AAOS Bulletin - April, 2006

Beyond the battlefield

“Extremity War Injuries: State of the art and future directions” brings combat injury research to the forefront

By Andrew N. Pollak, MD, & Jason H. Calhoun, MD

Surgeons in a mobile operating tent stabilize an injured soldier before he is transferred stateside for more complete care

In the first joint effort between military and civilian orthopaedic surgeons, the AAOS and the Orthopaedic Trauma Association (OTA) hosted a groundbreaking symposium on managing extremity trauma Jan. 24-27, 2006, in Washington, D.C. The research symposium, “Extremity War Injuries: State of the Art and Future Directions” (EWI), drew more than 100 participants and addressed wound management, antibiotics and infection, stabilization of long bones, management of segmental bone defects and amputee care. A follow-up symposium was held during the 2006 Annual Meeting.


During the 2005 Annual Meeting, members of the AAOS Board of Directors toured Walter Reed Army Medical Center (WRAMC). Our host—Lt. Col. Daniel W. White, MD, MC—and then-incoming AAOS President, Stuart L. Weinstein, MD, realized the benefits that could result from a joint effort between the Academy and the military regarding combat injuries.

According to Dr. White, “In the war on terrorism, the military health care system has performed exceptionally, resulting in the lowest died-of-wounds rate in history. Despite the delivery of exceptional medical care, we are still struggling with infections, bone and soft-tissue healing, and rehabilitation of these injured soldiers. The scope of research required to solve all battlefield-related orthopaedic challenges far exceeds the abilities of a single organization, such as the U.S. Army Institute of Surgical Research.”

Dr. White recommended a coordinated effort spanning the full range of orthopaedic trauma care, infection, and bone and soft-tissue regenerative research. “The benefits of this research will have an impact far beyond the battlefield to improve the orthopaedic care of all patients,” he added.

A nurse at WRAMC demonstrates a prosthetic arm currently being developed

The EWI symposium was initiated under a special directive from the AAOS Board of Directors. We were honored to be asked to co-chair this important program.

Improved treatments, but more severe injuries

Improvements in body armor and armored vehicles, intense training of U.S. military personnel and advances in medical care have given wounded soldiers a better-than-ever chance of survival. According to the U.S. Department of Defense’s Directorate for Information Operations and Reports, the likelihood of surviving battlefield wounds was 69.7 percent during World War II, but had risen to 76.4 percent by the end of the Vietnam War. Today, the likelihood of survival of those wounded in the current Iraq War has increased to an astounding 90.4 percent.

Approximately 70 percent of war wounds involve the musculoskeletal system. Providing the best possible orthopaedic care for injured soldiers is thus imperative. Military orthopaedic surgeons are playing an increasingly pivotal role in treating combat casualties in Iraq and Afghanistan.

Because a growing number of service men and women are surviving and needing treatment, even civilian orthopaedists are seeing more unique, severe injuries. These injuries affect our soldiers every day and orthopaedists need to assist in advancing potential orthopaedic research to benefit them as soon as possible.

Key findings

The EWI symposium addressed broad areas of common combat-related clinical problems. Sessions featured panels of military and civilian experts and included international participants from Iraq, Israel, Canada, the United Kingdom, and Serbia and Montenegro. Experts explored all aspects of medical care to understand where more research is needed to define ways to fight infection, manage wounds, treat severe fractures and improve amputee care.

(Left, left to right) George Cierny III, MD, Jason H. Calhoun, MD, and Paul Holtom, MD, participate in a panel discussion on antibiotics and infections

“It is important to continually examine the types of wounds and infections military orthopaedic surgeons are treating so we can direct research toward helping them provide our troops with the most timely, effective care possible,” said Dr. Weinstein.

The primary goal of the EWI symposium was to prioritize future military orthopaedic trauma research topics and determine the next steps to understand more about extremity war injuries. Key findings included:

• A team approach is crucial to amputee care.

• New antibiotics may be valuable in fighting severe infections in Iraq’s unique environment.

• Additional research is needed to learn how to treat major bone loss in blast injuries and to learn effective debridement techniques that can be used in austere environments.

In addition to sessions on wound management, antibiotics and infection, stabilization of long bones, management of segmental bone defects, and amputee care, breakout groups discussed issues such as timing and technique of debridement, prophylaxis regimens, new technologies and prosthetic development.

Additional activities

Several legislators were invited to address the symposium participants, and two senators—Sen. Ted Stevens (R-Alaska), chairman of the U.S. Senate Appropriations Defense Subcommittee, and Sen. Conrad Burns (R-Mont.), a member of the subcommittee—attended the opening reception. Both spoke of their strong commitment to funding trauma research and promised their future support.

The symposium also featured a site visit to WRAMC, hosted by Col. William C. Doukas, MD, MC, and several staff members, including Col. Richard A. Schaefer, MD; retired Col. Charles Scoville, M.Ed., MPT; Col. William Howard, SP, MSS, OTR/L CHT, and Lt. Col. Barbara Springer, SP, PT, PhD, OCS, SCS.

The extremity injuries seen at WRAMC from Operation Iraqi Freedom and Operation Enduring Freedom have been devastating. Symposium participants interacted with key WRAMC rehabilitation staff and patients to see how research has benefited amputees.

Fortunately, patients at WRAMC—particularly those in the amputee care program—have seen extraordinary advances in treatment. Today’s prosthetic technology has helped countless patients return to independent daily living. Amputees are now able to run marathons, go snowboarding and ski.

According to Dr. Doukas, “It was once again an honor to have a contingent from the AAOS visit our facility to witness our Amputee Patient Care Program. The success of this multidisciplinary endeavor results from the cooperation of many providers across the health care domain. We appreciate the interest that the Academy has shown in partnering with us to help provide state-of-the-art care to our wounded warriors through joint research initiatives, and we look forward to future collaboration on this very important issue.”

The fiscal year 2006 Defense Appropriations bill included approximately $7.5 million, specifically earmarked and requested by the AAOS, to develop the Orthopaedic Extremity Trauma Research Program at the U.S. Army Institute of Surgical Research (ISR) in Ft. Sam Houston, Texas.

AAOS worked closely with top military orthopaedic surgeons at the ISR, Brooke Army Medical Center and WRAMC to identify gaps in musculoskeletal trauma research and to use this information to advocate for an increased federal commitment to research on such trauma.

The ISR will be responsible for administering this program, which will fund intramural and extramural peer-reviewed orthopaedic trauma research. The AAOS Washington office is currently working with key contacts on Capitol Hill to secure continued funding for this program in the FY 2007 appropriations cycle.

Next steps

Based on the success of the EWI symposia in Washington and Chicago, the AAOS and OTA are prepared to move forward with additional trauma-related projects, including:

• Publication of symposium proceedings and a list of future research directions in an upcoming supplement to the Journal of the American Academy of Orthopaedic Surgeons (JAAOS)

• Dissemination of future research directions on Capitol Hill, in coordination with the AAOS Washington office

• Plans for a possible follow-up meeting in 2007

In advance of the JAAOS supplement, we hope you will stay tuned to the exciting arena of military orthopaedic research. The AAOS and OTA are embarking on an important and exciting mission; there is no greater reward than to assist our heroes—our soldiers with these devastating musculoskeletal injuries.

Andrew N. Pollack, MD, is chair of the Board of Specialty Societies (BOS/COMSS) and a member of the AAOS Board of Directors. He can be reached at apollak@uoma.umm.edu. Jason H. Calhoun, MD, is chair of the AAOS Infections Committee; he can be reached at calhounj@missouri.health.edu

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