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J Am Acad Orthop Surg, Vol 14, No 10, September 2006, viii-ix.
© 2006 the American Academy of Orthopaedic Surgeons
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introduction

Introduction

Andrew N. Pollak, MD, Co-Chair and Jason H. Calhoun, MD, Co-Chair

There is a timely need for research on the management of wartime extremity injuries. Advancements in body armor technology have decreased mortality from blast injuries in recent conflicts and consequently have increased the incidence of mangled extremities. In Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), surgeons struggle with infection, bone and tissue healing, and rehabilitation. Of 256 battle casualties treated at the Landstuhl Regional Medical Center in Germany during the first two months of OIF, 68% sustained an extremity injury. Of those injuries, 48% were from explosives, 30% from gunshot wounds, and 21% from blunt trauma.1 The result of such trauma is open, complex wounds with severe bone fragmentation. Often there is nerve damage as well as damage to tendons, muscles, vessels, and soft tissue. In these types of wounds, infection is often a problem. According to the Joint Theater Trauma Registry of the Center for Army Medical Department Strategic Studies, 53% of the extremity wounds are classified as penetrating soft-tissue wounds, while fractures compose 26% of extremity wounds. Other types of extremity wounds composing <5% each are burns, sprains, nerve damage, abrasions, amputations, contusions, dislocations, and vascular injuries.

A coordinated effort is necessary to address the full scope of orthopaedic trauma care and to place focus on the need for increased government funding for research, increased research collaboration between civilian and military orthopaedic surgeons, and an overall increased awareness of extremity war injuries. During the 2005 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in Washington, DC, members of the AAOS Board of Directors had the opportunity to tour Walter Reed Army Medical Center (WRAMC). Lt. Col. Daniel W. White, MD, MC, and then-incoming AAOS President Stuart L. Weinstein, MD, realized then the benefits that could result from a joint effort between the Academy and the military regarding combat injuries.

As a result, a symposium was convened that paired military and civilian orthopaedic surgeons to jointly examine research gaps and suggest research priorities. This symposium, Extremity War Injuries: State of the Art and Future Directions (EWI), was developed by special request from the AAOS Board of Directors. Its purpose was to define current knowledge of the management of extremity war injuries. In collaboration with professional organizations, orthopaedic industry sponsors, government agencies, extremity wound care experts, and research grant agencies, the AAOS and the Orthopaedic Trauma Association (OTA) cosponsored the symposium, which took place January 24-27, 2006, in Washington, DC. The three-day event addressed wound management, antibiotics and infection, long-bone stabilization, management of segmental bone defects, and amputee care.

The symposium yielded mutual benefits. Techniques and treatments developed and employed for wartime injuries can be used in managing civilian trauma and medical complications. Advances in the management of extremity injuries will lead to quicker recovery times from blast injuries, better response rates to infection, and new advances in amputee care, benefiting both military and civilian patients.

Symposium sessions featured panels of military and civilian experts and included international participants from Iraq, Israel, Canada, the United Kingdom, and Serbia and Montenegro. The symposium featured site visits to the Amputee Care Center of WRAMC and the National Museum of Health and Medicine of the Armed Forces Institute of Pathology. Senators Ted Stevens (R-Alaska), chairman of the US Senate Appropriations Defense Subcommittee, and Conrad Burns (R-Montana), also a member of the subcommittee, participated in the EWI opening reception and pledged a strong commitment to extremity trauma research funding.

The United States government has already recognized the need for additional orthopaedic research funding. The Fiscal Year 2006 Defense Appropriations Bill established the Orthopaedic Trauma Research Program (OTRP) as a part of the Medical Research and Materiel Command (MRMC) medical research program. Administered by the United States Army Institute of Surgical Research (USAISR) at Fort Sam Houston, Texas, the program, funded at $7.5 million, was the first program created in the Department of Defense (DOD) allocated exclusively to funding peer-reviewed intramural and extramural orthopaedic trauma research. The USAISR has extensive experience in administering similar grant programs, and it is the only DOD research laboratory dedicated solely to improving combat casualty care. The intent of the OTRP is to foster collaboration between military and civilian orthopaedic surgeons and researchers. This year, the USAISR has received a considerable number of grant applications. Although this is a significant start, the EWI symposium and this Special Issue of the Journal of the American Academy of Orthopaedic Surgeons serve as a foundation for the advocacy of continued and additional trauma research funding.

This supplemental Special Issue opens with a brief history of extremity war injury, followed by an elucidation of the levels of care and an overview of combat orthopaedics. The scope of wounds from the global war on terrorism is addressed in detail, as well as the definitive treatment of combat casualties. Trauma care and research are illustrated from the perspectives of an Iraqi and an American orthopaedic military surgeon. Each session of the symposium, which was comoderated by a civilian and a military surgeon, translated into a chapter of this Special Issue. The final article outlines future research directions for the treatment and management of extremity war injuries. The future research directions serve as a tool to promote awareness of orthopaedic extremity trauma and to continue to garner research in this area.

Partial symposium funding was received from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health (NIH), the Orthopaedic Research and Education Foundation (OREF), and the Orthopaedic Research Society (ORS). The AAOS and OTA acknowledge the following industry contributors for their assistance in making the symposium and this supplement possible:

The symposium was supported by the Amputee Coalition of America (ACA), The US Bone and Joint Decade (USBJD), the Board of Specialty Societies (COMSS) of the AAOS, the Orthopaedic Rehabilitation Association (ORA), and the Society of Military Orthopaedic Surgeons (SOMOS).

We would also like to thank the numerous individuals and groups that made this symposium possible: Gunnar B.J. Andersson, MD, PhD, and the AAOS Research Development Committee; Joshua J. Jacobs, MD, and the AAOS Council on Research, Quality Assessment and Technology; Col. William Doukas, MD, MC, Richard Schaefer, MD, and the staff and the brave patients of Walter Reed Army Medical Center; Adrianne Noe, PhD, and the National Museum of Health and Medicine of the Armed Forces Institute of Pathology; Stuart Weinstein, MD, Richard Kyle, MD, Karen L. Hackett, FACHE, CAE, and the AAOS Board of Directors; the EWI Steering Committee; and AAOS staff leadership, including David Lovett, JD, Christy M.P. Gilmour, Erin L. Ransford, David C. Smith, Laura Goetz, Anita Cooper, Nancy Franzon, and Kathy Pontzer.


   References
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 References
 

  1. Johnson BA, Carmack D, Neary M, Tenuta J, Chen J: Operation Iraqi Freedom: The Landstuhl Regional Medical Center experience. J Foot Ankle Surg 2005; 44: 177-183. [Medline]



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