Volume 20-1, Spring 2011

Care of the combat casualty with spinal column or spinal cord injury has not been previously described, particularly in regards to spinal immobilization. The ultimate goal of spinal immobilization in the combat casualty is to first ‘‘do no further harm’’ and then provide a stable, painless spine and an optimal neurologic recovery. The protocol for treatment of the combat casualty with suspected spinal column or spinal cord injury from the battlefield to final arrival at a definitive treatment center is discussed, and the special considerations for medical evacuation off the battlefield and for aeromedical transport are delineated. Selective prehospital spine immobilization, which involves spinal immobilization with backboard, semi-rigid cervical collar, lateral supports, and straps or tape, is recommended if there is suspicion of spinal column or spinal cord injury in the combat casualty and when conditions and resources permit. The authors do not recommend spinal immobilization for the combat casualty with isolated penetrating trauma. (Journal of Surgical Orthopaedic Advances 20(1):2–7, 2011)Key words: aeromedical evacuation, cervical spine, combat, immobilization, spinal cord injury, spine fracture, trauma

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population. (Journal of Surgical Orthopaedic Advances 20(1):8–18, 2011) Key words: carbon fiber ankle-foot orthosis, combat wounds, energy-storing ankle-foot orthosis, limb salvage

Throughout the current conflicts in Afghanistan and Iraq, there have been more than 1100 combatrelatedmajor limb amputations, with approximately 80% involving the lower extremity. There is, however, a paucity of data regarding the number of amputations below the level of the ankle. Although not as common, partial foot amputations, in the appropriate setting, offer a way to improve function and decrease energy consumption when compared to proximal amputations. Sound surgical tenets are prerequisite for successful outcomes when performing a distal amputation. Maintaining a robust soft tissue envelope allowing for tension-free wound closure is paramount in determining the feasibility of a partial foot amputation. Careful consideration of tendon balancing is also of utmost importance in avoiding common complications of contracture and deformity. Partial foot amputations present a viable surgical option for successful outcomes and maximization of patient function in the combat injured when certain criteria are met. (Journal of Surgical Orthopaedic Advances 20(1):19–22, 2011) Key words: amputation, foot trauma, partial foot, war trauma

Disasters, both man-made and natural, are a known cause of morbidity and mortality among vulnerable populations. The initial phase of public health response typically addresses immediate traumatic injury or death in the wake of a disaster. However, little is known about the magnitude and cost of subsequent nontraumatic injury and illness in disaster zones. Known as ‘‘the hidden epidemic,’’ the incidence and epidemiology of disease and nonbattle injuries among military service members in deployed settings has been more extensively investigated and may serve as a proxy for the evaluation of civilian populations following natural disaster. Further, prior reports from the military setting may serve to inform the broader population on the ultimate burden of nontraumatic injury and illness in recent disasters, particularly as they relate to musculoskeletal health. (Journal of Surgical Orthopaedic Advances 20(1):23–29, 2011) Key words: disaster, epidemiology, injury, military, musculoskeletal, nonbattle

Recent wartime contingencies have demanded frequent aeromedical evacuation of polytrauma patients, all with risk factors for the development of compartment syndrome. This study investigated the effect of altitude on the pressure in uninjured myofascial compartments of 10 pigs as part of a program with the ultimate goal of determining the behavior of an injured extremity in a changing altitude environment. The data showed a trend toward a small increase in pressure with increase in altitude — an average maximal delta of 2.7 mm Hg from the opening pressure. A small increase in compartment pressure, such as seen in this study, in a normal, uninjured compartment would likely go clinically unnoticed. However, aeromedical evacuation missions fly patients with fractures that can affect the physiology of compartments. Potentially, even a small change in pressure can lead to a compartment syndrome. Further study involving a fracture modelwill be required to further elucidate this clinical question. (Journal of Surgical Orthopaedic Advances 20(1):30–33, 2011) Key words: compartment syndrome, critical care aeromedical transport (CCAT)

This retrospective study investigated active duty soldiers with delayed definitive fixation of combatrelated talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis. (Journal of Surgical Orthopaedic Advances 20(1):34–37, 2011) Key words: delayed fixation, Hawkins sign, osteonecrosis, posttraumatic arthritis, talus fracture

The USNS Mercy, one of the two hospital ships in the United States Navy, has provided disaster relief and humanitarian assistance for multiple natural disasters around the world. As a self-sustaining 1000-bed hospital, the USNS Mercy provides a full complement of surgical and medical capabilities to care for the sick and injured in a mobile platform environment. This article describes the recent missions of the USNS Mercy, highlighting the capabilities and humanitarian mission goals. (Journal of Surgical Orthopaedic Advances 20(1):38–43, 2011) Key words: disaster relief, hospital ship, humanitarian assistance, navy, USNS Mercy

This prospective, randomized, blinded pilot study determined if a difference was present in the histology and apoptotic rate of articular cartilage after application of a negative pressure wound therapy (NPWT) device to an uninjured joint surface compared to a control side using Capra hircus goats. The goats were euthanized at 3 or 7 days after surgery. The en bloc joint resection was divided into medial (direct sponge contact) and lateral compartments (no sponge contact; indirect NPWT). In the necropsied cartilage and menisci, there were no gross or histologic/morphometric differences identified by a blinded veterinary pathologist. The percentages of apoptotic and necrotic chondrocytes based on flow cytometry were not statistically different. This study demonstrated that there were no observable deleterious effects to uninjured cartilage from direct or indirect intra-articular NPWT placement. These data suggest that NPWT may be placed safely in an intra-articular position for up to 7 days. Further studies in humans are warranted. (Journal of Surgical Orthopaedic Advances 20(1):44–49, 2011) Key words: animal, cartilage, intra-articular, knee, negative pressure wound therapy

Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army’s telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting were the most common recommended treatments for all orthopaedic consults. Of the 170 consults requesting specific treatment recommendations for patients who likely otherwise would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively. The novel Army telemedicine orthopaedic consultation program developed for combat-deployed service members provides expert treatment recommendations for a variety of musculoskeletal injuries. Deployed health care providers located in austere combat environments can better determine both the necessity of medical evacuation and appropriate treatments for service members with musculoskeletal injuries when aided by orthopaedic surgery consultants, thereby limiting the number of unnecessary medical evacuations. (Journal of Surgical Orthopaedic Advances 20(1):50–55, 2011) Key words: musculoskeletal injury, orthopaedic consultation, teleconsultation, telemedicine

The Military Orthopaedic Trauma Registry (MOTR) is a comprehensive joint service registry of military orthopaedic injuries. Conceived in 2006, MOTR is now operational for retrospective data entry and prospective data collection of extremity injuries sustained by U.S. service members serving in current Overseas Contingency Operations. Running in tandem with data from the United States Army Institute of Surgical Research’s Joint Theater Trauma Registry (JTTR), MOTR augments the casualty data included in JTTR with additional orthopaedic specific data (i.e., the injury patterns, characteristics, treatment, and complications associated with extremity war injuries). Extremity war injuries are the major clinical burden of the current conflicts. However, the scope of the injuries in detail useful to the orthopaedic researcher has never been prospectively collected. MOTR is designed to fill that gap in extremity trauma research. As such, MOTR represents an evolutionary step in the refinement of data-driven disaster management. (Journal of Surgical Orthopaedic Advances 20(1):56–61, 2011) Key words: orthopaedic registry, orthopaedic research, registry data, trauma registry

After the devastating earthquake in Haiti, the United States Air Force deployed multiple medical units as part of the disaster response. Air Force Special Operations Command medical teams provided initial medical response and assisted in the organization of medical assets. A small portable expeditionary aeromedical rapid response team with the assistance of a mobile aeromedical staging facility team stabilized patients for flight and coordinated air evacuation to the United States. An expeditionary medical support hospital was set up and assisted in patient movement to and from the USNS Comfort hospital ship. These units were able to adapt to the unique circumstances in Haiti and provide great patient care. The lessons learned from these experiences may help the United States better respond to future disasters. (Journal of Surgical Orthopaedic Advances 20(1):62–66, 2011) Key words: Air Force, disaster, earthquake, Haiti, military, response, trauma

There is a significant need for orthopaedic care in developing countries. For the past 10 years, the United States Army has supported annual orthopaedic hand surgery humanitarian missions to Honduras. The goal of this article is to compare the premission planning to the realities of mission execution to provide a template for future missions. Premission planning began 1 year before the mission. Based on previous missions, supplies were brought for 50 surgical cases. The mission began with 1 preoperative clinic day followed by 8 operative days and 1 postoperative clinic day. Of the 99 prescreened patients, 65 were indicated for surgery. A total of 58 surgerieswere performed using innovative methods to stretch available supplies. A multidisciplinary and multination concerted effort is required for a successful humanitarian medical mission. A premission plan is critical prior to arrival and a contingency plan must be in place for missing mission-critical items. (Journal of Surgical Orthopaedic Advances 20(1):67–73, 2011) Key words: hand surgery, Honduras, humanitarian mission

External fixation is an important option in the acute management of unstable femoral and tibial fractures and the temporary stabilization of periarticular injuries of the knee or ankle. The value of external fixation as the modality of choice in selective civilian and military applications is well documented. Primary indications include damage control for multitrauma management in patients with concomitant traumatized integument and/or excessive swelling and/or systemic instability and stabilization for transport in hostile or austere environments. The purpose of this article is to discuss the indications for temporary external fixation of lower extremity long bones and complicated distal femoral, proximal tibia, and tibial plafond fractures; to outline technical considerations in the application of temporary external fixation devices; and to summarize the experience in the use of prepackaged external fixators and their indications in combat. (Journal of Surgical Orthopaedic Advances 20(1):74–81, 2011) Key words: external fixation