Military surgeons launch a multicenter clinical outcomes reporting network
In the past decade, efforts to establish nationwide databases to collect "big data" for orthopaedic research have exploded. Goals include learning more about the burden of musculoskeletal disease, improving clinical outcomes, and enhancing efficiencies in the delivery of care. The successes of the Multicenter Orthopaedic Outcomes Network (MOON) and the Multicenter Anterior Cruciate Ligament Revision Study (MARS) demonstrate the power of information pooled from the experiences of multiple surgeons and outcomes from thousands of patients. Military orthopaedic surgeons have followed suit with the recent launch of the Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION.)

Establishing MOTION
MOTION's story begins with the creation of the Society of Military Orthopaedic Surgeons (SOMOS) Collaborative Network in 2003 by John M. Tokish, MD, and other military surgeons. This network was one of the first organized attempts to collect outcomes data on patients treated in the Military Health System (MHS)—a historically difficult proposition given the migratory nature of a military patient population due to routine changes of station and overseas deployments.

Along with Dr. Tokish, Brett A. Freedman, MD, Brett D. Owens, MD, B. Kyle Potter, MD, Matthew T. Provencher, MD, John-Paul H. Rue, MD, and Steven J. Svoboda, MD, worked to prospectively collect data from military treatment facilities (MTFs) of the U.S. Air Force Academy, the U.S. Naval Academy, and other MTFs. This group achieved several notable successes in pooling their resources to publish compelling data on concussions and return-to-play rates after shoulder instability episodes among military academy cadets. However, the establishment of a unified apparatus remained elusive, due in large part to inconsistent funding mechanisms and Department of Defense (DOD) regulations governing the adoption of a centralized, electronic data-sharing platform. Consequently, the creation of a streamlined, triservice collaboration was challenged by limited resources and multiple chains of command. Military surgeons were left to make the most of smaller subsets of siloed data to understand epidemiologic trends and improve clinical care, until Jonathan F. Dickens, MD, took on the role of MOTION principal investigator. Dr. Dickens adroitly advocated for a DOD-wide, prospective outcomes collection apparatus in the context of the massive burden of musculoskeletal disease on the MHS.

The impact of combat-related musculoskeletal injuries among service members related to global ongoing contingency operations is well established. These injuries represent the number one cause for medical evacuations. Dr. Dickens placed a special emphasis on the effect of musculoskeletal disease and non-battle injury (DNBI) on the MHS. As noted by Dr. Dickens, the Department of Veterans Affairs pays in excess of $5.5 billion annually for musculoskeletal-related conditions. Among 800,000 active- duty members, more than two million outpatient clinic visits per year are related to DNBI, with the total direct and indirect costs of care exceeding $3.7 billion annually. Perhaps most striking is the effect on military medical readiness, with DNBI accounting for 25 million days of limited duty days annually among service members. Dr. Dickens believes that an enhanced awareness for these realities has been a key driver in marshaling the resources needed to get MOTION off of the ground. 

Collecting data
Recently, several new funding sources have enabled the implementation of a unified, enterprise electronic system capable of collecting data prospectively at multiple MTFs. Peer-reviewed, institutional grants as well as support from the Congressionally Directed Medical Research Program (CDMRP) have resulted in an infusion of more than $2 million into MOTION's budget. These resources have been used to help streamline the installation of a viable, electronic data collection platform and the hiring of site coordinators to oversee MOTION's implementation at a variety of MTFs across the country.

Dr. Dickens points to the confluence of several important variables—including upgraded information technology, new funding sources, and a servicewide emphasis on enhancing medical readiness—that created a climate favorable to MOTION's launch.

"Military orthopaedics and the MOTION collaborative are uniquely positioned to provide important answers to the musculoskeletal injuries that plague our young, high-demand patient population," said Dr. Dickens. "This quality improvement and research effort will enable a pivot forward in the clinical practice model to one that prioritizes patient-reported outcomes in the evolution of best clinical practices. This data-driven approach will provide the foundation to enhance return to duty, return to sport, and military medical readiness that will benefit both the military and the larger orthopaedic community."

Looking forward
Currently, MOTION has "gone live" at five DOD MTFs (United States Military Academy, United States Naval Academy, Walter Reed National Military Medical Center, William Beaumont Army Medical Center, and Tripler Army Medical Center) with imminent participation anticipated at the San Antonio Military Medical Center, United States Air Force Academy, Womack Army Medical Center, Naval Medical Center San Diego, and Madigan Army Medical Center. Additionally, multiple initiatives are underway to expand MOTION to smaller DOD MTFs across the country. More than 12,000 patients have already been added to the MOTION database. Dr. Dickens and his co-principal investigators have focused preliminary study efforts on anterior cruciate ligament reconstruction and shoulder instability, but plan to expand data collection related to involving hip arthroscopy and meniscal repair outcomes.

The implications of MOTION are exciting and far-reaching, as military surgeons finally have the tools necessary to study a variety of musculoskeletal conditions among a large, active patient population. Harnessing the power of large volumes of high-quality, prospectively collected clinical data, MOTION investigators aim to enhance patient care, optimize military medical readiness, and catalyze collaboration with civilian surgeons for decades to come. Kudos to the "coalition of the willing," so to speak, for their vision and to an emerging generation of military surgeons for seeing that vision through.

Andrew J. Sheean, MD, is an orthopaedic surgery chief resident at the San Antonio Military Medical Center, and is a member of the AAOS Now Editorial Board. He can be reached at ajsheean@gmail.com

Matthew R. Schmitz, MD, is a staff orthopaedic surgeon, director of Young Adult Hip Preservation, and MOTION site principal investigator at the San Antonio Military Medical Center. He can be reached at mattrschmitz@gmail.com