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AAOS Now

Published 2/1/2015
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Jennie McKee

EWI: A Decade of Groundbreaking Combat Injury Research

Symposium series has advanced treatment strategies for extremity war injuries

American military surgeons faced major challenges in treating severe extremity injuries resulting from improvised explosive devices and other trauma during conflicts in Iraq and Afghanistan. Surgeons lacked a forum for collaborating with one another and with civilian trauma surgeons regarding best practices for caring for vascular injuries, infections, and other devastating problems not seen since the Viet Nam War.

That much-needed forum was established in 2006, with the first Extremity War Injuries (EWI) research symposium, sponsored by the AAOS, the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, and the Orthopaedic Research Society. Participants began working to establish and prioritize research directions and to obtain much needed research funding. They’ve been extraordinarily successful; since that initial symposium, more than $300 million has been allocated for studies on extremity combat injuries sustained by active-duty military personnel.

AAOS Now recently spoke with Andrew N. Pollak, MD, and COL Romney C. Andersen, MD, about how EWI and other efforts have far contributed to increasing the knowledge base on the treatment of severe extremity injuries. Dr. Pollak served as the EWI symposium inaugural co-chair and was the first project team chair; Dr. Andersen is the EWI symposium immediate past chair and scientific director of the 2015 program.

AAOS Now: Why was there such a great need for this symposium?

Dr. Andersen: It started in about 2003, when the first casualties were coming back from Afghanistan, and later on, from Iraq. We were seeing injuries that we had just never seen before. Some of these types of injuries had been treated at Level One trauma centers around the country, but only on a one- or two-case basis, rather than on a large scale.

Dr. Pollak: And there was no forum then to address the challenges facing military orthopaedists. So military medical personnel didn’t have the opportunity to share their experiences with treating extremity combat injuries, except very informally. We had to create the opportunity for surgeons to come together and discuss the clinical challenges so they could learn from one another.

In addition, we recognized that additional research was needed to develop the evidence-based principles for delivering care in the future. That required funding, and there was essentially no funding then. We wanted to bring together military orthopaedic surgeons so they could tell their stories, not just for one another, but for members of Congress and congressional staffers. We invited members of Congress to come to the symposium to hear what was being discussed so they could understand the challenges these injuries posed to military orthopaedic surgeons—and, more importantly, to the men and women who were in combat at the time.

Finally, to build a functional research program, we needed to understand what we knew from the civilian world and where the gaps in knowledge were. We needed to prioritize that list so that we knew where to begin in terms of research. This was very effective because the list we developed, which was published in a special issue of the Journal of the AAOS, was subsequently used by the Department of Defense (DOD) to assist in determining how best to spend the initial dollars Congress appropriated for research.

AAOS Now: What have been some of EWI’s most significant contributions in helping advance the treatment of extremity war injuries?

Dr. Andersen: We recognized that individual investigators doing many small studies would not get us to the “finish line,” per se. No one institution treated enough of these extreme injuries on a regular basis to do a large study until researchers at the Institute of Surgical Research in San Antonio, Texas, proposed a large consortium grant. This led to the creation of the Major Extremity Trauma Research Consortium (METRC). The consortium collects data on severe extremity injuries from civilian trauma centers, military treatment facilities, and satellite centers around the country. METRC has numerous studies underway to learn more about these injuries and their treatment. We’re getting close to obtaining some answers.

Dr. Pollak: A great deal of important research has come out of EWI. Some of the most important long-term work has come from METRC, which currently has about a dozen prospective trials underway funded by the DOD. METRC is the largest and most organized effort ever in orthopaedic trauma research. This kind of consortium makes it possible to develop valuable information that can lead to significant results.

AAOS Now: How has the EWI changed over the years?

Dr. Pollak: In the beginning, we didn’t have much experience with treating these types of injuries in the context of the modern capacity to deliver medical care. So, it was especially important to get the perspective of international experts from countries such as Israel that had more recent combat experience. In addition, we collaborated with medical experts from many different countries, including Australia and Canada, that had military personnel involved in the invasion of Iraq.

Throughout the years, we’ve tried to cover a wide range of challenges military orthopaedic surgeons and injured soldiers face, such as amputee care, antibiotics and infection, segmental bone defects, and stabilization of long bones. EWI has also included discussions of topics such as spinal injuries and tissue engineering.

Dr. Andersen: Early on, we saw a great deal of infection and heterotopic ossification in patients. We have gained a lot of knowledge about which parameters indicate whether an infection is cleared or is still present. Several clinical studies are ongoing in the areas of infection and heterotopic ossification, and we are starting to get some answers.

As the war has been winding down, disability has become an important issue. So, at the 2015 EWI Symposium, we focused on the disabilities associated with certain injuries, and what can be done to mitigate those disabilities. Most soldiers who are non-deployable—meaning not able to continue functioning in their roles—have not sustained a combat injury. Instead, they may have had a routine spine injury, knee injury, or routine upper extremity injury, for instance, that keeps them from deploying and being an effective member of the military. The cumulative effect of disability probably has a bigger impact on military readiness than the number individuals who have lost limbs or sustained other major injuries.

AAOS Now: Any final thoughts on EWI and how it has helped advance orthopaedic research?

Dr. Pollak: The research funded by Congress as a result of the efforts of the AAOS and other organizations has been groundbreaking in terms of the structures that have been set up to conduct effective clinical research. This simply would not have happened without the AAOS.

Secondly, there will unfortunately be a time in the future when our troops are again called to action. Because of that, we need to remain vigilant about understanding how to care for these injuries. Certain civilian injuries are analogous to these war injuries. We must continue to fund research studies in civilian centers so we’re as prepared as possible the next time we send men and women into harm’s way.

Dr. Andersen: Someone once said that the only good things that come from war are medical advances. We have learned so much, thanks to the research funding we have received. The translation of these efforts from the military to the civilian sector will make it possible to help all patients—not just trauma patients—who have disabilities from routine injuries. I think that’s going to be the biggest long-term benefit of the EWI Symposium.

For more information on EWI, visit www.aaos.org/ewi ; for information on METRC, visit http://metrc.org

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org