More than 40,000 U.S. military personnel have been wounded in battle over the past dozen years, 80 percent of them sustaining extremity injuries. Treating these injuries is challenging because many are the product of improvised explosive device blasts, resulting in high-energy injuries rarely seen elsewhere.

Since 2005, the AAOS, the Orthopedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), and the Orthopaedic Research Society (ORS) have sponsored a series of Extremity War Injuries (EWI) symposia, covering treatment options, advances in care, and recovery and rehabilitation.

Cochairs Marc Swiontkowski, MD, and COL Romney Andersen, MD, developed a balanced program focuse on the clinical issues of most relevance to the treatment teams dealing with these patients. “Dr. Andersen has been the lead resource in this regard and has first-hand knowledge of the clinical problems under active discussion in the military treatment facilities,:” said Dr. Swiontkowski, “and an intimate knowledge of the individuals pursuing research involving the most cutting-edge treatments. “

Educating Congress is crucial
The threat to military-funding of orthopaedic research was examined by Andrew N. Pollak, MD, chief of orthopaedic trauma at the R. Adams Cowley Shock Trauma Center (Md.). The passing of Sen. Daniel Inouye, a key supporter of such research, means there will be a new chair for the Senate Appropriations Committee and the Defense subcommittee. In addition, Congress is increasingly aware of the unsustainable nature of current and projected budget deficits.

“This year’s challenges will include educating the new chairs of the Defense Appropriations Committee and the Senate Appropriations Committee and winning their support,” Dr. Pollak said. “Although the new chair may be someone inclined to include the program, getting the Department of Defense (DoD) to include the program in the budget proposal that the President sends to Congress would be even better. Achieving either goal will require substantial effort.”

Posttraumatic arthritis
One of the most significant sequelae of extremity injuries is the burden of posttraumatic osteoarthritis (PTOA). According to LTC Anthony Johnson, MD, San Antonio Military Medical Center, PTOA of the hip, knee, or ankle accounts for approximately 12 percent of all symptomatic OA. The aggregate financial burden of treating PTOA totals more than $3 billion or 0.15 percent of total U.S. healthcare direct costs.

Arthritis, he said, was the most common condition in service members undergoing medical discharge—with 94.4 percent of the OA can be attributed to combat injury, such as intra-articular fractures due to explosions, traumatic arthrotomies due to fragment projectiles, and gunshot wounds.

Efforts to reduce the impact of PTOA by preserving and protecting joints have ranged from studies on the biology of cartilage injury and repair and biologic interventions to preserve articular cartilage and prevent cell death after injury to surgical interventions to preserve articular cartilage and articular surfaces. As OA develops, however, joint replacement becomes a primary treatment. In this situation, indications, bearing choices, and return to duty are key areas of research.

Upper extremity injuries
Upper extremity war injuries present a unique set of challenges to orthopaedic hand and trauma surgeons, as well as to plastic reconstructive surgeons, which were exemplified in the presentation by Dr. W. P. Andrew Lee, the Milton T. Edgerton, MD, Professor and chairman of department of plastic and reconstructive surgery at the Johns Hopkins University School of Medicine.

A hand surgeon and basic science researcher, Dr. Lee investigate tolerance strategies for vascularized composite allografts (VCAs), such as hand or face transplants, to ameliorate the need for long-term systemic immunosuppression. He recently led an interdisciplinary team of doctors and nurses who successfully performed the most extensive bilateral arm transplant to date. The 26-year-old patient, Sgt. Brendan Marrocco, was gravely injured outside Baghdad in 2009 when the armored vehicle he was driving was hit by a roadside bomb. All of his limbs had to be amputated, and he became the first soldier to survive as a quadruple amputee. Today, Marrocco has new arms and hands.

“I believe that immunosuppression and the long-term sequelae of hand transplant hold the key to widespread application of vascularized composite allotransplantation,” said Dr. Lee. He explained that VCA has become a viable and immediately available alternative when conventional reconstruction for devastating combat injuries is not optimal or feasible.

According to Dr. Lee, during the past decade about 90 upper extremity transplants have been performed around the world with favorable long-term success rates and highly encouraging functional outcomes. However, the toxicities and adverse effects of the high-dose immunosuppressive drugs needed have curtailed wider application.

The conventional maintenance therapy in both solid organ transplantation and VCA, he noted, has been associated with substantial morbidity such as opportunistic infections, metabolic disorders, or malignancies. As a result novel treatment concepts are needed to minimize or avoid immunosuppression and extend the benefits of these life-enhancing procedures to the military and civilian patient populations.

Dr. Lee’s team has pioneered donor bone marrow (BM) cell-based strategies to modulate, rather than suppress, immune rejection. This helps minimize the need for immunosuppressive medication after upper extremity transplantation. He detailed a recent case series of six patients who received a total of 10 hand/forearm transplants [two bilateral hand, two bilateral hand/forearm, and two unilateral hand]. On postoperative day 14, patients received an unmodified whole donor BM cell infusion isolated from nine vertebral bodies.

Results were quite positive: Acute episodes of skin rejection were infrequent and all were reversible. No systemic infectious (bacterial or viral) complications occurred. Patients demonstrate sustained improvements in motor function (range of motion, intrinsic return, grip and pinch strength) and sensory return correlating with the time after transplantation, level of amputation, and participation in hand therapy.

Dr. Lee pointed out that data suggest that the BM cell-based immunomodulatory protocol is safe, efficacious, and well-tolerated and has enabled hand/forearm transplantation with minimal immunosuppression.

Infection
Infectious complications of combat wounds are a significant threat following polytrauma. Several presentations covered this area including the following:

• Combat wound assessment using biomarkers and molecular models
• Suppression of the inflammatory immune response and vaccination
• Molecular tethering of antibiotics to metal or bone surfaces
• Antibiofilm strategies for the treatment of chronic orthopaedic extremity infections
• Temperature regulation as an infection treatment
• Enhancing antimicrobial activity against biofilm bacteria

“The time is now.”
Lt. Gen. Patricia D. Horoho, MSN, RN, MS, Surgeon General and Commanding General of the United States Army Medical Command, pledged her resources, focus, and passion to implement a mission of health and healing. “Your work,” she told the audience, “directly supports the trauma care, rehabilitation, and recovery of our injured soldiers, sailors, airmen, and marines.”

General Horoho shared her experiences in the delivery of care on the battlefield in Afghanistan as well as her vision for the future of military delivery of care. “I think we have the ability to shape the future of health care. My challenge to you is to look at 10 years down the road. What are the physical and psychological sequelae that we might face in 2023 and beyond? How should we prepare? We have to begin that right now. We must be able to prevent, rather than react. Our nation and our army medicine is depending on you.”

For more information on the EWI symposia, visit www.aaos.org/ewi

G. Jake Jaquet is executive editor of AAOS Now. He can be reached at jaquet@aaos.org