Through the ages, military medicine has contributed to medical advancements in trauma care by the sheer necessity and creativity required to care for large numbers of severely injured persons. Since the Vietnam War, conflicts involving American military personnel have brought to light certain deficiencies in optimal combat casualty care. As the United States entered Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq), the military medical system faced these deficiencies head on by collecting clinically relevant and consistent trauma data through the genesis of the Joint Theater Trauma Registry (JTTR).

Housed at the US Army Institute of Surgical Research (USAISR), the Joint Trauma System (JTS) positions personnel into far forward battle conditions to collect trauma data. Within one year of its establishment, JTTR contributed combat casualty care data that informed the first combat theater Clinical Practice Guideline (CPG) on blood product ratios. Since then, 45 additional trauma system and critical care transport CPGs have been established.

The JTTR, now called the Department of Defense Trauma Registry (DoDTR), has unquestionably been an incredible asset to improving the treatment of those wounded in combat. However, it was designed by and for the deployed general surgeon. Therefore, its contributions to combat casualty care have not been fully realized.

Most combat injuries and resultant long-term disabilities are to and of the musculoskeletal system. Some of the DoDTR CPGs are directed to the field of orthopaedics; these include the use of field tourniquets, early recognition of compartment syndrome, and fasciotomies, pelvic fracture care, and amputations. However, in terms of enhancing acute orthopaedic care to optimize long-term outcomes and minimize long-term disability, the DoDTR does not provide the detailed data needed by orthopaedic surgeons and researchers.

An orthopaedic registry
The need for an orthopaedic equivalent to DoDTR became evident shortly after the deployment of JTS registry nurses in 2005. The 2006 Extremity War Injury (EWI) Symposium, sponsored by the AAOS, the Orthopaedic Trauma Association (OTA), the Orthopaedic Research Society (ORS), and the Society of Military Orthopaedic Surgeons (SOMOS), further highlighted gaps in orthopaedic combat casualty care and called for the compilation of orthopaedic data.

Following the second EWI Symposium (Development of Clinical Treatment Principles) in 2007, a number of research priorities were identified, including the following:

• prehospital management of extremity wounds
• guidelines on débridement and initial fracture stabilization
• transport/evacuation wound management

With no orthopaedic-specific data repository, these needs would go unmet because researchers would lack the requisite evidence-based medicine to drive the development of orthopaedic CPGs. Thus the Military Orthopaedic Trauma Registry (MOTR) was conceived.

MOTR began as an interim module within the DoDTR, and so when DoD funding ($10.2 million) was allocated in 2011, it moved from an interim status to a live trauma registry. Computer interface items were edited and expanded and, in 2013, MOTR “went live” when the first patient data was entered. Today, MOTR has 12 full-time data abstractors, a branch chief, a custodian, and co-custodian working to ensure that it is a vital resource for the military orthopaedist.

With MOTR, orthopaedic researchers will have the quality and quantity of data needed to develop informed CPGs and to guide future research—much as the DoDTR has for trauma surgeons. Early implementation of quality assurance checks have indicated excellent granularity of the orthopaedic data, exceeding even that available from DoDTR and other repositories.

For example, a casualty who sustains severe lower extremity trauma, including an open tibial shaft fracture, may be identified by the ICD-9 code for tibia shaft fracture in the DoDTR. However, the DoDTR does not include information on the severity of the injury or the fracture classification. Thus, the orthopaedic surgeon studying severe lower extremity trauma would not be able to identify the details pertinent to the research question or to the CPG.

Data for the same casualty, after abstracted into MOTR, will include the ICD-9 code, the Gustilo and Anderson open fracture classification, and the OTA/AO fracture classification—in the data output and in searchable format.

Orthopaedic treatment details for managing bone and soft tissue (skin, muscle, ligament/tendon, cartilage, and nerve) are also available, enabling a reconstruction of the timeline of orthopaedic treatments. MOTR also includes orthopaedic complications by date. By including the treatment timelines and complications, MOTR contains information detailed enough to provide a thorough outlet for development of treatment CPGs.

Future plans
With this wealth of specific orthopaedic injury, treatment, and complication information, the future of MOTR is bright. It promises to be a data source for performance improvement, development of informed CPGs, and research. Additionally, collaborators outside of the DoD will have the opportunity, as the registry matures, to work through the JTS with MOTR on combat orthopaedic outcomes studies.

Although DoDTR paved the way to inform general surgery CPGs, MOTR is at work to provide the same granular data for combat casualty care and disaster management in military orthopaedics. The success of the MOTR implementation is a shining example of the AAOS contribution to military orthopaedics through EWI.

Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Maj Jessica C. Rivera, MD, is the associate custodian for MOTR; LtCol (Ret) Renee M. Greer is the MOTR supervisor; Joseph C. Wenke, PhD, is the extremity trauma and regenerative medicine program manager at the USAISR; Col. (Ret) James R. Ficke, MD, is the immediate past chairman of the department of orthopaedics and rehabilitation (DOR) at the San Antonio Military Medical Center (SAMMC); and Lt. Col. Anthony E. Johnson, MD, is the custodian of MOTR and the current chair of the DOR, SAMMC.

Bottom Line

• Data from the Department of Defense Trauma Registry (DoDTR) have been used to develop clinical practice guidelines (CPGs)—including some orthopaedic-related guidelines—for general surgeons serving in frontline positions.
• As a result of the Extremity War Injuries (EWI) symposia, the need for an orthopaedic-focused military trauma registry with more granular data was identified.
• The Military Orthopaedic Trauma Registry (MOTR) is designed to provide the in-depth data necessary for developing orthopaedic-specific CPGs.

Coming soon: EWI X
The AAOS/OTA/SOMOS/ORS Extremity War Injuries (EWI) X: Return to Health and Function will be held Jan. 26–28, 2015, at the Mandarin Oriental Hotel in Washington, D.C. For the first time, the symposium will be open to all interested researchers. Watch AAOS Headline News Now for the call for abstracts; for more information on the EWI symposia, visit www.aaos.org/ewi

References:

1. Cross JD, Wenke JC, Ficke JR, Johnson AE: Data-driven disaster management requires data: Implementation of a military orthopaedic trauma registry. J Surg Orthop Adv 2011;20(1):56-61.
2. Eastridge BJ, Costanzo G, Jenkins D,et al: Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am J Surg 2009;198(6):852-857.
3. Perkins JG, Brosch LR, Beekley AC, Warfield KL, Wade CE, Holcomb JB: Research and analytics in combat trauma care: Converting data and experience to practical guidelines. Surg Clin North Am 2012;92(4):1041-1054.
4. Rivera JC, Johnson AE: “Military Orthopaedic Trauma Registry: Quality Data Now Available.” Podium presentation Military Health System Research Symposium, Fort Lauderdale, FL. August 2014.

Additional Information:

• Military clinical practice guidelines
• U.S. Army Institute of Surgical Research Joint Trauma System