JAAOS

JAAOS, Volume 20, No. supplement


Advanced Protection Technology for Ground Combat Vehicles

Just as highway drivers use radar detectors to attempt to stay ahead of police armed with the latest radar technology, the Armed Forces are locked in a spiral to protect combat vehicles and their crews against the latest threats in both the contemporary operating environment and the anticipated operating environment (ie, beyond 2020). In response to bigger, heavier, or better-protected vehicles, adversaries build and deploy larger explosive devices or bombs. However, making improvements to combat vehicles is much more expensive than deploying larger explosives. In addition, demand is increasing for lighter-weight vehicles capable of rapid deployment. Together, these two facts give the threat a clear advantage in the future. To protect vehicles and crews, technologies focusing on detection and hit avoidance, denial of penetration, and crew survivability must be combined synergistically to provide the best chance of survival on the modern battlefield.

      Axioms Altered With Research

      The medical community is actively engaged in research to provide the highest level of evidence to support clinical practice. The care of wounded warriors creates unique challenges, and conducting research that provides evidence for clinical practice is important to outcomes in this patient population. When the current wars began, much debate centered on the best way to care for wounded warriors. To address these concerns, we use a MythBusters format, based on the popular television show, to describe how recent research has dispelled some earlier misconceptions and clarify how clinical practice has been changed. In addition, we assess the progress that has been made on addressing the original prioritized research objectives of the first Extremity War Injuries symposium.

          • Subspecialty:
          • Basic Science

        Challenges in Severe Lower Limb Injury Rehabilitation

        Restoration of lower limb function following severe injury is a challenge. Rehabilitation must take into account psychosocial factors and patient self-efficacy as well as functional goals. The Return to Run clinical pathway, an integrated orthotic and rehabilitation initiative, is an example of goal-oriented rehabilitation with periodic assessment aimed at restoring wounded warriors to high-level performance following severe lower extremity trauma. Objective assessment measures of surgical and rehabilitation interventions are lacking for persons with high-level performance demands, such as those required by service members. Thus, the Military Performance Laboratory at the Center for the Intrepid has established normative data for several physical performance measures, some of which are now routinely used to assess service members with severe lower extremity trauma. Patient expectations of treatment and rehabilitation are high and must be met to avoid poor outcomes attributed to nonanatomic factors.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

          Evolution of Acute Orthopaedic Care

          Current combat battlefield injuries are among the most complex and challenging orthopaedic cases. These injuries carry high risks for exsanguination and global contamination of extensive soft-tissue and complicated bony injuries. Military orthopaedic surgeons must employ the latest advances in acute combat casualty care to achieve favorable outcomes. Adaptive changes over the past 10 years of war have given today's surgeons the armamentarium to optimize patient care. Innovative methods of damage control resuscitation and surgery have led to increased survival. However, the fundamentals of surgical hemostasis and decontamination remain critical to successful management. The acute treatment of combat casualties involves a continuum of care from the point of injury through transport out of theater. Future research and education are paramount to better prepare military orthopaedic surgeons to further increase survivability and enhance the outcomes of service members with complex wounds.

              Evolution of Orthopaedic Reconstructive Care

              The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.

                  Evolution of Orthopaedic Rehabilitation Care

                  Rehabilitation following surgical reconstruction for combat-related extremity injuries sustained in the current conflicts in Iraq and Afghanistan has been challenging. The goal of rehabilitation is to restore limb function to facilitate the reintegration of patients with these severe injuries into society. The US Department of Defense has developed a network of rehabilitation centers of excellence within the military healthcare system in collaboration with the US Department of Veterans Affairs to optimize outcomes using technologic and systemic advances in prostheses in patients who have undergone limb salvage procedures or amputation. Managing pain during rehabilitation and optimizing function following high bilateral lower extremity amputation remains a clinical challenge. However, continued research is likely to improve outcomes in this severely injured patient population. To that end, two research consortia, the Bridging Advanced Developments for Exceptional Rehabilitation and the Center for Rehabilitation Sciences Research, have recently been created to address identified knowledge gaps.

                      Factors Associated With Mortality in Combat-related Pelvic Fractures

                      Pelvic fractures were sustained by >26% of service members who died during Operation Enduring Freedom and Operation Iraqi Freedom in 2008. To determine factors associated with patient mortality following combat-related pelvic fracture (CRPF), the Joint Theater Trauma Registry database was searched to identify service members who survived CRPF sustained in the year 2008 (group 1), and the Armed Forces Medical Examiner System was searched to identify nonsurvivors of such trauma in the same year (group 2). Stable pelvic ring injuries were associated with a lower mortality rate than were unstable injuries when controlling for large-vessel and anatomic brain injuries (43% and 85%, respectively; P < 0.05). Associated injuries that were significant predictors of mortality included large-vessel, anatomic brain, cardiopulmonary, and solid organ abdominal (P < 0.05). Compared with a similar cohort of nonsurvivors, persons who survive CRPF have less severe pelvic fractures and associated injuries. In addition, pelvic fractures secondary to direct combat (ie, blast-related blunt injury, penetrating injury) were significantly more lethal than were those caused by mechanisms analogous to civilian trauma.

                          • Subspecialty:
                          • Trauma

                          • Adult Reconstruction

                        Long-term Disabilities Associated With Combat Casualties: Measuring Disability and Reintegration in Combat Veterans

                        Many physical and mental health problems associated with combat casualties affect the reintegration of service members into home and community life. Quantifying and measuring reintegration is important to answer questions about clinical, research, economic, and policy issues that directly affect combat veterans. Although the construct of participation presented in the International Statistical Classification of Diseases and Related Health Problems and in the International Classification of Functioning, Disability and Health provides a theoretical framework with which to understand and measure community reintegration in general, a measure was needed that specifically addressed the reintegration of combat veterans. To address this need, the Community Reintegration for Service Members global outcomes measure was developed. It consists of three scales, which measure extent of participation, perceived limitations, and satisfaction. The measure was validated in a general sample of veterans and in a sample of severely wounded service members. The computer-adapted test version shows good precision, reliability, construct validity, and predictive validity.

                            • Subspecialty:
                            • Trauma

                          Management of Posttraumatic Osteoarthritis With an Integrated Orthotic and Rehabilitation Initiative

                          Posttraumatic osteoarthritis affects approximately 5.6 million Americans annually. Those affected are typically younger and more active than persons with primary osteoarthritis. Arthrodesis is the typical management option for persons with end-stage ankle and subtalar posttraumatic arthritis. Arthroplasty is typically reserved for elderly persons. The functional limitations resulting from any of these strategies make treatment of this young population challenging. Combat wounds frequently lead to severe lower extremity injuries. We present a series of patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint after combat trauma. They were treated at our institution with an integrated orthotic and rehabilitation initiative called the Return To Run clinical pathway. This clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint.

                              • Subspecialty:
                              • Trauma

                              • Foot and Ankle

                            Measurement of Functional Outcomes in the Major Extremity Trauma Research Consortium (METRC)

                            Measurement of functional outcome is a central tool in the assessment of the human and economic consequences of trauma. As such, functional outcome is the ideal basis against which to judge the efficacy of surgical approaches, drugs, and devices in the context of evidence-based medicine. A well-designed outcome measurement plan improves the validity of clinical research, facilitates the optimal use of limited research resources, and maximizes opportunities for future secondary data analyses. However, a key challenge in the development of a study measurement plan is the identification of appropriate, practical, well-validated measures. The Major Extremity Trauma Research Consortium (METRC) is a large 5-year research effort to develop and conduct multicenter clinical studies relevant to the treatment and outcomes of orthopaedic trauma. METRC is funded to conduct nine clinical studies. One of the main goals is to benefit from the consortium approach by standardizing data collection across these studies. METRC investigators have developed a standard set of measurement instruments designed to examine outcomes across a defined set of key domains: complications, depression, posttraumatic stress disorder, pain, activity and participation, health-related quality of life, patient satisfaction, and healthcare utilization. In addition, METRC investigators have developed a standard set of sociodemographic and clinical covariates to be collected across all studies.

                                • Subspecialty:
                                • Trauma

                              Orthopaedic Outcomes: Combat and Civilian Trauma Care

                              Important advances have been made in the management of complex trauma through careful scientific analysis of outcomes. Outcomes analysis in combat extremity trauma is exemplified and highlighted by scholarly work in the treatment of catastrophic lower extremity trauma. The success of this line of research in civilian trauma is exemplified by the Lower Extremity Assessment Project (LEAP) study on the outcomes of civilian lower extremity trauma. This highly successful effort was followed by the Military Extremity Trauma Amputation/Limb Salvage (METALS) study. Current ongoing analysis of both the LEAP and METALS studies by the Major Extremity Trauma Research Consortium seeks to compare and contrast the similarities and differences of both studies and to advance evidence-based patient-centered care. The effects of psychological trauma on the injured individual underscore the global effect of severe trauma and the need for a multidisciplinary approach to trauma care. Statistical modeling is being used to analyze outcomes to further the ability to scientifically and definitively determine the best practices for patient care.

                                  Overview of Axial Skeleton Injuries: Burden of Disease

                                  Axial skeletal injury and related illness is a major cause of medical disability and force attrition in deployed service members. Predeployment identification of at-risk personnel is unreliable. Risk of axial skeletal injury or illness during deployment is heterogeneous. Major spinal trauma casualties are uncommon, accounting for 1% of casualties, and are usually related to battle injuries. These major spinal injuries are often associated with multiple system/anatomic injuries. Spinal cord injuries account for 18% of major spinal injuries in persons with battle-related spinal injury. Non-battle spine pain, that is, back or neck area pain not associated with major trauma, is a significant force attrition problem, accounting for 40% of all combat casualty evacuation in some years. Personnel attrition due to neck and back pain not associated with major trauma is highly variable by unit and exposure, including psychological exposure. Return-to-duty rates for both traumatic and atraumatic spine injuries is poor (<15%); this rate is predicted by psychological comorbidities.

                                      • Subspecialty:
                                      • Trauma

                                      • Spine

                                    Physical Performance Assessment in Military Service Members

                                    Few established measures allow effective quantification of physical performance in severely injured service members. We sought to establish preliminary normative data in 180 healthy, active-duty service members for physical performance measures that can be readily implemented in a clinical setting. Interrater and test-retest reliability and minimal detectable change (MDC) values were also determined. Physical performance testing included self-selected walking velocity on level and uneven terrain, timed stair ascent, the sit-to-stand five times test, the four-square step test, and the 6-minute walk test. Data analysis included descriptive statistics, intraclass correlation coefficients, and MDC. Interrater and test-retest reliability were excellent for all measures (intraclass correlation coefficients >0.75). MDC values for timed measures were <0.3 seconds for interrater comparisons and <1.5 seconds for between-day comparisons. Physical performance measures had a narrow range of normal performance and were reliable and stable between days.

                                        • Subspecialty:
                                        • Trauma

                                      Posttraumatic Osteoarthritis Caused by Battlefield Injuries: The Primary Source of Disability in Warriors

                                      The Army Physical Evaluation Board results for wounded warriors from a previously described cohort were reviewed to identify permanently disabling conditions and whether the conditions were preexisting or caused by battlefield injury. Arthritis was the most common unfitting condition in this cohort, with 94.4% of cases attributed to combat injury and only 5.6% attributed to preexisting conditions or documented in the health records prior to battle injury. The most common causes of injury that resulted in arthritis were intra-articular fractures secondary to explosions, traumatic arthrotomies resulting from fragment projectiles, and gunshot wounds. Arthritis was recognized as a disabling condition an average of 19 +/- 10 months after injury. Research is needed to enhance prevention and management of joint injuries in order to minimize the disabling effects of joint degeneration in this young patient population.

                                          • Subspecialty:
                                          • Trauma

                                        Reprioritization of Research for Combat Casualty Care

                                        Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

                                            Special Topics

                                            Concerning the past decade of war, three special topics were examined at the Extremity War Injuries VII Symposium. These topics included the implementation of tourniquets and their effect on decreasing mortality and the possibility of transitioning the lessons gained to the civilian sector. In addition, the training of surgeons for war as well as residents in a wartime environment was reviewed.

                                                The Changing Face of Disability in the US Army: The Operation Enduring Freedom and Operation Iraqi Freedom Effect

                                                Orthopaedic disorders account for significant disability among adults in the United States. Previous studies have demonstrated long-term disability in military personnel with musculoskeletal conditions. However, these studies focused primarily on battlefield-injured service members and did not evaluate the entire population. The goal of this study was to determine and compare the disabling conditions of the entire United States Army during peacetime and war. We identified the conditions leading to separation from military service before and during Operation Iraqi Freedom and Operation Enduring Freedom. During war, more soldiers are found to be unfit for duty, and they have more conditions per individual that make them unfit. Orthopaedic conditions account for the greatest number of soldiers separated from military service at both time points studied (ie, January through March 2001, January through March 2009). Back pain and osteoarthritis are the two most common causes of separation from military service; these conditions are responsible for the most disability during peacetime and war.

                                                    • Subspecialty:
                                                    • Trauma

                                                  The Role of Pain Management in Recovery Following Trauma and Orthopaedic Surgery

                                                  War often serves as a catalyst for medical innovation and progressive change. The current conflicts are no exception, particularly in the area of pain management of wounded warriors. Morphine administration has served as the primary method of battlefield pain management since the American Civil War. Although traditional opioid-based pain management is effective, it has significant side effects that can complicate recovery and rehabilitation following injury. These side effects (eg, sedation, nausea and vomiting, ileus, respiratory depression) can be fatal to persons wounded in combat. This fact, along with recent research findings indicating that pain itself may constitute a disease process, points to the need for significant improvements in pain management in order to adequately address current battlefield realities. The US Army Pain Management Task Force evaluated pain medicine practices at 28 military and civilian institutions and provided several recommendations to enhance pain management in wounded warriors.

                                                      • Subspecialty:
                                                      • Trauma

                                                      • Pain Management

                                                    Updates on Disaster Preparedness and Progress in Disaster Relief

                                                    Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

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