Epidemiology of Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom: Orthopaedic Burden of Disease - LTC Philip J. Belmont, Jr., MD

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The United States forces in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) are primarily engaged in counterinsurgency operations within an irregular war. The US combat medical experience has reported new injury patterns secondary to the enemy’s reliance on explosive mechanisms, particularly improvised explosive devices (IEDs), and the widespread use of individual and vehicular body armor. Musculoskeletal extremity injuries have been reported to comprise approximately 50% of all combat wounds for OIF/OEF. Utilization of individual body armor has dramatically reduced thoracic injuries and has decreased the lethality of gunshot wounds, as measured by the percent killed in action, which in conflicts prior to OIF/OEF was estimated at 33% but is now 4.6%. Explosive mechanisms of injury, with IEDs being the most common, account for over 75% of all combat casualties. The lethality of IEDs coupled with the protection of the thorax and abdomen provided by individual body armor has resulted in increasingly severe orthopaedic injuries. Collection and careful examination of orthopaedic combat casualties will allow for improved military personnel protective measures and treatment of injured soldiers. (Journal of Surgical Orthopaedic Advances 19(1):2–7, 2010) Key words: casualty, combat, epidemiology, injury, military, wound

Blast Injuries: Mechanics and Wounding Patterns - CAPT Dana C. Covey, MD, and Christopher T. Born, MD

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Blast and fragment injuries are the most frequently encountered wounds in modern warfare. Explosive devices have become the preferred weapon of domestic and foreign terrorists because they are relatively inexpensive to manufacture and can cause substantial casualties. Although blast injuries have traditionally been associated with the battlefield, this type of trauma is being seen more commonly today among noncombatants due to increasing worldwide terrorism. (Journal of Surgical Orthopaedic Advances 19(1):8–12, 2010) Key words: blast injuries, musculoskeletal, war wounds

Damage Control Orthopaedics: An In-Theater Perspective - LTC(P) Romney C. Andersen, MD, MAJ Victor A. Ursua, MD, MAJ John M. Valosen, MD, LTC Scott B. Shawen, MD

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Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.. (Journal of Surgical Orthopaedic Advances 19(1):13–17, 2010) Key words: combat damage control surgery, external fixation, negative pressure wound therapy, Operation Enduring Freedom, Operation Iraqi Freedom

Earlier Debridement and Antibiotic Administration Decrease Infection - MAJ Kate V. Brown, MRCS, John A. Walker, MD, Douglas S. Cortez, BS, LTC Clinton K. Murray

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Timing of debridement and local antibiotic administration on infection has not been clearly defined. A contaminated critical size rat femur defect model was used to determine if earlier debridement with local antibiotics decreased infection. Defects were inoculated with Staphylococcus aureus. At 2, 6, or 24 hours following contamination, defects were irrigated and debrided then directly closed or treated with antibiotic-impregnated PMMA beads and then closed. Two weeks later, defects were examined for evidence of infection. There was a significant increase in evidence of infection between 2 and 6 hours and a further increase between 6 and 24 hours with debridement alone as well as with debridement plus local antibiotics. Treatment with antibiotics resulted in significantly less evidence of infection at 2 and 6 hours compared to debridement alone. It was concluded that early debridement in combination with local delivery of antibiotics of contaminated defects may reduce infections. (Journal of Surgical Orthopaedic Advances 19(1):18–22, 2010) Key words: infection, irrigation, local antibiotics

Composite Bone and Soft Tissue Loss Treated With Distraction Histiogenesis - CPT Michael J. Beltran, MD, CPT Leah M. Ochoa, MD, MAJ Richard M. Graves, MD

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The purpose of this article is to describe the use of shortening and angulation to manage composite bone and soft tissue loss associated with combat-related type IIIB open tibia fractures. Four patients underwent placement of a software-driven circular fixator with acute shortening and angulation to manage composite bone and soft tissue loss. Frames were applied using the Rings First Method, and an induced deformity was created with the soft tissue defect within the concavity. Distraction histiogenesis was utilized to restore limb length and regenerate soft tissues. Three patients had healed fractures and mature regenerate allowing frame removal, while one remained in his frame for further consolidation. Mechanical alignment and limb length were restored in all patients. No major frame adjustments were required and all distracted soft tissues healed without complication. The article concludes that composite bone and soft tissue loss is effectively managed with distraction histiogenesis and the use of a software-driven circular fixator. (Journal of Surgical Orthopaedic Advances 19(1):23–28, 2010) Key words: distraction histiogenesis, Ilizarov, shortening and angulation, Taylor spatial frame

Soft Tissue Coverage of Combat Wounds - LT Scott M. Tintle, MD, CDR (sel) David E. Gwinn, MD, LTC Romney C. Andersen, MD, and CDR Anand R. Kumar, MD

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Warfare-related open fractures with large soft tissue defects create a significant reconstructive challenge. The objective of this article is to review current and evolving treatment strategies for soft tissue coverage of warfare-induced extremity wounds. A review of previously published literature and current data evaluating combat-injured personnel requiring extremity flap reconstruction performed by a single surgeon within the National Capital Area from 2004 to 2009 was performed. Collected data reviewed included injury patterns, methods of reconstruction, and success rates. Seventy-five (59 pedicled flaps and 16 free) extremity reconstructions employing flaps (34 fasciocutaneous, 34 muscle, and 7 adipofascial) were performed in the subacute time period between 7 days and 3 months. One hundred percent of the wounds were associated with open fractures. Early postoperative infections (

Lower Extremity Combat-Related Amputations - LT Scott M. Tintle, MD, LCDR Jonathan Agner Forsberg, MD, CDR John J. Keeling, MD, LTC Scott B. Shawen, MD

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Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb amputations among United States service members. With a sustained military presence in the Middle East, continued severe lower extremity trauma is inevitable. For this reason, combat surgeons must understand the various amputation levels as well as the anatomic and technical details that enable an optimal functional outcome. These amputations are unique and usually result from blast mechanisms and are complicated by broad zones of injury with severe contamination and ongoing infection. The combat servicemen are young, previously healthy, and have the promising potential to rehabilitate to very high levels of activity. Therefore, every practical effort should be made to perform sound initial and definitive trauma-related amputations so that these casualties may return to their highest possible level of function. (Journal of Surgical Orthopaedic Advances 19(1):35–43, 2010) Key words: amputation, combat trauma, residual limb, war wounds

Use of Negative Pressure Wound Therapy During Aeromedical Evacuation of Patients With Combat-Related Blast Injuries - Andrew N. Pollak, MD, Col (ret) Elisha T.

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The purpose of the study was to evaluate safety and feasibility of negative pressure wound therapy (NPWT) during aeromedical evacuation from a combat zone to a regional treatment center. A retrospective review of patients who received NPWT during aeromedical evacuation from Iraq or Afghanistan to Landstuhl Regional Medical Center (LRMC) was performed. Data were collected describing mechanism of injury; anatomic site of NPWT application; number of sites per patient; date and time of NPWT application; date, time, and wound condition on arrival and inspection at LRMC; and complications encountered during aeromedical evacuation. Broad definitions of complications were employed. Any reported malfunction of NPWT devices or need to reinforce NPWT dressings was abstracted. Presence of tissue under the dressing requiring debridement was defined as a minor complication. Major complications were defined as wound sepsis with systemic manifestations. A total of 218 patients who had received NPWT for 298 wounds (1.37 per patient) during aeromedical evacuation were identified. Most wounds were due to high-energy blast or ballistic mechanisms. Average time from NPWT application to removal was 53 hours (range, 18–133 š 22 hours). Complications occurred at 14% of NPWT sites and in 19% of patients receiving NPWT. Most recorded complications were minor (95%). Two patients who arrived at LRMC with fever and evidence of wound sepsis improved rapidly after additional operative debridement. In no case was failure of the NPWT device in flight specifically implicated in the genesis of a recorded complication. In-flight device problems were identified in seven cases. Four of these could not be repaired in flight and were clamped. Complications were not increased in this cohort. Use of NPWT during aeromedical evacuation appears safe and feasible in a large cohort of patients with high-energy injuries. Complications were consistent with severity of injury and not related to failure of NPWT. (Journal of Surgical Orthopaedic Advances 19(1):44–48, 2010) Key words: aeromedical evacuation, extremity blast injury, negative pressure wound therapy, wound management

Outcomes of Internal Fixation in a Combat Environment - CPT Daniel J. Stinner, MD, Lt Col James A. Keeney, MD, MAJ(P) Joseph R. Hsu, MD, CPT Jeremy K. Rush, MD

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Due to the nature of the wounds and environment, internal fixation in battlefield treatment facilities is discouraged despite the lack of data. The purpose of this review is to describe the outcomes of fractures that were internally fixed in the combat environment. The records of patients who had internal fixation performed in the theater of combat operations were reviewed. Demographics, injury characteristics, procedure history, and outcomes were recorded and analyzed. Forty-seven patients had internal fixation performed on 50 fractures in a combat theater hospital. Hip, forearm, and ankle fractures made up the majority of cases with 14 (28%), 14 (28%), and 10 (20%), respectively. Sixteen (32%) fractures were open. The average Injury Severity Score was 11.4 š 1.1 (range, 4–34). Thirty-nine fractures (78%) healed without incidence. There was one (2%) infection and one (2%) acute surgical complication. Ten (20%) fractures, including the one infection, required additional procedures. Because internal fixation in the combat environment was used judiciously, complications were not higher than previously reported. (Journal of Surgical Orthopaedic Advances 19(1):49–53, 2010) Key words: combat injury internal fixation, complications

Heterotopic Ossification in Wartime Wounds - LCDR Jonathan Agner Forsberg, MD, and MAJ Benjamin Kyle Potter, MD

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Heterotopic ossification (HO) refers to the formation of mature lamellar bone in nonosseous tissue. In the setting of high-energy wartime extremity wounds, HO is expected to complicate up to 64% of patients, has a predilection for the residual limbs of amputees, and remains a significant source of disability. Although the inciting events and the definitive cell(s) of origin continue to remain elusive, animal models and human histology samples suggest that HO formation follows a predictable sequence of events culminating in endochondral ossification. Primary prophylaxis is not medically or logistically practical in most cases because patients have generally sustained massive wounds and are undergoing serial debridements during an intercontinental aeromedical evacuation. Surgical excision of symptomatic lesions is warranted only after an appropriate trial of conservative measures and is associated with low recurrence rates in appropriately selected patients. Future research regarding prognostication and defining the early molecular biology of ectopic bone may permit individualized prophylaxis and development of novel targeted therapies. (Journal of Surgical Orthopaedic Advances 19(1):54–61, 2010) Key words: heterotopic ossification, trauma, war wounds

Extrapolation of Battlefield Resuscitative Care to the Civilian Setting - MAJ Jean-Claude G. D’Alleyrand, MD, Richard P. Dutton, MD, MBA, and Andrew N. Pollak

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Experiences in treating wartime casualties in Iraq and Afghanistan have already led to changes in civilian trauma care practices. While advances in the care of civilian musculoskeletal injuries are likely as a result of ongoing military basic and clinical research, major advances in resuscitative care have already been realized. Early liberal use of tourniquets to control bleeding from combat-associated extremity trauma has led to decreased mortality. Military experience has demonstrated that use of temporary intravascular shunts is effective for mitigating ischemic injury from vascular trauma until definitive repair can be accomplished. Hemostatic dressings have improved the surgeon’s hemorrhage control armamentarium. Clinical experience with hypotensive resuscitation has led to refinement and improvement in the technique. Use of recombinant factor VIIa has improved hemorrhage control in the context of brain injury and coagulopathy and increasing the ratio of plasma to red cells during early shock resuscitation has improved survival. (Journal of Surgical Orthopaedic Advances 19(1):62–69, 2010) Key words: combat casualty, factor VIIa, hemostatic dressing, resuscitation, shock, tourniquet, vascular shunt

Combat Foot and Ankle Trauma - LT Scott M. Tintle, MD, CDR John J. Keeling, MD, and LTC Scott B. Shawen, MD

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Injury to the lower extremity is common in the current conflicts, often severely affecting the foot and ankle. Secondary to continued surgical advances, many lower extremities are able to undergo limb salvage procedures. However, scoring systems still do not reliably predict which patient will be best served with an amputation or limb salvage. Because of this, limb salvage should be attempted whenever possible, awaiting definitive treatment at a later time. Treatment begins at the time and location of injury with aggressive debridement, with reduction and external fixation of fractures when possible. Serial debridements are often necessary until the traumatic wounds are ready for coverage or closure. Forefoot injuries are treated with varying techniques depending on the location of the injury. Amputation of toes and/or flap coverage is often necessary secondary to tenuous soft tissues.Midfoot injury patterns are complex, possibly requiring arthrodesis, antibiotic spacers, soft tissue coverage, and thin-wire ring external fixation. Hindfoot or calcaneal injuries are often the most difficult to treat, requiring extraordinary efforts to salvage a viable limb. Early reduction of the remaining fragments and percutaneous fixation are often followed by arthrodesis of the subtalar joint. Fractures of the calcaneus requiring free soft tissue coverage frequently lead to amputation. Blast injuries to the lower extremity are severe injuries. They are frequently associated with fractures to multiple levels. Early elective amputation at the level V treatment center is frequently performed. When limb salvage is performed, basic principles must be followed to optimize treatment. (Journal of Surgical Orthopaedic Advances 19(1):70–76, 2010) Key words: amputation, ankle, calcaneus, foot, fracture, metatarsal, talus

Reconstructive Challenges of Complex Battlefield Injury - LCDR Luke F. Bremner, MD, and CDR Michael Mazurek, MD

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Throughout our current conflicts in both Iraq and Afghanistan, the likelihood of surviving a battlefield injury has been near 90% according to reports provided by the US Army Medical Research and Materiel Command. This is the highest survival rate recorded in modern combat. Advancements in protective equipment, rapid evacuation of casualties from point of injury to both stabilization and definitive care, improved medic and corpsmen personnel, more readily available resuscitation, and forward positioned surgical units have all significantly decreased troop mortality. Along with this phenomenon of increased survival, however, has come a surge in the number and significance of injuries seen by the medical community. As a result, orthopaedists have been forced to confront reconstructive challenges and difficult decisions in an often highly motivated patient population with high functional expectations. The objective of this article is to outline a few examples of difficult challenges encountered in battlefield trauma care and discuss the treatments utilized. (Journal of Surgical Orthopaedic Advances 19(1):77–84, 2010) Key words: humerus allograft, latissimus free flap, limb salvage

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