EWI XI Symposium explores progress made, challenges of maintaining force readiness
During the last 15 years, while our U.S. Armed Forces have fought in very remote, austere, and hostile environments, combat casualty care as practiced by U.S. Coalition Forces has reached a new pinnacle of success," said Andrew Schmidt, MD, chief of the Department of Orthopedic Surgery at Hennepin County Medical Center in Minneapolis and cochair of the eleventh annual Extremity War Injuries (EWI) Symposium. "In recent years, a soldier injured in the most remote areas of Afghanistan had a greater than 90 percent chance of surviving, a survival rate that is higher than in some of our own cities here at home," he said

As troop levels in Iraq and Afghanistan have decreased, the need for maintaining force readiness during an era of military transition has come to the fore. This year's EWI Symposium, held in conjunction with the AAOS, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons, and Orthopaedic Research Society, explored the latest in combat casualty research, streamlining combat casualty care, and preventing obstacles to returning to function.

The EWI XI Symposium was part of an annual series of symposia promoting the collaboration of military and civilian orthopaedic surgeons and researchers to advance the care of the wounded warrior.

Advocating for research
After Dr. Schmidt provided an overview of the significance of the EWI symposium, cochair Col. Jeffrey Davila, MD, Orthopaedic Surgery Consultant for the National Capitol Region and the senior sports surgeon at the Walter Reed National Military Medical Center, introduced Gen. Frederick M. Franks, Jr. (Ret.). Gen. Franks served in the Vietnam War and Gulf War, earning two Purple Hearts and four awards for valor. He was promoted to four star general in 1991 and worked with the Wounded Warriors program and the Amputee Advisory Board after his retirement from active duty in 1994.

Gen. Franks called for our nation to continue to support those who have been wounded in service to the country. The major challenge today, he said, is continuing to sustain and advance the world class extremity war injury care even as casualty rates drop and direct combat actions diminish. He also suggested that orthopaedic surgeons need to ensure that a combination of theory, research, and practice is sustained, and he indicated that Congress has been a great ally in this effort.

Rep. C.A. Dutch Ruppersberger (D-MD) spoke on the work being done in Washington, D.C. to advance orthopaedic care of wounded soldiers. Rep. Ruppersberger currently serves on the House Intelligence Committee and previously served on Appropriations and Government Reform Committees. The congressman has worked with AAOS to garner support for the Department of Defense Peer Reviewed Orthopaedic Research Program (PRORP), established by Congress in fiscal year (FY) 2009 to support military-relevant, peer-reviewed orthopaedic research.

In a letter to Congress, then-AAOS President David D. Teuscher, MD, wrote that more than 80 percent of injuries from the Global War on Terror involve the extremities. These injuries are often severe and include multiple injuries to the arms and legs.

"The Peer Reviewed Orthopaedic Research Program, operated by the U.S. Army Medical Research and Material Command, was established to quickly develop focused, basic and clinical research," he wrote. "The goal is to help military surgeons find new limb-sparing techniques, avoid amputations, and preserve and restore the function of injured extremities."

Current research and outcomes
In addition to PRORP, a number of research programs were discussed, including the Armed Forces Institute of Regenerative Medicine (AFIRM), which was established in 2008 with the mission of developing new products and therapies to treat severe injuries sustained by U.S. service members. New funding was recently awarded to the program to continue accelerating the delivery of regenerative medicine therapies. AFIRM has continued to advance technologies at both civilian and military treatment facilities.

The Bridging Advanced Developments for Exceptional Rehabilitation (BADER) Consortium, which was formed as a result of an award from PRORP, seeks to create a partnership among military, government, academia, and industry to rapidly conduct innovative, high-impact, clinically relevant research. The BADER Consortium's research initiative cycle has directly supported the identification and establishment of eight clinical studies that have a net planned enrollment of more than 1,400 subjects.

The Major Extremity Trauma Research Consortium, established in 2009 to produce evidence for establishing treatment guidelines for the optimal care of the wounded warrior, is currently funded to conduct 18 prospective studies in several core research areas, including bone defect reconstruction and measurement of orthopaedic trauma outcomes.

The Performance Optimization Warrior-Enhanced Rehabilitation (POWER) initiative recognizes that although some service members may be physically ready to return to duty, they may not yet have recovered psychologically. MAJ Daniel Stinner, MD, medical director for the Center for the Intrepid and the EWI scientific director, explained how the POWER program focuses on human optimization through cognitive, nutritional, and fitness enhancements.

EWI symposium participants also discussed the activities of the Center for Rehabilitation Sciences Research, which was established to advance rehabilitative care of service members with combat-related injuries. They also noted that PRORP funds research in a number of different focus areas aimed at improving the health of the fighting force.

Advancing casualty care
One of the largest healthcare dilemmas facing the U.S. Armed Services today is musculoskeletal injury. Although the state of combat casualty care has greatly advanced, saving untold numbers of lives, many opportunities for innovation still exist. In an effort to pursue some of those opportunities, civilian and military surgeons and researchers participated in small group discussions during the symposium, identifying knowledge gaps and developing recommendations for improving military training and outcomes in the continuum of care via methods such as collecting patient-reported outcomes. They also explored the need for a common electronic medical records system to facilitate transitions of care and discussed recommendations for leveraging cross-disciplinary research consortia to enhance collaboration and data sharing. Clinical knowledge gaps involving amputation and prosthetics, compartment syndrome, injectable therapies for healing tissue injuries, and protocols for upper extremity injury prevention were also addressed.

Recommendations will be submitted to the U.S. Department of Defense's Congressionally Directed Medical Research Programs for consideration of future funding requests. The EWI XI proceedings article will be published in a future issue of the Journal of the AAOS. For additional information about EWI, visit www.aaos.org/ewi

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

More about PRORP
Thirty million dollars for PRORP was included in the FY 2016 appropriations bill, with congressional appropriations totaling $278.5 million since 2009. The AAOS office of government relations is already undertaking actions to continue funding in 2017. For more information and to get involved, visit http://www.aaos.org/Advocacy/ResearchAppropriations/