Symposium examines challenges in trauma care

More than 33,000 U.S. service members have been wounded in Iraq and Afghanistan. An estimated 60 percent to 70 percent of those wounded have musculoskeletal injuries. Figures like these underscore the extreme challenges to orthopaedic surgeons presented by the war on terror.

During the 2009 Annual Meeting, a panel of military and civilian orthopaedists examined those challenges and the orthopaedic response. Moderated by CAPT Dana C. Covey, MD, USN, “Advances in the Care of Battlefield Orthopaedic Trauma,” featured presentations by COL Mark W. Richardson, MD, USAF; CDR Michael T. Mazurek, MD, USN; Steven J. Morgan, MD; and MAJ Joseph R. Hsu, MD, USA.

The debate over negative pressure therapy
Several issues surround the use of portable vacuum-assisted wound closure devices (VACs) for negative pressure wound therapy (NPWT) during medical evacuation. Blast injuries often produce large exudative wounds that are difficult to manage with traditional dressings, explained Dr. Richardson. Although the use of NPWT has increased in the civilian trauma community, its use in a military setting, particularly during air evacuation, remains controversial.

If a VAC device fails during flight, the closed environment could result in an anaerobic infection, and in fact, a few patients evacuated from Iraq and Afghanistan who were treated with NPWT have arrived in the United States with failed VACs and wound sepsis. The noisy environment on board the airplane makes it difficult for the medical crew to hear the alarm of a failing VAC.

Yet, NPWT offers the advantage of maintaining a closed environment that does not need changing in flight, resulting in a decreased risk of secondary contamination. Furthermore, NPWT promotes granulation tissue, removes exudate, and resuscitates borderline tissue in the zone of stasis.

Dr. Richardson reported on a retrospective review of patients transported to Landstuhl Regional Medical Center (LRMC) between October 2006 and September 2007. Of 277 VAC dressings (203 patients), only 37 complications (36 patients) occurred, all but one of which were considered minor. The single major complication involved a VAC device that had seven problems during the flight, four of which required prolonged clamping.

Speaking in favor of the use of NPWT, Dr. Richardson said that dry dressings can be problematic, particularly when dressings need to be changed during transport. To address the issue of VAC failures during transport, his team has begun experimenting with using antibiotic beads with NPWT. Although he admitted that such a system seems counterintuitive—the VAC will suck out some of the “antibiotic soup”—the beads can serve as a filler. If the VAC fails during transport, the patient still has a bead pouch.

Bone where it shouldn’t be
Heterotopic ossification (HO)—the formation of mature lamellar bone in tissues such as muscle, joint capsules, ligaments, and tendons that normally do not exhibit ossification—was the subject of Dr. Mazurek’s presentation. HO is most commonly associated with head or spinal cord trauma, blunt injury trauma, periarticular injury, arthroplasty, or genetic causes.

According to Dr. Mazurek, the development of heterotopic bone appears to be influenced by the amount of trauma to which a patient is exposed—a situation particularly applicable to war injuries. In one study of 243 war-wounded who underwent at least one operation, HO developed in 157 (64.6 percent). Independent variables affecting the development of HO included age (younger than 30 years), amputation, multiple extremity injury, traumatic brain injury, and an injury severity score of less than 16.

HO can develop to varying degrees of pathology, from no functional limitation (Brooker I) to ankylosis (Brooker IV). HO presents with pain, swelling, stiffness, and, as it progresses, a potential decrease in joint range of movement. Dr. Mazurek said that HO seems to be caused by the stimulation of stem cells, resulting in bone formation.

Radiation treatments (XRT) have been suggested as a possible prophylaxis for HO. He reviewed one study that compared XRT prophylaxis, indomethacin prophylaxis, and no treatment. No statistically significant difference was found in the development of HO between XRT and indomethacin prophylaxes; HO developed in 100 percent of the untreated patients.

However, at least one other study offered contradictory results. In a randomized, double-blind, placebo-controlled study, the researchers found no significant difference in the incidence of HO between patients given indomethacin and those who received a placebo.

Unfortunately, one consequence of HO prophylaxis is that nonunions are more likely to occur. When HO does develop, surgical excision of the extra bone material often results in favorable outcomes.

The price of war
Dr. Hsu’s research focuses on the costs of dealing with extremity injuries in the military. According to his study, extremity injuries require the greatest medical resources and are the greatest source of physical disability in combat casualties from the current conflicts—responsible for an estimated $463 million in initial hospitalization costs and $1.2 billion in disability benefits to date.

To determine the monetary expenses incurred by such casualties, Dr. Hsu’s team examined the records of 1,333 consecutive admissions to the Joint Theater Trauma Registry from October 2001 to January 2005. Disabilities due to extremity injuries accounted for 64 percent of total disability compensation.

Furthermore, extremity injuries accounted for 65 percent of resource utilization, 63 percent of primary admission diagnoses, and longer than average inpatient stays.

Volunteer surgeons at LRMC
The Visiting Orthopaedic Scholars Program is also aimed at increasing communication between military and civilian orthopaedists. Modeled after the Visiting Senior Trauma Surgeon Program instituted by the American College of Surgeons, the program sends civilian surgeons to Landstuhl to work alongside military surgeons as Red Cross volunteers. So far, 20 civilian surgeons have been sent to LRMC.

According to Dr. Morgan, the program’s goals include improving the pace at which advances made in the military orthopaedic community are translated to the civilian orthopaedic community and granting opportunities to military surgeons to gain continuing medical education (CME) credits through classes taught by the visiting civilian surgeons.

Surgeons who wish to participate in the program must submit a formal application, pass review by a selection committee of civilian and military trauma surgeons, be fellowship-trained in orthopaedic trauma care, and have at least 10 years experience in extremity trauma.

Visiting surgeons participate in a daily morning conference to discuss care plans, incoming injuries, and transport plans. They also participate in surgical care, evaluate new patients, and take part in video conferences to discuss specific cases with other surgeons. Finally, they offer a weekly lecture attended by military surgeons for CME credit.

Given the potential for terrorist attacks in the continental United States, developing an institutional memory for dealing with cases of extreme trauma brought on by high velocity injuries is important, ex­plained Dr. Morgan. The Visiting Orthopaedic Scholars Program affords the opportunity for civilian surgeons to develop these memories.

The presenters reported the following disclosures: Dr. Hsu—none; Dr. Richardson—Stryker; Dr. Mazurek—Synthes AO; Dr. Covey—Arthrex, DePuy A Johnson & Johnson Company, Medtronic, Medtronic Sofamor Danek, Mitek, Osteotech, Stryker, Synthes, Zimmer; Dr. Morgan—AO, Smith & Nephew, Stryker, Synthes, DePuy A Johnson & Johnson Company, Wyeth, Twin Star Medical, Medtronic, KCI, Johnson & Johnson, Cerapedics.

Disclaimer: Opinions presented by military personnel are their own and not necessarily the official position of the U.S. Department of Defense.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org