Since United States service members initially began direct combat in 2001, more than 30,000 service personnel have been injured, and as many as 82% of these have had at least one extremity injury.1 The burden of these injuries is enormous, and evidence has been published demonstrating a substantial allocation of resources for patient care. In fact, of a subset of severely battle-injured patients earlier in the conflict, 464 of 1,566 were no longer able to continue active service, and four of the five most common unfitting conditions involved extremity injury.2
The initial Extremity War Injuries (EWI) symposium, held in 2006, captured current understanding of care of the combat-injured service personnel and identified gaps in evidence-based treatment. Over the past 4 years, the EWI symposia have charted progress and promoted understanding of the full spectrum of care, from acute care and resuscitation through the evacuation and patient transport system and, finally, the definitive treatment of severe limb injuries and amputation.3–6 The conferences have included focused sessions on national care practices and challenges as well as on the collaboration of military and government treatment organizations with civilians in disaster planning, readiness, and education. The inclusion of senior military leadership in the EWI efforts has directly and significantly affected the research funding process for the substantial war-related extremity trauma injury burden.
EWI V, “Barriers to Return of Function and Duty,” was held January 2729, 2010, in Washington, DC. The symposium convened experts in clinical and research domains relative to the improvement of care for wounded service personnel and identified progress gaps in the management and diagnosis of chronic infection, perceived performance differences in limb salvage versus amputation of the lower limbs, and functional outcomes of severe upper extremity trauma. This supplement to the Journal of the AAOS is intended to provide an overview of the progress made during the symposium and to emphasize research advancements since the first supplement was published 5 years ago. The contributing authors have chronicled the contributions of the speakers for particular sessions, reviewed the available literature, and identified significant scientific progress.
Management and Diagnosis of Chronic Infection
A panel of national experts illustrated contemporary evidence-based management of the spectrum of extremity infections resulting from severe trauma. These topics included acute treatment, current antibiotic strategies, soft-tissue coverage, and chronic posttraumatic osteomyelitis. One of the greatest barriers to return to function is development of chronic osteomyelitis. Prevention, through early and aggressive wound excision, skeletal stabilization, and timely wound coverage, remains the primary focus in early management. Advances in techniques of free-tissue transfer and wound-management adjuvant treatments may have significant long-term improvements.7 Current infectious disease strategies directed at multidrug-resistant organisms, including Klebsiella, Pseudomonas, Escherichia coli, and methicillin-resistant Staphylococcus aureus; infection control measures, including universal and contact precautions; and surgical débridements were discussed.
Perceived Performance Differences: Limb Salvage Versus Amputation in the Lower Extremity
Will limb salvage surgery or amputation result in the higher level of function? This is one of the most hotly debated and frequently discussed topics for patients with severely traumatized lower extremities. Much of this debate arises from the observation that neither method results in consistently high levels of performance. There is scant evidence in the literature to guide patients, surgeons, and rehabilitation experts toward a strong recommendation. This session identified the most common challenges facing definitive treatment and issues frequently encountered with late amputation. These areas, including posttraumatic osteoarthritis, volumetric muscle loss, chronic pain, and major nerve injuries, are also among the primary focus areas of the Armed Forces Institute of Regenerative Medicine (AFIRM). Current approaches to limb salvage rehabilitation include early return to impact exercises and interdisciplinary athletic training approaches, while the physical loss of soft tissue—muscles, nerves, and periarticular structures —is a tremendous impediment to function. Participants identified posttraumatic arthritis and volumetric muscle loss as having the highest impact and being the least understood and least correctable conditions resulting in impaired function.
Enhancing Function in Severe Upper Extremity Trauma
Although the vast majority of amputations involve loss of the lower extremity, the prevalence of severe upper extremity trauma is quite high in armed conflict. Limb salvage for the upper extremity is equally important, given the current state of science with upper extremity prostheses. One of the most notable areas of progress in the past decade has been the treatment of complex elbow trauma. Standard plating in traditional orthogonal fixation techniques has progressed to the gradual adoption of preformed plates and parallel plating. More aggressive internal fixation for fractures includes glenoid and clavicle fractures about the shoulder as well as coronoid fractures at the elbow.8 Heterotopic ossification (HO) is one frequent complication for injuries of the shoulder and elbow. Recurrence of HO is common after resection and excision, and future research is needed to elucidate the pathway and strategies for identifying persons at risk, as well as prevention. Additional critical areas impeding return to function in the upper extremity include nerve injuries. Surgery to include neurolysis, direct repair, and graft reconstruction has shown significant functional improvements. Upper extremity surgery involving the musculocutaneous nerve has the highest rate of functional recovery, followed by the radial, median, and ulnar nerves. Principles of surgery emphasize skeletal stabilization and a healed, soft, noninflamed operative field before definitive surgery. Additional work on nerve recovery is currently in progress with AFIRM. This session also included a discussion of the stiff and contracted hand and the importance of teamwork with the occupational therapist.
Currently, more than 200 service personnel have sustained limb loss of the upper extremity as a result of combat injuries sustained while serving in Iraq and Afghanistan. Upper extremity amputation results in the highest impairment of all extremity war injuries. Although advances in limb prosthetic technology and rehabilitation have been tremendous, reconstructive transplantation is an alternative option in select patients who will not benefit from or who refuse existing prosthetic technologies. During the past decade, more than 50 hand transplants have been performed worldwide, with encouraging functional and graft survival results. This procedure requires lifelong immunosuppression with some reported adverse effects, including diabetes mellitus, nephrotoxicity, bilateral hip osteonecrosis, hypertension, hyperlipidemia, mycosis, osteomyelitis, herpes simplex, molluscum contagiosum, and cytomegalovirus infection.9
Recent immunomodulatory approaches that address solid-organ transplants have enabled significant reduction of overall drug treatment. Clinicians and scientists working with AFIRM provided state-of-the-science updates on current protocols in clinical trials for hand and face transplants. Hand transplantation for catastrophic combat trauma is an innovative reconstructive strategy that offers independence and, most importantly, hand sensibility for recipients.
The Armed Forces Institute of Regenerative Medicine: Program Status and Current Projects
In 2008, the US Department of Defense, through the US Army Medical Research and Materiel Command (USAMRMC), established AFIRM. AFIRM includes two large academic clinical consortia that include more than 30 institutions and the US Army Institute of Surgical Research. One consortium is led by Rutgers University and the Cleveland Clinic. The other is led by Wake Forest University and the University of Pittsburgh. The mission of AFIRM is to develop new products and therapies to treat severe injuries suffered by US service members. AFIRM was founded with the commitment to focus on technologies and approaches having high levels of potential impact and relatively short timelines for implementation into clinical practice or clinical trials—with 1 to 5 years.10 AFIRM is also committed to a culture of collaboration between clinicians and scientists that inspires and facilitates accelerated development and competitive assessment. The areas of highest priority include limb salvage, with repairs of defects in bone, nerve, major blood vessels, muscle, and tendon; facial reconstruction; burn repair; scarless wound repair; and compartment syndrome sequelae. Several articles highlighting research progress are included in this supplement.
The Orthopaedic Extremity Trauma Research Program and Peer-Reviewed Orthopaedic Research Program
One of the most significant impacts of this EWI symposium series has been the identification and articulation of significant gaps in understanding of severe extremity trauma. In the initial symposium, 10 focus areas were identified that comprised these most significant gaps. These areas became the rallying point for what has become the most significant congressional orthopaedics research funding in history. Since 2006, the US Congress has appropriated $188 million for militaryrelevant orthopaedic research.11 Investigators have focused on improving care at the point of injury; definitive care of battle injuries or similar severe civilian trauma; rehabilitation following amputation or limb-threatening injuries; and prosthetics and orthoses development to improve the function of amputees as well as limb-salvage patients. This research has been directed and managed through two major research programs: the Orthopaedic Extremity Trauma Research Program (OETRP) and the Peer Reviewed Orthopaedic Research Program (PRORP). Most recently, the PRORP awarded funding for a large clinical consortium to examine the greatest treatment challenges from the most severe extremity injuries. The Major Extremity Trauma Research Consortium comprises 24 civilian trauma centers across the nation and 4 military treatment facilities within the Department of Defense and constitutes the largest such cooperative effort in orthopaedic trauma.
Partnered Disaster Preparedness: Lessons Learned From International Events
During the past two EWI symposia, sessions were dedicated to identification of opportunities for collaboration and cooperation between civilian disaster response entities and the Department of Defense. These have included discussions by experts from the US Northern Command (NORTHCOM), the National Disaster Medical System (NDMS), and civilians involved in education, training, credentialing, and internal response. This session highlighted lessons learned from the tsunami in Indonesia in December 2004; the US Army response to the Pakistani earthquake in October 2005; and the overall response to Hurricane Katrina in August 2005. The large earthquake that struck the nation of Haiti on January 12, 2010, just 2 weeks before the symposium, played a critical role in the attendance as well as in the discussion during this session. One of the highlights of this session included a live audio conference with surgeons aboard the US Naval Ship Comfort, providing care for Haitian victims.
As a result of this session, the American Academy of Orthopaedic Surgeons (AAOS) identified the need and established a formal project team to develop an action plan for future physician disaster relief credentialing, consistent training, and development of a volunteer database of surgeons wishing to participate in disaster responses.
Critical Areas of Focus for Future Progress
US service members have been serving in the conflicts in Iraq and Afghanistan for the past 9 years. During this time, more than 30,000 service personnel have been injured in battle, and as many as 82% have sustained extremity injuries. Nearly 1,200 have lost at least one limb. Several thousand more have sustained limb-threatening, lifelong disabling injuries. This burden has been the driving force for the five EWI symposia that have been sponsored by the AAOS, the Orthopaedic Trauma Association (OTA), the Society of Military Orthopaedic Surgeons (SOMOS), and the Orthopaedic Research Society (ORS). These sessions have identified areas for increased cooperation between scientists and clinicians and between civilians and the military. They have also highlighted progress made and successes. Considerable room remains for further progress. Although these sessions have focused on acute care, definitive management, and disaster response, injuries involving the spine and rehabilitation to improve outcomes are areas that may benefit significantly with focus of future sessions. Clinical trials and the development of large cooperative consortia are encouraging for highly powered, prospective investigation. The AFIRM and METRC groups are advancing our understanding of these debilitating injuries. Additionally, efforts in posttraumatic osteoarthritis, soft-tissue loss, and prevention of complications will be critical lines of effort for improving outcomes of extremity war injuries.
Acknowledgment of Contributors
It has been a privilege to organize and work closely with all who made this symposium possible. The unique cooperation between government, military, and civilian experts speaks to their commitment toward improving outcomes of extremity trauma. We want to acknowledge the speakers for this symposium and thank the leadership from the AAOS, OTA, SOMOS, and ORS, and the Department of Defense:
LTC Romney Andersen, MD; Steven Badylak, PhD; LTC Fred Baechler, MD; Christopher Born, MD; Andrew Burgess, MD; Jason Calhoun, MD; George Cierney III, MD; CAPT Dana Covey, MD; CPT Jessica Cross, MD; RADM Thomas Cullison, MD; Alan Davis, PhD; LTC Jeffrey Dean, MD; LCDR Jonathan Forsberg, MD; MAJ Brandon Goff, DO; Scott Guelcher, PhD; Ranjan Gupta, MD; COL Dallas Hack, MD; Warren Haggard, PhD; COL (ret) Roman Hayda, MD (from Haiti); LTC Joseph Hsu, MD; COL (ret) Jack Ingari, MD; Adam Katz, MD; CDR John Keeling, MD; W. P. Andrew Lee, MD; L. Scott Levin, MD; Ellen MacKenzie, PhD; Norman McSwain, MD; Erika Mitchell, MD; LTC Clinton Murray, MD; George Muschler, MD; Andrew Pollak, MD; MAJ Benjamin Kyle Potter, MD; COL Lawrence Riddles, MD; COL Damian Rispoli, MD; LTC Scott Shawen, MD; Al Shimkus, MD; Maria Siemionow, MD, PhD; Scott Steinman, MD; Elizabeth Sump; Marc Swiontkowski, MD; Huan Wang, MD, PhD; Lawrence Webb, MD; and Joseph Wenke, PhD.
The AAOS, OTA, SOMOS, and ORS acknowledge the following industry contributors and their representatives for financial support of the EWI V symposium:
- Kinetic Concepts, Inc. (Gold Level)
- Smith & Nephew (Gold Level)
- DePuy (Silver Level)
- Medtronic Spinal and Biologics (Silver Level)
- Stryker (Silver Level)
- Synthes Trauma (Silver Level)
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2. Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC: Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg
3. Ficke JR, Pollak AN: Extremity war injuries: Development of clinical treatment principles. J Am Acad Orthop Surg
4. Pollak AN, Calhoun JH: Extremity war injuries: State of the art and future directions. Prioritized future research objectives. J Am Acad Orthop Surg
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5. Pollak AN, Ficke JR; Extremity War Injuries III Session Moderators: Extremity war injuries: Challenges in definitive reconstruction. J Am Acad Orthop Surg
6. Pollak AN, Ficke CJ; Extremity War Injuries IV Session Moderators: Extremity war injuries: Collaborative efforts in research, host nation care, and disaster preparedness. J Am Acad Orthop Surg
7. Murray CK, Hsu JR, Solomkin JS, et al: Prevention and management of infections associated with combat-related extremity injuries. J Trauma
8. Steinmann S: Posttraumatic joint reconstruction of the shoulder and elbow. Presented at Extremity War Injuries V: Barriers to Return of Function and Duty, Washington, DC, January 27-29, 2010.
9. Lee WP, Gorantla V: Long-term complications of hand transplant. Presented at Extremity War Injuries V: Barriers to Return of Function and Duty, Washington, DC, January 27-29, 2010.
10. Muschler G, Yaszemski M: Armed Forces Institute of Regenerative Medicine. Presented at Extremity War Injuries V: Barriers to Return of Function and Duty, Washington, DC, January 27-29, 2010.
11. Hack D: Orthopaedic Extremity Trauma Research Program: Program status and research projects. Presented at Extremity War Injuries V: Barriers to Return of Function and Duty, Washington, DC, January 27-29, 2010.