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The United States Armed Forces have been engaged in combat operations for more than 10 years. Not enough can be said about nor enough gratitude expressed to our troops for their commitment and sacrifice during this period. This supplement to the Journal of the American Academy of Orthopaedic Surgeons is dedicated to the men and women of the United States Armed Services and to their families and friends who support them. The terrorist attacks on New York City, Washington, DC, and Pennsylvania on September 11, 2001, set in motion what has become the longest sustained armed conflict in American history. In the past decade of war, much has been learned about the care of the combat casualty and combat-related wounds. These advances would not have been possible without the cooperation of many dedicated civilian orthopaedic organizations. Since combat operations began in 2001, more than 6,400 US service members have lost their lives, and more than 48,000 have sustained combat injuries.1 Troop vehicle design, body armor, and far-forward advanced surgical care have combined to yield the highest war injury survival rates in history. In World War II, the survivability rate was 70.7%.2 This rate increased to the mid 70th percentile for the conflicts in Korea and Vietnam. For the conflicts in Iraq and Afghanistan, the survivability rate was 89.7% as of 2011. Survivability steadily increased from 80.8% in 2001 to 92.0% in 2011. More than 70% of combat casualties suffer extremity trauma.3 Unpublished data obtained from the US Military Amputee Database indicate that as of April 24, 2012, 1,453 injured US service members had required limb amputation, with 1,015 experiencing single limb loss and 438 experiencing multiple limb loss. Many other wounded service members have undergone successful limb salvage. The inaugural Extremity War Injuries (EWI) symposium, held in 2006, focused on the difficulties related to combat casualty care and defined the state of practice at that time., Pub. in Journal of the American Academy of Orthopaedic Surgeons, v19 n1, p8-10, 2011.

Concerning the past decade of war, three special topics were examined at the Extremity War Injuries VII Symposium. These topics included the implementation of tourniquets and their effect on decreasing mortality and the possibility of transitioning the lessons gained to the civilian sector. In addition, the training of surgeons for war as well as residents in a wartime environment was reviewed., Pub. in Journal of American Academy of Orthopaedic Surgeons, v20 n1, ps94-s08, 2012.

It is estimated that there have been several hundred tibia fractures that have occurred in the global war on terror. Little is known about the long-term consequences of these injuries and their treatment. Objective: Our main objective is to determine significant predictors of poor outcome following open tibia fractures so that suitable modifications can be made to treatment and rehabilitative therapy. Of particular interest is an evaluation of differences in outcomes for various algorithms for the treatment of open tibia fractures. Specific Aims: We aim to: (1) describe the long term consequences of open tibia fractures; (2) identify clinical and patient characteristics that explain variations in outcome; and (3) make recommendations for treatment adjustments. Study Design: Patients will be identified retrospectively. The retrospective cohort (numbering approximately 430) will consist of all soldiers who meet the inclusion criteria and were injured as of September 30, 2006 and cared for at one of the participating facilities. Principal sources of data will include: (1) clinical data abstracted from the medical record; (2) baseline interviews; and (3) a follow-up interview one-year following the baseline interview. Relevance: This long term follow-up will provide a unique opportunity to (1) examine the benefits of different treatment modalities for open tibia fractures in a military population; (2) identify ongoing needs for additional services; (3) provide the basis for targeted interventions; and (4) assist in assuring that these and future soldiers are provided with every opportunity for a good long-term outcome.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infect ions have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data and from in Vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents use of negative pressure wound therapy, and for oxygen supplementation in flight., Pub. in the Journal of Trauma Injury, Infection, and Critical Care, v71 n2, pS202-S209, Aug 2011.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. 'This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of hlgh-dose cefazolin with or without metronidazole tor most postinjury indications, and recommendations tor redosing of antimicrobial agents, for use of negative pressure wound therapy, and tor oxygen supplementation in flight., Pub. in Journal of Trauma, Injury, Infection, and Critical Care, v71 n2, pS210-S234, 2011.

Background: Predictive models permitting individualized prognostication for patients with fracture nonunion are lacking. The objective of this study was to train, test, and cross-validate a native Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy. Methods: Prospectively collected data from 349 patients with delayed fracture union or a nonunion were utilized to develop a naive Bayesian belief network model to estimate site-specific fracture-nonunion healing in patients treated with extracorporeal shock wave therapy. Receiver operating characteristic curve analysis and tenfold cross-validation of the model were used to determine the clinical utility of the approach. Results: Predictors of fracture-healing at six months following shock wave treatment were the time between the fracture and the first shock wave treatment, the time between the fracture and the surgery, intramedullary stabilization, the number of bone-grafting procedures, the number of extracorporeal shock wave therapy treatments, work-related injury, and the bone involved (p < 0.05 for all comparisons). These variables were all included in the naive Bayesian belief network model. Conclusions: A clinically relevant Bayesian classifier was developed to predict the outcome after extracorporeal shock wave therapy for fracture nonunions. The time to treatment and the anatomic site of the fracture nonunion significantly impacted healing outcomes. Although this study population was restricted to patients treated with shock wave therapy, Bayesian-derived predictive models may be developed for application to other fracture populations at risk for nonunion., Investigation performed at the AUVA-Trauma Center, Meidling, Vienna, Austria; DecisionQ Corporation, Washington, DC; Walter Reed Army Medical Center, Washington, DC; and National Naval Medical Center, Bethesda, Maryland.. The original document contains color images. Published in Journal of Bone and Joint Surgery, v93 A p187-194, 19 Jan 2011.

It is estimated that there have been several hundred tibia fractures that have occurred in the global war on terror. Little is known about the long-term consequences of these injuries and their treatment. Objective: Our main objective is to determine significant predictors of poor outcome following open tibia fractures so that suitable modifications can be made to treatment and rehabilitative therapy. Of particular interest is an evaluation of differences in outcomes for various algorithms for the treatment of open tibia fractures. Specific Aims: We aim to: (1) describe the long term consequences of open tibia fractures; (2) identify clinical and patient characteristics that explain variations in outcome; and (3) make recommendations for treatment adjustments. Study Design: Patients will be identified retrospectively. The retrospective cohort (numbering approximately 430) will consist of all soldiers who meet the inclusion criteria and were injured as of September 30, 2006 and cared for at one of the participating facilities. Principal sources of data will include: (1) clinical data abstracted from the medical record; (2) baseline interviews; and (3) a follow-up interview one-year following the baseline interview. Relevance: This long term follow-up will provide a unique opportunity to (1) examine the benefits of different treatment modalities for open tibia fractures in a military population; (2) identify ongoing needs for additional services; (3) provide the basis for targeted interventions; and (4) assist in assuring that these and future soldiers are provided with every opportunity for a good long-term outcome.

The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care., Pub. in Military Medicine, v175 n7 p18-24, 2010. Supported in part by U.S. Navy Bureau of Medicine and Surgery.

It is estimated that there have been several hundred tibia fractures that have occurred in the global war on terror. Little is known about the long-term consequences of these injuries and their treatment. Objective: Our main objective is to determine significant predictors of poor outcome following open tibia fractures so that suitable modifications can be made to treatment and rehabilitative therapy. Of particular interest is an evaluation of differences in outcomes for various algorithms for the treatment of open tibia fractures. Specific Aims: We aim to: (1) describe the long term consequences of open tibia fractures; (2) identify clinical and patient characteristics that explain variations in outcome; and (3) make recommendations for treatment adjustments. Study Design: Patients will be identified retrospectively. The retrospective cohort (numbering approximately 430) will consist of all soldiers who meet the inclusion criteria and were injured as of September 30, 2006 and cared for at one of the participating facilities. Principal sources of data will include: (1) clinical data abstracted from the medical record; (2) baseline interviews; and (3) a follow-up interview one-year following the baseline interview. Relevance: This long term follow-up will provide a unique opportunity to (1) examine the benefits of different treatment modalities for open tibia fractures in a military population; (2) identify ongoing needs for additional services; (3) provide the basis for targeted interventions; and (4) assist in assuring that these and future soldiers are provided with every opportunity for a good long-term outcome.