The sixth annual Extremity War Injuries (EWI) symposium, sponsored by the American Association of Orthopaedic Surgeons (AAOS), the Orthopaedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), and the Orthopaedic Research Society (ORS), focused on data-driven research in combat casualty care. Orthopaedic surgeons from all branches of the military, in conjunction with civilian traumatologists and researchers, shared promising treatments and rehabilitation methods in major extremity trauma as well as axial skeleton injuries.

Increased federal defense funding in FY 2010 enabled researchers to conduct several new studies and surgical trials in the areas of wound care and wound therapy. The results of these studies were reflected in presentations made on promising therapies for patients sustaining spinal cord injuries and extremity injuries. But attendees expressed concern about defense budget cuts that may compromise both ongoing and new studies.

Axial skeleton injuries
A major focal area of this year’s symposium was on the initial management and treatment of axial skeleton injuries. MAJ Joel W. Jenné, MD, an active duty Air Force orthopaedic spine surgeon, discussed indications for initial immobilization of soldiers wounded on the battlefield. Immediate medical care is focused on basic life support—maintaining an airway and controlling blood loss. He noted that immobilization is not indicated for patients with penetrating injuries because it offers no survival benefit and may, in fact, increase the mortality risk.

Michael G. Fehlings, MD, PhD, FRCSC, FACS, medical director of the Krembil Neuroscience Center, shared the findings of a prospective cohort study assessing the effects of early (less than 24 hours after injury) and late (24 hours or longer after injury) surgical decompression on outcomes in patients with acute spinal cord injuries.

At 6 months, 20 percent of patients who had early decompression improved by two or more grades (Abbreviated Injury Scale), compared to 10 percent of patients who had late decompression. Dr. Fehlings noted that decompression within 24 hours of a cervical spinal cord injury is both safe and feasible. He also reviewed current clinical trials examining the potential benefits of new neuroprotective strategies, such as the use of riluzole, a drug traditionally used to slow the progress of amyotrophic lateral sclerosis.

Carlo Bellabarba, MD, director of Seattle’s Orthopaedic Spine Harborview Medical Center, discussed the evaluation and treatment of lumbosacral combat injuries, which are demographically much different than civilian injuries.

Data-driven outcomes
Following up on those differences, CDR David E. Gwinn, MD, a practicing spine surgeon at Walter Reed Medical Center, and LT James R. Bailey, MD, an orthopaedic surgery resident at San Diego’s Naval Medical Center, presented data on the differing indicators and associated injuries from penetrating and blunt injuries to the spine and pelvis.

Dr. Gwinn stressed the need for uniformity to ensure the best outcomes for military patients. “Penetrating spine wounds are encountered more often on the battlefield than in civilian settings,” he explained. “Treating providers must be aware of management principles used to identify, treat, and transport these patients through appropriate levels of care to maximize neurologic and functional capacity.”

Dr. Bailey’s presentation reflected the value of military trauma research to establish guidelines for injuries that occur on the battlefield. “Our study of nonsurvivors showed that penetrating pelvic fractures are 8 times more likely to cause large pelvic vessel injuries and 6 times more likely to cause intra-abdominal hollow viscous injuries than blunt trauma,” he said.

Improving quality of life
Improving the quality of life of trauma patients is a shared objective of surgeons, anesthesiologists, and rehabilitation practitioners. COL Chester Buckenmaier, MD, chief of the tri-service Defense and Veterans Pain Management Initiative, discussed the complications associated with unrelieved pain.

According to Dr. Buckenmaier, doctors must make both acute and perioperative pain management a priority for their patients. “Uncontrolled pain is a disease, not a symptom,” he asserted. “Electing to not treat pain is no longer an option.”

A promising orthotic device to improve the quality of life for lower-limb salvage patients, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was demonstrated in a study presented by CPT Jeanne C. Patzkowski, MD, an orthopaedic surgery resident at the San Antonio Military Medical Center. The study compared three different limb-salvage braces, including the IDEO, on a group of 18 patients. (No brace was used as the control.)

Each patient performed five trials with each brace condition, testing agility, power, and speed. The IDEO outperformed the other braces in every measure except in the sit-to-stand skills test, due to its bulk (which is being examined). Although additional tests must be performed to confirm the superiority of the IDEO, Dr. Patzkowski’s study showed that using the IDEO leads to significant improvements in lower-limb function. In fact, 62 percent of the patients in the study who initially considered lower limb amputation changed their minds after trying the IDEO.

A personal perspective
U.S. Marine Corps Sgt. Kenneth Michael Blair, a limb-salvage patient, gave the audience insight into his road to recovery and demonstrated how his surgeons and therapists have significantly improved the range of motion of his limbs. Sgt. Blair has had more than 60 reconstructive surgeries and, although he experiences chronic pain and limited limb function, he expressed his gratitude for being able to walk and play with his children.

LCT Romney C. Andersen, MD, of Walter Reed National Military Medical Center, was Sgt. Blair’s primary surgeon. Describing his patient as “an amazing individual who is determined to overcome devastating bilateral lower extremity injuries,” Dr. Andersen called for continued research into extremity injuries to help patients overcome long-term disabilities.

Evaluating disaster preparedness
The symposium concluded with several presentations on the successes and setbacks of the disaster response efforts in Haiti and the need for better cooperation in international disaster preparedness. Most injuries sustained in the Haitian earthquake were orthopaedic in nature; most patients sustained long-bone fractures and crush injuries.

Christopher T. Born, MD, professor of orthopaedic surgery at Brown University, detailed the work on an AAOS/OTA Comprehensive Disaster Preparedness Plan that will be presented to the AAOS Board of Directors in June. The plan will establish distinct pathways for training, certification, and credentialing of orthopaedic trauma-trained responders, general humanitarian responders, and non-orthopaedic trauma-trained orthopaedic responders.

Andrew N. Pollak, MD, president-elect of the OTA and chair of the AAOS Extremity War Injuries Project Team, unveiled plans for a new teaching hospital in Haiti’s capital, Port-au-Prince. The teaching hospital will include an orthopaedic trauma care specialist (OTCS) program to meet the critical need for orthopaedic surgeons in Haiti. The OTCS, a 2-year train-the-trainer program initially taught by international faculty, will focus solely on care of extremity injuries. As the program progresses, Haitian faculty will play an increased role to ensure the long-term viability of the program.

Government support
The EWI symposium gave participants a unique opportunity to discuss the innovations being used to treat victims of extremity trauma. It was also an opportunity to reinforce the fundamental need for continued investment in orthopaedic extremity research. Several key federal stakeholders took part in the symposium including double amputee and veteran Tammy Duckworth, assistant secretary for public and intergovernmental affairs at the Department of Veterans’ Affairs.

Each speaker proclaimed gratitude for the work of orthopaedic surgeons and their steadfast commitment to support our wounded military personnel and the research that has helped save their lives and limbs. “Orthopaedists are more important than ever when it comes to the quality of life of our military,” said Rep. Joe Wilson.

Likewise, Assistant Secretary Duckworth affirmed, “Our wounded warriors are capable of wonderful things, but couldn’t do what they do without the work of orthopaedic surgeons.”

Madeleine Lovette is the communications specialist in the AAOS office of government relations. She can be reached at lovette@aaos.org