserve amputation levels in the war-injured. So-called fillet flaps serve as "spare parts" and can be customized for specific recipient sites. The so-called perforator flap makes use of feeder vessels, thus providing cutaneous and other composite flaps without sacrificing major vessels. Finally, the advent of the sural flap has made it possible to avoid microsurgical reconstruction but still provide adequate, well-vascularized cover, particularly in the distal third of the leg.

    • Keywords:
    • Extremities|Humans|Surgical Flaps|Treatment Outcome|War|Wounds and Injuries

    • Subspecialty:
    • Trauma

Response of musculoskeletal cells to biomaterials.

Many of our current therapies are based on information obtained in cell cultures using substrates that have little in common with the substrates the cells will encounter in vivo. To produce materials that are clinically valuable, we must analyze more deeply how musculoskeletal cells interact with the physical features of their environments. An increasing body of information has examined the mechanisms by which osteoblasts interact with their substrate. The underlying substrate, particularly in bone, also has structural features that can alter the mechanical environment experienced by the cells. These structural features modulate the nature of cell attachment and the resulting cell shape, affecting cell proliferation and differentiation. The chemistry, surface energy, and microarchitecture of a material all influence the kinds of proteins that adsorb onto the surface, which in turn affects integrin-mediated attachment. Signaling via integrins initiates the transfer of information to the cell about the microenvironment. Cells can differentiate between crystallinities of the same chemistry and distinguish complex differences in surface structure. These differences in the in vitro response correspond to differences in clinical effectiveness. By designing biomaterials that maximally enhance mesenchymal cell attachment, migration, proliferation, and differentiation, the value of these materials for tissue repair will be markedly increased. The goal is to provide materials that are capable of supporting tissue regeneration in vivo, often at sites compromised by infection and loss of structure.

      • Subspecialty:
      • Basic Science

    Scope of wounds.

    The scope of extremity wounds in the current conflict presents surgeons with new lessons to master. Unique to this conflict is a new type of patient, one with multiple and severely injured extremities who is otherwise free of serious injury. These injuries provide challenges to the medical system in terms of the volume and complexity of care, and to the patient and surgeon trying to achieve limb salvage and rehabilitation. These patients present with a combination of high-energy injury, massive evolving tissue destruction, and widespread contamination, resulting in an evolving zone of injury that respects no tissue planes, anatomic boundaries, or normal physiologic rules. We must ensure that our skills and techniques as surgeons evolve faster than do the injuries themselves.

      • Keywords:
      • Extremities|Humans|Iraq War

      • 2003 -|Military Medicine|Orthopedic Procedures|United States|Wounds and Injuries

      • Subspecialty:
      • Trauma

    Shrapnel management.

    With the increased incidence of terrorism worldwide, it is important for surgeons to understand the role of shrapnel injury in mass casualty events. Several diagnostic modalities are available, including plain radiography, computed tomography, ultrasound, angiography, and computerized surgical navigation based on real-time acquisition of fluoroscopic data. Shrapnel management techniques are selected based on the following chronologic phases: acute, subacute, and late.

      • Keywords:
      • Humans|Mass Casualty Incidents|Orthopedic Procedures|Trauma Severity Indices|Treatment Outcome|Wounds

      • Gunshot

      • Subspecialty:
      • Trauma

    Skin substitutes as alternatives to autografting in a wartime trauma setting.

    Wartime injuries present extreme problems in wound management, with extensive skin degloving, deep tissue necrosis, and severe wound contamination. Several wound stabilization technologies, commonly used in burn and chronic wound treatment centers, have significantly advanced the treatment of wartime extremity trauma. Early skin coverage of these wounds is an ongoing challenge. Engineered skin substitutes offer advantages of expedited wound coverage and decreased donor site morbidity in the treatment of burns and chronic wounds. These substitutes, however, possess significant limitations when used in the presence of infection or full-thickness defects. Therefore, extrapolating the use of engineered skin substitutes to the coverage of acute war wounds is not clinically indicated. The timing and level of care in which skin substitutes could be applied for war wounds requires further clinical research.

      • Keywords:
      • Humans|Skin Transplantation|Skin

      • Artificial|Transplantation

      • Autologous|War|Wounds and Injuries

      • Subspecialty:
      • Trauma

    Standard wound coverage techniques for extremity war injury.

    Reconstruction of extremity war injuries begins with aggressive forward resuscitative care and stabilization of the trauma patient. After serial care in progressively better supported medical environments, definitive management is done at the level V military treatment facility. Aggressive forward care coupled with rapid air transport has enabled increasingly complex care to be administered at the continental United States military facilities; however, it has also made the decision between limb salvage and amputation more challenging. Yet to be determined are (1) the optimal timing of definitive wound closure or coverage in coordination with fracture stabilization and (2) the optimal types of flap for both upper and lower extremity reconstruction. Records of patients with complex lower and upper extremity wounds who were treated at the National Naval Medical Center between September 2004 and June 2006 reveal useful short-term data. Longer-term data, such as fracture union rate, time to ambulation, range of motion and global function of salvaged limbs, patient satisfaction with limb salvage, and average cost, are not yet available.

      • Keywords:
      • Bandages|Extremities|Humans|Iraq War

      • 2003 -|Orthopedic Procedures|Surgical Flaps|Time Factors|Treatment Outcome|United States|Wounds and Injuries

      • Subspecialty:
      • Trauma

    The contaminated high-energy open fracture: a protocol to prevent and treat inflammatory mediator storm-induced soft-tissue compartment syndrome (IMSICS).

    The treatment modalities currently used in surgical dbridement leave the traumatic wound with viable but tenuous tissue and a variable level of microcontaminants potentially laden with bacteria. In high-energy contaminated wounds, retention of these contaminants within the tenuous tissue of the so-called zone of stasis can result in further tissue necrosis and the development of infection. A novel protocol for managing the high-energy contaminated open fracture involves two new techniques. First, Bernoulli's principle is used to facilitate a systematic excision of contaminants, as well as the wound surface to which they are adsorbed, by means of a high-velocity fluid stream. Second, topical negative pressure is established as a means to resuscitate the remaining edema-laden wound tissue to help avoid embarrassment to microcirculatory blood flow.

      • Keywords:
      • Compartment Syndromes|Debridement|Fractures

      • Open|Humans|Irrigation|Pressure|Soft Tissue Infections|Treatment Outcome|Wound Healing

      • Subspecialty:
      • Trauma

    The scope of wounds encountered in casualties from the global war on terrorism: from the battlefield to the tertiary treatment facility.

    Injuries seen in Operation Iraqi Freedom range from those that can be managed with nonsurgical wound care only to those requiring amputation or multiple bony and soft-tissue procedures for limb salvage. The contamination and soft-tissue injury caused by exploding ordnance requires an aggressive treatment approach. Severe wounds treated near the battlefield (ie, level II) require meticulous surgical débridement, early fracture stabilization, broad-spectrum antibiotics, and rapid evacuation. Treatment at a level III combat support hospital involves a greater volume of patients and a longer stay because of the presence of Iraqi national patients. In the authors' experience, most US patients requiring surgical treatment were evacuated to a level IV facility (ie, Landstuhl Regional Medical Center) after one or two surgeries. The basic war surgery principles of aggressive resuscitation, early and thorough débridement, short-duration damage-control surgical procedures, and rapid evacuation were critical in our reduction of wound infection rates to below 7% for all admissions.

      • Keywords:
      • Humans|Mass Casualty Incidents|Military Medicine|Surgicenters|United States|Wounds and Injuries

      • Subspecialty:
      • Trauma

      • Basic Science

    The United States Armed Forces Amputee Patient Care Program.

    United States military amputees are treated at either Walter Reed Army Medical Center (Washington, DC) or Brooke Army Medical Center (Fort Sam Houston, TX). At each center, a multidisciplinary team from more than a dozen specialties works together to address the psychological, social, vocational, and spiritual needs of our soldiers, marines, sailors, and airmen, as well as their physical rehabilitation. Excellent outcomes are being achieved with the current practices of the Armed Forces Amputee Care Program, but a great deal of evidence-based research must be done to determine the optimal time to close the wound, the etiology of heterotopic ossification in blast injury, the factors determining optimal socket design, and the best sequence and timing for introduction of different prosthetic technologies in the rehabilitation process.

      • Keywords:
      • Amputees|Hospitals

      • Military|Humans|Military Medicine|Military Personnel|Patient Care|United States

      • Subspecialty:
      • Trauma

      • Basic Science

    Timing of débridement of open fractures.

    Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data supporting this recommendation are lacking. Most studies indicate that, in the context of modern antibiotic treatment, early débridement is not an independent predictor of decreased risk of infection. Achieving early débridement may pose unjustified risks to patient safety. Given the numerous factors that influence timing of surgical débridement in trauma centers, a prospective randomized trial of emergent versus urgent débridement is not feasible. However, a prospective longitudinal study could yield valuable data.

      • Keywords:
      • Debridement|Fracture Fixation|Fractures

      • Open|Humans|Time Factors

      • Subspecialty:
      • Clinical Practice Improvement

    Timing of wound coverage in extremity war injuries.

    Although several studies have been done on the timing of débridement of open fracture, none has specifically examined the effect of timing of soft-tissue coverage on outcome in the types of lower extremity injury being encountered in Iraq and Afghanistan, namely, injuries associated with the detonation of improvised explosive devices. Complex limb salvage requiring free tissue transfer or rotational flap coverage for soft-tissue defects has been commonly performed during the recent military conflicts in Iraq and Afghanistan. Current treatment protocols favor the inclusion of timely and stable axial limb fixation, radical débridement of all compromised soft tissues and osseous structures, and early wound closure with healthy, well-vascularized autologous tissue. In an attempt to minimize overall morbidity, a comprehensive plan must be made to sequentially reconstruct the involved extremity in order to achieve the highest level of function possible, with a durable construct, in the shortest period of time. Prospective studies are necessary to evaluate the effect of timing of coverage on outcome and on limb salvage.

      • Keywords:
      • Bandages|Extremities|Humans|Time Factors|Treatment Outcome|War|Wound Healing|Wounds and Injuries

      • Subspecialty:
      • Trauma

    Tissue engineering solutions for traumatic bone loss.

    Tissue engineering strategies for the repair, replacement, or augmentation of bone defects involves the use of cells, matrices, and bioregulatory factors. The source (endogenous, exogenous) and character of these factors, however, may vary greatly among the many approaches taken by current investigators. Although the results of current tissue engineering methods for regenerating bone have shown great promise, the extent of damage to extremities associated with war injuries may require the development of techniques that differ substantially from current practice.

      • Keywords:
      • Bone Regeneration|Bone and Bones|Fracture Healing|Fractures

      • Bone|Humans|Tissue Engineering

      • Subspecialty:
      • Trauma

      • Basic Science

    Treatment of acute infection.

    Military injuries are classically thought of as being limited to penetrating trauma caused by gunshot and blast injuries. However, blunt trauma caused by motor vehicle crashes and crush injuries can produce severe open injuries in the extremities. Most military injuries involve a higher level of energy than is commonly seen in civilian injuries, and the environment can be austere. These factors contribute to the development of infections that appear shortly after musculoskeletal trauma. Thus, the orthopaedic surgeon must know how to treat anaerobic soft-tissue infection, including clostridial fasciitis, clostridial myonecrosis, and tetanus; bacterial necrotizing fasciitis; and both superficial and deep bacterial wound infections.

      • Keywords:
      • Acute Disease|Anti-Bacterial Agents|Debridement|Humans|Treatment Outcome|War|Wound Infection|Wounds

      • Penetrating

      • Subspecialty:
      • Trauma

      • Basic Science

    Treatment of blast injuries of the extremity.

    Blast trauma is a complex event. Pathophysiologically, blast injuries are identified as primary (caused solely by the direct effect of blast overpressure on the tissue), secondary (caused by flying objects or fragments), tertiary (caused by bodily displacement), or quaternary (indirectly caused by the explosion). The range of primary blast injuries includes fractures, amputations, crush injury, burns, cuts, lacerations, acute occlusion of an artery, air embolism-induced injury, compartment syndrome, and others. Secondary injuries are the most common extremity blast injuries. Like primary injuries, they may necessitate limb amputation, be life-threatening, and produce severe contamination. Tertiary blast injuries of the extremity may result in traumatic amputations, fractures, and severe soft-tissue injuries. Quaternary injuries most often are burns. Following treatment and stabilization of immediate life-threatening conditions, all patients are given antibiotic and tetanus prophylaxis. Débridement and wound excision are started as early as possible, with repeat débridement performed as necessary; fasciotomies also are performed to prevent compartment syndrome. Well-vascularized muscular free flaps provide soft-tissue coverage for blast-injured extremities. The closed-open technique of flap closure allows reexamination of the wound, further irrigation, débridement, and later bone and soft-tissue reconstruction.

      • Keywords:
      • Blast Injuries|Extremities|Humans|Orthopedic Procedures|Treatment Outcome

      • Subspecialty:
      • Trauma

      • Basic Science

    Treatment of chronic infection.

    Failure of an acute inflammatory response to resolve a wound infection heralds a cascade of events that affects the host and pathogens, culminating in a chronic, refractory condition. The factors contributing to this outcome include immune compromise of the host, antimicrobial resistance, wound-healing deficiencies, and the adherence of pathogens to themselves and wound surfaces via an impenetrable, resistant biofilm. To eradicate chronic infection, the pathogens, biofilm, surfaces available for adherence, and compromised tissue must be removed.

      • Keywords:
      • Anti-Bacterial Agents|Chronic Disease|Debridement|Humans|Treatment Outcome|War|Wound Infection|Wounds

      • Penetrating

      • Subspecialty:
      • Trauma

      • General Orthopaedics

    Vascularized fibula graft for the traumatically induced long-bone defect.

    Long-bone defects resulting from trauma can be managed with a variety of techniques, including conventional bone grafting, distraction osteogenesis, bone graft substitutes, prosthetic devices, and vascularized bone grafting. Although there is an array of available methods for long-bone reconstruction of bony defects, vascularized bone transfer is particularly useful in large defects (> 6 cm) and in cases in which osteomyelitis and unstable soft-tissue or beds make conventional techniques difficult.

      • Keywords:
      • Bone Transplantation|Fibula|Humans|Leg Bones|Leg Injuries

      • Subspecialty:
      • Trauma

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