JAAOS

JAAOS, Volume 19, No. suppl 1


Battlefield Orthopaedic Injuries Cause the Majority of Long-term Disabilities

Extremity injuries make up 54% of combat wounds sustained in Operation Iraqi Freedom and Operation Enduring Freedom. In a cohort of war-wounded service members, we identified the conditions secondary to battle injury that result in disqualification from continued service. The Army Physical Evaluation Board records of 464 wounded service members who were injured between October 2001 and January 2005 were reviewed to determine the codes indicating unfitting conditions. Sixty-nine percent of these conditions were orthopaedic. Fifty-seven percent of the injured had unfitting conditions that were orthopaedic only. Of those evacuated from theater with a primary diagnosis of injury to the head, thorax, or abdomen and who suffered an orthopaedic injury as well, 76% had an orthopaedic diagnosis as the primary unfitting condition. Orthopaedic-related disability has a significant impact on the affected patient, the health care system, and, in the case of wounded service members, on military strength and readiness.

      • Subspecialty:
      • Trauma

    Congressionally Directed Research Will Improve Outcomes Through Funding Opportunities for Orthopaedics

    The large funding opportunities created by the US Congress have allowed the military and civilian orthopaedic communities to collaborate to define clinical problems and develop solutions. It is believed that this research effort will be constructive in the short term because of emphasis placed on funding projects that used relevant populations and approaches that will benefit patients soon. The immediate results will define best practice guidelines. Additionally, new therapies will be fielded that will reduce complications and improve the outcomes of both injured service personnel and civilians.

        Diagnosis and Management of Chronic Infection

        High-energy penetrating extremity injuries are often associated with severe open fractures that have varying degrees of soft-tissue contamination and tenuous soft-tissue coverage. The result is a relatively high prevalence of chronic osteomyelitis compared with that in civilian trauma patients. Diagnosing chronic osteomyelitis requires a careful history and thorough physical and radiographic examinations. Cross-sectional imaging can help delineate the extent of bony involvement, and scintigraphy can be used as a diagnostic tool and to gauge response to treatment. Clinical staging also directs surgical management. Adequacy of débridement remains the most important clinical predictor of success; thus, adopting an oncologic approach to complete (ie, wide) excision is important. Reconstruction can be safely performed by a variety of methods; however, proper staging and patient selection remain critical to a successful outcome. Although systemic and depot delivery of antibiotics plays a supporting role in the treatment of chronic osteomyelitis, the ideal dosing regimens, and the duration of treatment, remain controversial.

            • Subspecialty:
            • Trauma

          Limb Salvage With Major Nerve Injury: Current Management and Future Directions

          Major peripheral nerve injuries are often associated with devastating functional deficits. Current management techniques fail to achieve adequate functional neural regeneration, and the development of adjunct therapies is necessary to improve outcomes. Recent efforts at enhancing the regeneration rate of peripheral nerves and developing axonal guidance channels or conduits have had limited success. The neuromuscular junction serves as the interface between the peripheral nerves and muscle. This critical area undergoes significant changes following peripheral nerve injury and induces end-organ atrophy after denervation, which limits the chance of true functional regeneration. Stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair and should be explored as a method of managing major nerve injuries.

              • Subspecialty:
              • Trauma

            Moderators' Summary: Perceived Performance Differences. Limb Salvage Versus Amputation in the Lower Extremity (Session II)

            Severe extremity trauma is a significant cause of morbidity and disability; these injuries are often considered for amputation. Two studies have shown few differences between amputation and limb salvage outcomes. Functional limitations that result from loss of muscle needed to cover bone and provide limb function are a major factor in the decision to amputate a salvaged limb. Several studies have reported successful management of muscle loss with soft-tissue transfer. Extracellular matrix scaffolds and muscle regeneration using stem cells are promising technologies. However, no single strategy has proved to be effective in the management of limb pain following extremity trauma; a multimodal approach is required for best results. Additional knowledge gaps exist, such as the effect of occupational and physical therapy on the outcome of severe limb injury, factors such as peer visitation and social support networks, and the effect of sex, cultural differences, and patient personality.

                New Minimal Immunosuppression Strategies for Composite Tissue Allograft Transplantation: The Cleveland Clinic Experience

                Clinical application of composite tissue allografts requires the introduction of new minimal immunosuppressive or tolerance-inducing protocols. We have established a protocol for tolerance induction under α/β selective blocking antibody T-cell receptor combined with interleukin-2 blocker cyclosporin A therapy. Application of this therapy resulted in induction of tolerance in fully allogenic and semiallogenic limb allograft transplants. Based on this experience we have found that the bone marrow component of the allograft is essential for tolerance induction and have confirmed that injection of bone marrow of donor origin directly into the bone marrow compartment of allograft recipients resulted in higher chimerism levels. In addition, we have developed a system for isolation of chimeric cells, which are specific for both the donor and recipient, by using magnetic activated cell sorting technique and flow cytometry. These new, experimental approaches confirm that introducing minimal suppression to patients undergoing hand or face transplantation will likely be achieved in the near future.

                    • Subspecialty:
                    • Basic Science

                  Painful Sequelae Following Limb Salvage: Etiology and Management

                  Inadequately controlled pain is a significant problem during limb salvage and is associated with poor outcomes. This pain has several causes, and many management options exist. Chronic pain associated with limb salvage causes unnecessary suffering and negatively affects long-term function. Chronic pain and disability in this population may be prevented with early, aggressive, comprehensive treatment. Ongoing research into the cause and clinical course of limb salvage pain likely will lead to advances in pain management and functional improvement.

                      • Subspecialty:
                      • Trauma

                      • Pain Management

                    Partnered Disaster Preparedness: Lessons Learned From International Events

                    Military, governmental, and civilian agencies routinely respond to disasters around the world, including large-scale mass casualty events such as the earthquake in Pakistan in 2005, Hurricane Katrina in the United States in 2005, and the earthquake in Haiti in 2010. Potential exists for improved coordination of medical response between civilian and military sectors and for the creation of a planned and practiced interface. Disaster preparedness could be enhanced with more robust disaster education for civilian responders; creation of a database of precredentialed, precertified medical specialists; implementation of a communication bridge; and the establishment of agreements between military and civilian medical/surgical groups in advance of major catastrophic events.

                        • Subspecialty:
                        • Trauma

                      Volumetric Muscle Loss

                      Prevention of infection, as well as bone covering and healing, is paramount in the management of limb injury with associated muscle injury. Volumetric muscle loss (VML) is the traumatic or surgical loss of skeletal muscle with resultant functional impairment. No standardized evaluation protocol exists for the characterization and quantification of VML. Clinical photographs and video recordings, range of motion measurements, manual muscle strength testing, and isokinetic muscle function testing may prove to be useful in documenting VML. Current treatment options include functional free muscle transfer and the use of advanced bracing designs. Advances in powered bracing and regenerative medicine may one day provide additional therapeutic options. Further research on VML is warranted.

                          • Subspecialty:
                          • Trauma

                        Advertisements

                        Advertisement