During the course of Operations Iraqi Freedom and Enduring Freedom, more than 80 percent of the 36,000 casualties sustained by U.S. military personnel have involved extremity trauma. Many of those injuries were inflicted by improvised explosive devices.

That grim accounting was a focal point of the fifth annual Extremity War Injuries (EWI) symposium sponsored by the AAOS, the Orthopaedic Trauma Association (OTA), and the Society of Military Orthopaedic Surgeons, Jan. 27–29, 2010, in Washington, D.C.

“The distinguished service of our military surgeons never ceases to amaze me,” said COL James R. Ficke, MD, EWI-V cochair. “The continued dedication of surgeons and the incredible courage of our patients continue to inspire advances that enhance the treatment, research, and knowledge of blast injuries.

“Most battlefield wounds affect extremities. Extremity wounds are responsible for two thirds of inpatient hospital and disability costs and are the main reasons why up to one third of the wounded never fully recover. This underscores the fact that current therapy options are not capable of restoring full function to those injured,” he said.

CAPT Michael J. Bosse, MD, EWI-V cochair, concurred. “Over the past several years, peer-reviewed orthopaedic research has been an essential element of our continued efforts to encourage researchers to focus on improving the treatment of high-energy extremity war injuries.

“The EWI symposium gave us an opportunity to discuss this type of research and to learn more about helping military orthopaedic surgeons discover new and innovative ways to best treat these complex injuries. To improve the quality of life for these injured troops, we have to recognize the need for sustained, robust investment in this type of research,” he said.

Securing that sustained investment has been the mission of many AAOS fellows associated with the EWI programs, especially Andrew N. Pollak, MD, chair of the AAOS Extremity War Injuries and Disaster Preparedness Workgroup. Dr. Pollak opened the symposium with a recap of Congressional actions relative to funding peer-reviewed orthopaedic research within the Department of Defense.

“As we educate congressional staff and AAOS members, we need to make them understand that all other injuries pale in comparison to musculoskeletal injuries when it comes to prevalence, incidence, and burden,” explained Dr. Pollak. He singled out the Orthopaedic Extremity Trauma Research Program (OETRP) and the Peer-Reviewed Orthopaedic Research Program (PRORP) as being instrumental in developing greater understanding in the treatment of extremity war injuries and removing some of the barriers to return of function and duty that were the very basis of the symposium.

From infections to amputations
The symposium included reviews of successful and emerging techniques available to treat those injured in combat and facilitate their return to active duty. Topics ranged from diagnosis and management of chronic infections to limb salvage versus amputation.

In a spirited point-counterpoint, Drs. Ficke and Bosse discussed the Ertl technique in osteomyoplastic transtibial amputations—a technique with widely varying levels of approval within the orthopaedic community. Afterward, attendees used an audience response system to key in their reaction to the debate; Dr. Ficke, who argued for the technique, edged Dr. Bosse by a margin of less than a single percentage point.

The many challenges of limb salvage were also discussed. Ellen MacKenzie, PhD, principal investigator for the Military Extremity Trauma Amputation Versus Limb Salvage (METALS) study—a Department of Defense-funded intramural investigation intended to describe the long-term consequences of major limb trauma—updated the audience on findings to date.

Overall, the METALS study found outcomes to be poor: poor physical functioning, moderate to high rates of pain, depression, and posttraumatic stress disorder. Similar outcomes were found among those undergoing amputation compared to reconstruction. Among those with unilateral lower limb injuries, a tendency toward better functional outcomes was found among amputees. Dr. MacKenzie said future analyses will include all patients and adjust for potential confounders; she also noted a need to look at outcomes for patients with multiple limb injuries.

Government support
The impact of EWI attracted several VIPs to the symposium, including Rep. Tim Walz (D-Minn.); Air Force Surgeon General C. Bruce Green, MD; and Assistant Secretary of Defense for Health Affairs Ellen Embrey. Ms. Embrey discussed orthopaedic research programs within the Department of Defense, particularly the Armed Forces Institute of Regenerative Medicine (AFIRM).

Created in 2008, AFIRM is focused on developing clinical therapies for burn repair; wound healing without scarring; craniofacial reconstruction; limb reconstruction, regeneration, or transplantation; and compartment syndrome, a condition related to inflammation after surgery.

Rep. Walz also voiced the need for federal support of orthopaedic care, noting that the signature injury in Operations Enduring Freedom and Iraqi Freedom—traumatic brain injury—is almost always accompanied by some form of musculoskeletal trauma.

On the ground in Haiti
The symposium concluded with several presentations on the topic of disaster preparedness and the issues faced by first responders to major disasters, as exemplified by the activities of orthopaedic surgeons in Haiti in the wake of that country’s recent devastating earthquake. Dr. Pollak and Christopher T. Born, MD—both of whom had recently returned from relief efforts—discussed their experiences in the Haitian capital of Port-au-Prince. Although resources were limited and the need overwhelming, they witnessed an inspiring response of the international medical community, along with occasionally improvised surgical techniques.

Especially compelling was a presentation via telephone from Roman A. Hayda, MD, who was in Haiti aboard the hospital ship USNS Comfort and provided a real-time, in-person assessment of the state of the disaster response.

The Journal of the AAOS will publish a supplement later this year based on the presentations given at EWI V.

Visit the Extremity War Injuries symposia web site for more information.

For more information on AAOS efforts to increase federal funding for orthopaedic research, visit the AAOS office of government relations web site.

Jamie A. Gregorian is the manager of research advocacy in the AAOS office of government relations; he can be reached at gregorian@aaos.org