On Feb. 10–12, 2014, military and civilian orthopaedic surgeons—along with researchers and government personnel—met in Washington, D.C., for the Extremity War Injuries (EWI) IX Symposium. The event was hosted by the AAOS, along with the Orthopaedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), and the Orthopaedic Research Society (ORS).

Since 2006, the EWI symposia have served to define current knowledge regarding management of extremity war injuries for the National Institutes of Health (NIH), Congress, the Department of Defense (DoD), orthopaedic surgeons, researchers, industry, and other relevant governmental agencies. This ninth symposium focused on advancing the care of the wounded warrior by identifying knowledge gaps related to reducing disability within the military.

Combat care
With the United States still engaged in regions of conflict around the world, combat casualty care remains a central focus of the military medical community. Despite advances that have contributed to the highest war injury survival rates in history, new challenges have arisen, particularly in the arena of orthopaedic-related upper and lower extremity injuries, which account for most of the trauma.

Orthopaedic care for the wounded was pivotal, for example, during Operation Iraqi Freedom and Operation Enduring Freedom. However, recent surveys indicated that few providers felt sufficiently prepared or had adequate predeployment-specific training to treat the type of trauma they faced while in the field.

To highlight this concern, Lawrence B. Bone, MD, who recently returned to the United States after a 9-month deployment, contrasted the civilian and military trauma experiences. According to Dr. Bone, many providers trained in civilian trauma are not adequately prepared for the “M*A*S*H” style of medicine that is required in the deployment trauma situation.

Dr. Bone described his experience at Forward Operating Base Shank, located in the Logar province of Eastern Afghanistan. It was, he said, “like going back 40 years.” Surgeons had little access to modern technology, but still had to deal with difficult surgeries. Computed tomography scans were not always available, and “coming to that environment without proper introduction is less than adequate.”

To address this issue, Dr. Bone believes that first-time deploying providers should receive training unique to the deployment environment. In addition, course-specific training should be required for all first-time deploying general and orthopaedic surgeons. Specifically, Dr. Bone recommended that surgeons be certified in Advanced Trauma Life Support within one year prior to deployment.

Among the resources he listed as helpful in preparing surgeons for deployment are the following:

• Army Trauma Training Center
• Advanced Surgical Skills for Exposure in Trauma Course
• Combat Extremity Surgery Course
• Clinical Practice Guidelines
• Books such as the DoD’s Emergency War Surgery: The Survivalist’s Medical Desk Reference, Springer’s Front Line Extremity and Orthopaedic Surgery: A Practical Guide, and the U.S. Army Medical Department’s War Surgery in Afghanistan and Iraq: A Series of Cases, 2003–2007

“We’ve learned a lot about how to manage these patients,” said Dr. Bone, “but we also know that preventable deaths are occurring.”

Funding opportunities
COL Todd Rasmussen, MD, FACS, approached combat casualty care from the research perspective and discussed many of the funding opportunities that are available in this area. According to Dr. Rasmussen, case fatality rates are decreasing while injury severity scores are increasing. These data, said Dr. Rasmussen, “provide information as to how we are doing with combat casualty care” along with “clues as to where we want to focus research efforts in coming years.”

One priority he suggested would be “out-of-hospital care,” including patient movement or transport (en route care). Dr. Rasmussen cautioned that avoiding a “one and done” phenomenon is important; one or two studies and a published paper aren’t enough. The DoD would prefer to “connect the dots” and amass practice-changing knowledge. Although “fewer balls” may be advanced using this approach, Dr. Rasmussen explained, “they get all the way down the field.”

Civilian opportunities
“Research funding opportunities exist in the civilian sector for the investigation of important clinical and basic science questions,” said James D. Heckman, MD, chair of the Research Grants Committee for the Orthopaedic Research and Education Foundation (OREF). Funding, he said, is available for both investigator-initiated and agenda-driven studies.

Investigator-initiated opportunities at the OREF include the New Investigator Grant, the OREF Mentored Clinician-Scientist Grant, the Resident Clinician Scientist Training Grant, and the Resident Research Project Grant. On the “agenda-driven” side, the OTA is seeking new technology for the management of orthopaedic infection; the OREF is funding research focused on musculoskeletal regeneration using stem cells and on infection prevention and control; and the Collaborative Spine Research Foundation has as its top priority clinical research to assess the effectiveness of management strategies and/or treatment methods and techniques for patients with acute spinal traumatic injury, with or without spinal cord injury.

However, he also noted that many funders are more interested in specific outcomes and “no longer just willing to hand out funding.”

In addition to the general sessions, the EWI symposium used breakout sessions with small groups focused on each clinical area—upper extremity trauma, lower extremity trauma, and spinal and pelvic trauma. Groups were charged with identifying knowledge gaps and developing priorities for issues such as nerve injuries, articular cartilage defects, and infection.

Special guest speakers included Rep. C.A. “Dutch” Ruppersberger (D-Maine) and Rear Admiral Raquel C. Bono, MD. For more information on EWI, visit the AAOS website www.aaos.org/ewi

Elizabeth Fassbender is the communications specialist in the AAOS office of government relations. She can be reached at fassbender@aaos.org

Additional Information

• Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF: Understanding combat casualty care statistics. J Trauma 2006;60(2):397-401.
• Schoenfeld AJ, Dunn JC, Bader JO, Belmont PJ Jr: The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003–2011. J Trauma Acute Care Surg 2013;75(2):287-291.
• Department of Defense: Emergency War Surgery: The Survivalist’s Medical Desk Reference. 2012.
• Bone LB, Mamczak CN: Front Line Extremity and Orthopaedic Surgery: A Practical Guide. Springer, 2014.
• Nessen SC, Lounsbury DE, Hetz SP, Woodruff B, Walter Reed Army Medical Center Borden Institute: War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007 (Textbooks of Military Medicine).
• Resources on civilian funding opportunities: OTA (ota.org/research), OREF (oref.org/research), and CSRF (csrfoundation.net)