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OBJECTIVES Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN A retrospective cohort study. SETTING Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION Not applicable. MAIN OUTCOME MEASUREMENTS Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: this is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of treatment were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: overall response rates were modest (59.2 %) and significantly different between those who underwent amputation (64.5 %) and those treated with limb salvage (55.4 %) (p = 0.02). Also, 38.3 % screened positive for depressive symptoms and 17.9 %, for posttraumatic stress disorder (PTSD). One-third (34.0 %) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. Conclusions: major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

The symposium Extremity War Injuries X: Return to Health and Function, presented by the American Academy of Orthopaedic Surgeons, the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, and the Orthopaedic Research Society, was held in Washington, DC, on January 27 and 28, 2015. Course chairs Marc F. Swiontkowski, MD, and COL Jeffrey N. Davila, MD, presided over 2 days of general session lectures focusing on war/trauma-related musculoskeletal injuries resulting in service member disability, followed by small group discussions, with a goal of identifying knowledge gaps in the treatment of these injuries. Recognized civilian and military clinicians and researchers summarized the current state of knowledge in their topic areas and led these discussion groups with meeting participants. Musculoskeletal conditions discussed included posttraumatic osteoarthritis of the knee, foot, and ankle and their relationship to chronic ligament injuries; back disability; peripheral nerve injury; hand transplantation updates; the role of biologics; and prosthetic acceptance and function. A scientific program highlighting research presented by 12 investigators was led by COL (Ret) Romney C. Andersen, MD. Keynote speaker LT GEN Douglas J. Robb, MD, discussed the future of military research funding and the anticipated consolidation of medical care among the three military branches. Additional presentations referencing the impact of military medical care and the government's continued commitment to funding medical research occurred throughout the symposium and were given by five congressional representatives.

Objective: There are several options for soft tissue coverage following external hemipelvectomy; however, in cases of war-related blast trauma, standard flaps are not always available as a result of the extensive soft tissue damage. Methods: We detail a novel closure technique following a subtotal hemipelvectomy with exposed abdominal viscera using a residual hamstring myofascial cutaneous flap. Results: This flap allowed for fascial tissue to fill the pelvic defect and provided excellent soft tissue coverage for future prosthetic wear. Discussion: In the current literature, there is limited information regarding surgical options for soft tissue coverage following traumatic hip disarticulation. Most cases result from malignancies or severe infection, where tissue distal to the lesion is viable and provides adequate coverage. This case report used a novel technique, provided excellent soft tissue coverage with no wound healing complications, allowed for excellent prosthetic fitting, and the patient...

Extremity War Injury Symposium IX focused on reducing disability within the military, centering on cartilage defects, amputations, and spinal cord injury. Many areas of upper and lower extremity trauma and disability were discussed, including segmental nerve injuries, upper extremity allotransplantation, and the importance of patient-reported functional outcomes compared with the traditionally reported measures. Strategic planning addressed progression toward clinical solutions by setting clear objectives and goals and outlining pathways to address the "translation gap" that often prevents bridging of basic science to clinical application.

Orthopedic trauma remains one of the most survivable battlefield injuries seen in modern conflicts. Translating research into practice is a critical bridge that permits surgeons to further optimize medical outcomes. Orthopedic surgeons serving in the military may treat little to no trauma in their stateside practice. In conflict zones, however, the majority of their patients will have traumatic injuries. Determining risk factors for nonevidence-based practice can help identify provider knowledge gaps, which can then be targeted before deployment. Surveys were developed which sought to identify factors contributing to continued medical education and practice, as well as scenario-based questions on military-relevant orthopedic trauma. Analysis of 188 survey respondents revealed that providers with military service and less than 10 years of practice are optimally bridging research into military-relevant orthopedic trauma practice.

Objective Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients. Design Retrospective review of a consecutive series of patients. Setting Tertiary Military Medical Center. Patients/participants Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009. Intervention We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients. Main outcome measurements The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status. Results At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4). Conclusions In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

Military experience managing complex blast injuries during the long conflicts in Afghanistan and Iraq has advanced the understanding of the biophysics of blast trauma and has allowed for the development of treatment algorithms to manage associated injuries. Military blast-injured patients typically arrive in extremis, often with severe pelvic or perineal injuries and extremity amputations. Resource demand for even one of these patients can be quite significant, and in austere environments can severely impact the reserves of the managing facility.

Heterotopic ossification (HO) develops frequently after modern high-energy penetrating war injuries. The purpose of this prospective study was to identify and characterize the unique cytokine and chemokine profile associated with the development of HO as it pertained to the systemic inflammatory response after penetrating combat-related trauma.Patients with high-energy penetrating extremity wounds were prospectively enrolled. Surgical debridement along with the use of a pulse lavage and vacuum-assisted-closure device was performed every 48-72 hours until definitive wound closure. Wound bed tissue biopsy, wound effluent, and serum were collected before each debridement. Effluent and serum were analyzed for 22 relevant cytokines and chemokines. Tissue was analyzed quantitatively for bacterial colonization. Correlations between specific wound and patient characteristics were also analyzed. The primary clinical outcome measure was the formation of HO as confirmed by radiographs at a minimum of 2 months of follow-up.Thirty-six penetrating extremity war wounds in 24 patients were investigated. The observed rate of HO in the study population was 38%. Of the 36 wounds, 13 (36%) demonstrated HO at a minimum follow-up of 2 months. An elevated injury severity score was associated with the development of HO (P = 0.006). Wound characteristics that correlated with the development of HO included impaired healing (P = 0.005) and bacterial colonization (P0.001). Both serum (interleukin-6, interleukin-10, and MCP-1) and wound effluent (IP-10 and MIP-1α) cytokine and chemokine bioprofiles were individually associated and suggestive of the development of HO (P0.05).A severe systemic and wound-specific inflammatory state as evident by elevated levels of inflammatory cytokines, elevated injury severity score, and bacterial wound colonization is associated with the development of HO. These findings suggest that the development of HO in traumatic combat-related wounds is associated with a hyper-inflammatory systemic response to injury.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Objectives The purpose of this study is to determine the rate of late (secondary) amputation and to identify risk factors for amputation in injuries that were initially treated with limb preservation on the battlefield. Methods A retrospective review at our institution identified 24 consecutive patients with 26 blast-induced open fractures distal to the joint that had associated arterial injuries. All injuries were initially cared for on the battlefield and during the evacuation chain of care with limb preservation protocols. All definitive orthopaedic care was provided by a single fellowship-trained orthopaedic trauma surgeon at a tertiary care stateside facility. Injury factors were analyzed based on radiographic and chart review to determine associations with amputation. Results Twenty of 26 injured limbs received an amputation for a total amputation rate of 76.9% (95% confidence interval, 57.9-88.9%). Fourteen limbs received early amputation before limb salvage attempts. Six of the 12 limbs that received limb salvage underwent late amputation. Conclusions The rate of amputation in severe blast-induced extremity fractures combined with an arterial injury initially treated with limb preservation on the battlefield and before transfer to the definitive military treatment facility is extremely high. Blast-injured lower limbs with a combined severe bony and soft tissue injury should be carefully assessed when arterial injury is present because they may require early amputation during initial surgical care on the battlefield.

The percentage of combat wounds involving the eyes, maxillofacial, and neck regions reported in the literature is increasing, representing 36% of all combat-related injuries at the start of the Iraq War. Recent meta-analysis of 21st century eye, maxillofacial, and neck injuries described combat injury incidences of 8% to 20% for the face, 2% to 11% for the neck, and 0.5% to 13% for the eye and periocular structures. This article reviews recent data from military and civilian studies to support evidence-based recommendations for the prevention of infections associated with combat-related eye, maxillofacial, and neck injuries. The major emphasis of this review is on recent developments in surgical practice as new antimicrobial studies were not performed. Further studies of bacterial infection epidemiology and postinjury antimicrobial use in combat-related injuries to the eyes, maxillofacial, and neck region are needed to improve evidence-based medicine recommendations. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections associated with Combat-related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Burns are a very real component of combat-related injuries, and infections are the leading cause of mortality in burn casualties. The prevention of infection in the burn casualty transitioning from the battlefield to definitive care provided at the burn center is critical in reducing overall morbidity and mortality. This review highlights evidence-based medicine recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for initial care of burned combat casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Combat-related injuries to the central nervous system (CNS) are of critical importance because of potential catastrophic outcomes. Although the overall infection rate of combat-related CNS injuries is between 5% and 10%, the development of an infectious complication is associated with a very high morbidity and mortality. This review focuses on the prevention of infections related to injuries to the brain or the spinal cord and provides evidence-based medicine recommendations from military and civilian data for the prevention of infection from combat-related CNS injuries. Prevention strategies emphasize the importance of expert evaluation and management by a neurosurgeon as expeditiously as possible. Areas of focus include elimination of cerebrospinal fluid leaks, wound coverage, postinjury antimicrobial therapy, irrigation, and debridement. Given that these recommendations are not supported by randomized control trials or adequate cohort studies in a military population, further efforts are needed to determine the best treatment strategies. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

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 high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Background: The complications of bone-bridging amputations remain ill defined. The purpose of this study was to compare the early and intermediate-term complications leading to reoperation between the modified Burgess and modified Ertl tibiofibular synostosis in combat-related transtibial amputations. Methods: We conducted a retrospective review of consecutive, contemporaneous cohorts of thirty-seven modified Ertl bone-bridge and 100 modified Burgess combat-related transtibial amputations. The primary outcome measure was the need for reoperation following definitive closure. Results: At a mean follow-up of two years (range, nine to forty-eight months), there was a 53% overall reoperation rate. The overall complications included infection (34%), neuroma excision (18%), heterotopic ossification excision (15%), myodesis failure (4%), and scar revision (7%). A significantly higher rate of overall complications (p = 0.008) was noted in the bone-bridge group. Additionally, there was an increased rate of noninfectious complications in the bone-bridge group (p = 0.02). A positive selection bias was also noted for performing bone-bridge amputations late (p = 0.0002) and outside the zone of injury (p < 0.0001). Bone-bridge-specific complications occurred in 32% of the modified Ertl group. Delayed union or nonunion of the synostosis (11%) and implant-related complications (27%) predominated. Three bone bridges were ultimately removed. Conclusions: Reoperations were needed at a significantly greater rate overall and for noninfectious complications following bone-bridge synostosis compared with modified Burgess transtibial amputations. Additionally, despite the positive selection bias favoring the bridge synostosis cohort, infection rates were not lower in that group. Detailed patient counseling and careful patient selection are indicated prior to performing modified Ertl amputations, particularly in the absence of convincing evidence regarding objective functional benefits from the procedure. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

We describe fixation of transcondylar distal humeral fractures with column screws in geriatric patients and review our initial results. We conducted a retrospective review of a prospectively collected database at a Level I trauma center. Six patients met inclusion criteria of age older than 65 years and treatment of minimally or nondisplaced transcondylar distal humeral fracture with column screws only. All were closed fractures with no associated nerve injuries. One patient was lost to follow-up. The mechanism of injury was low-energy fall for the 5 remaining patients (average age, 74 y; age range, 70 to 83 y; average follow-up duration, 10.6 wk). One patient had a traumatic brain injury and a contralateral metacarpal fracture that was treated with internal fixation. The remaining 4 patients sustained isolated distal humeral fractures. No complications were noted, and all fractures healed at an average radiographic union time of 7.2 weeks. Average range of motion was 22 degrees extension [95% CI (-1.47, 45.47)], 114 degrees flexion [95% CI (89.4, 138.6)], and 92 degrees arc of motion [95% CI (58.68, 125.38)]. Treatment of select transcondylar distal humeral fractures with column screws in geriatric patients provides an option for stable fixation that allows early range of motion with minimal surgical morbidity.

Background: Preservation of optimal residual limb length following a traumatic amputation can be challenging. The purpose of this study was to determine if acceptable results can be achieved by definitive fixation of a long-bone fracture proximal to a traumatic amputation. Methods: We identified thirty-seven active-duty military service members who underwent internal fixation of a long-bone fracture proximal to a traumatic amputation. Functional status was assessed with the Tegner activity level scale and prosthesis use. Secondary outcome measures were the development of nonunion, infection, and heterotopic ossification. Results: Twelve patients (32%) underwent amputation and fracture in the same osseous segment. Ten patients (27%) sustained bilateral traumatic amputations, and eight (22%) had a major fracture of the contralateral extremity. The median times to fracture fixation and amputation closure were twelve days and nineteen days, respectively, after the injury. The mean Tegner activity score was 3.32 (range, 1 to 6); patients with isolated extremity injuries had significantly higher Tegner scores than those with severe bilateral injuries (3.59 and 2.38, respectively; p = 0.04). Thirty-three patients (89%) developed an infection requiring surgical debridement. However, all fractures were treated until union occurred, and amputation level salvage was successful in all instances. Heterotopic ossification developed in twenty-eight patients (76%), with operative excision required in eleven patients (39%). Conclusions: High complication rates, but acceptable final results, can be achieved with internal fixation of a fracture proximal to a traumatic amputation to preserve functional joint levels or salvage residual limb length. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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.

On account of the composite nature of blast injuries and high-velocity projectile wounds, combat war injuries around the knee present a significant challenge to orthopedic traumatologists and reconstructive plastic surgeons. The tremendous magnitude of soft tissue destruction and systemic illness that accompanies these injuries mandates a comprehensive and cooperative effort among trauma, vascular, orthopedic, and plastic surgeons to achieve optimal outcomes. The open wounds that accompany wartime traumatic knee injuries leave large soft tissue voids and may involve injury to the stabilizing structures around the knee. In these situations, well- vascularized soft tissue coverage of the bone, ligaments, and tendons of the knee must be achieved. Reconstruction of the open fractures and the lost or traumatized skin and soft tissue must be achieved to salvage a functional joint. Frequently, this includes the reconstruction of the stabilizing ligaments and may involve a requirement for reconstruction of the extensor mechanism of the knee. This study will review preoperative assessment, complications, and recent advances in the management of soft tissue trauma around the knee in war-injured patients treated at level 5 treatment facilities.

Background Many service members returning from Iraq and Afghanistan with severe penetrating extremity injuries are treated with ring fixators and hydroxyapatite (HA) coated pins for limb salvage. The purpose of this study was to determine the pin loosening rate in these severe injuries and to identify factors associated with pin loosening. Methods A retrospective review identified 43 patients with severe open extremity fractures treated with ring external fixation, using 222 HA-coated half pins. A pin was considered loose if the pin site demonstrated erythema, pain, or discharge and concordant radiographs showed 1 mm of radiolucency on both sides of the proximal cortex around the pin. Chi-squared and logistic regression was used to test the association between pin loosening and categorical treatment and injury variables. Results Fifteen (6.8%) pins loosened in nine patients before completion of treatment. Fracture grade, type of tissue traversed, and pins within the zone of injury were associated with pin loosening (P Conclusions Ring external fixation utilizing HA-coated half pins are safe and effective for the treatment of severe wartime fractures. Pins that traverse muscle flaps or the zone of injury increase the risk of pin loosening. Preoperative planning before frame application should minimize pin placement through muscle compartments or mobile soft tissue.

The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Throughout most of the history of warfare, more soldiers died from disease than combat wounds, and misconceptions regarding the best timing and mode of treatment for injuries often resulted in more harm than good. Since the 19th century, mortality from war wounds steadily decreased as surgeons on all sides of conflicts developed systems for rapidly moving the wounded from the battlefield to frontline hospitals where surgical care is delivered. We review the most important trends in US and Western military trauma management over two centuries, including the shift from primary to delayed closure in wound management, refinement of amputation techniques, advances in evacuation philosophy and technology, the development of antiseptic practices, and the use of antibiotics. We also discuss how the lessons of history are reflected in contemporary US practices in Iraq and Afghanistan.

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

Orthopedic injuries suffered by casualties during combat constitute approximately 65% of the total percentage of injuries and are evenly distributed between upper and lower extremities. The high-energy explosive injuries, environmental contamination, varying evacuation procedures, and progressive levels of medical care make managing combat-related injuries challenging. The goals of orthopedic injury management are to prevent infection, promote fracture healing, and restore function. It appears that 2% to 15% of combat-related extremity injuries develop osteomyelitis, although lower extremity injuries are at higher risk of infections than upper extremity. Management strategies of combat-related injuries primarily focus on early surgical debridement and stabilization, antibiotic administration, and delayed primary closure. Herein, we provide evidence-based recommendations from military and civilian data to the management of combat-related injuries of the extremity. Areas of emphasis include the utility of bacterial cultures, antimicrobial therapy, irrigation fluids and techniques, timing of surgical care, fixation, antibiotic impregnated beads, wound closure, and wound coverage with negative pressure wound therapy. Most of the recommendations are not supported by randomized controlled trials or adequate cohorts studies in a military population and further efforts are needed to answer best treatment strategies.

Despite technological advances in the treatment of severe extremity trauma, the timing of wound closure remains the subjective clinical decision of the treating surgeon. Traditional serum markers are poor predictors of wound-healing. The objective of this study was to evaluate the cytokine and chemokine profiles of severe extremity wounds prior to closure to determine if wound effluent markers can be used to predict healing.Serum and effluent (exudate) samples were collected prospectively from adult volunteers with multiple high-energy penetrating extremity wounds sustained during military combat. Samples were collected prior to definitive wound closure or flap coverage. Wounds were followed clinically for six weeks. The primary clinical outcome measures were wound-healing and dehiscence. Control serum samples were collected from normal age and sex-matched adult volunteers. All samples were analyzed for the following cytokines and chemokines: procalcitonin; eotaxin; granulocyte macrophage colony stimulating factor; interferon (IFN)-gamma; interleukin (IL)-1 through 8, 10, 12, 13, and 15; IFN-gamma inducible protein-10; monocyte chemotactic protein-1; macrophage inflammatory protein-1alpha; the protein regulated on activation, normal T expressed and secreted (RANTES); and tumor necrosis factor (TNF)-alpha.Fifty wounds were analyzed in twenty patients. Four of the fifty wounds dehisced. An increased rate of wound dehiscence was observed in patients with a concomitant closed head injury as well as in those with an associated arterial injury of the affected limb (p0.05). Among the serum chemokines and cytokines, only serum procalcitonin levels correlated with wound dehiscence (p0.05). Effluent analysis showed that, compared with wounds that healed, wounds that dehisced were associated with elevated procalcitonin, decreased RANTES protein, and decreased IL-13 concentrations (p0.05). No wound with an effluent procalcitonin concentration of220 pg/mL, an IL-13 concentration of12 pg/mL, or a RANTES protein concentration of1000 pg/mL failed to heal.Effluent procalcitonin, IL-13, and RANTES protein levels as well as serum procalcitonin levels correlate with wound dehiscence following closure of severe open extremity wounds. These preliminary results indicate that effluent biomarker analysis may be an objective means of determining the timing of traumatic wound closure.

Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques.Retrospective review.Level II trauma center.Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013.We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs.Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function.Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation.This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Recent armed conflicts and the expanded reach of international terror groups has resulted in an increased incidence of blast-related injuries in both military and civilian populations. Mass-casualty incidents may require both on-scene and in-hospital triage to maximize survival rates and conserve limited resources. Initial evaluation should focus on the identification and control of potentially life-threatening conditions, especially life-threatening hemorrhage. Early operative priorities for musculoskeletal injuries focus on the principles of damage-control orthopaedics, with early and aggressive debridement of soft-tissue wounds, vascular shunting or grafting to restore limb perfusion, and long-bone fracture stabilization via external fixation. Special considerations such as patient transport, infection control and prevention, and amputation management are also discussed. All orthopedic surgeons, regardless of practice setting, should be familiar with the basic principles of evaluation, resuscitation, and initial management of explosive blast injuries.

More than 9,000 casualties have been evacuated during the current conflict, and more than 40,000 orthopaedic surgical procedures have been performed. The most severely injured patients are treated in the United States at military medical centers. Individualized reconstructive plans are developed, and patients are treated with state-of-the-art techniques. Rehabilitation includes the assistance of the physical medicine and rehabilitation, physical therapy, and occupational therapy services, as well as, when necessary, psychiatric or other services. The extreme challenges of treating war-related soft-tissue defects include neurovascular injuries, burns, heterotopic ossification, infection, prolonged recovery, and persistent pain. Such injuries do not allow full restoration of function. Because of such devastating injuries, and despite use of up-to-date methods, outcomes can be less than optimal.

Pelvic ring disruption that results in a locked pubic symphysis is an unusual injury. A locked pubic symphysis is defined as a compression of the pelvic ring, with the intact pubis becoming trapped against the contralateral pubis. Although the injury pattern is well recognized in clinical practice, to the best of our knowledge, only eight patients with this injury have been reported in the English-language literature1-8 since its original description by Eggers in 19523. A proposed mechanism for a locked symphysis is forced hyperextension and adduction of the hip1 resulting from a lateral compression force to the pelvis. This injury causes a rupture of the ligaments that normally stabilize the symphysis. The superior, anterior, and posterior ligaments are weak, while the arcuate (or inferior) ligament is thought to confer most of the stability to this fibrocartilaginous joint9. After rupture of these ligaments, the displaced pelvic bone may lie either anterior or posterior to the contralateral pubis. Because of the direction and magnitude of this pubic displacement, the injury pattern has been associated with urethral injury2,3,5,7. Although an initial attempt at closed reduction has been advocated6, there is otherwise only limited guidance in the literature regarding the treatment of a locked symphysis. One technique for closed reduction involves using the femur as a lever by locking it in flexion, abduction, and external rotation. The iliofemoral ligaments are thought to hold the femoral head within the acetabulum and to allow reduction with a gentle abduction and rocking motion of the affected extremity3. Authors have cited a risk of femoral fracture in association with this reduction technique and therefore have advocated external rotation of the hemipelvis with a force applied mostly to the …

Foot and ankle reconstruction following blast trauma is particularly challenging based on the devastating soft tissue injuries associated with open comminuted fractures. Considering the difficulties encountered in reconstruction, the functional limitations associated with many salvaged limbs, and the superior performance of contemporary prosthetics, many injured service members may benefit more from below knee amputation than from limb salvage. Limb salvage of blast-injured extremities is a multidisciplinary effort directed toward eradication of infection, treatment of soft tissue and bone defects, and management of late reconstructive procedures. External ring fixators have an important and expanding role in the treatment algorithm.

Study design A biomechanical study of human cadaveric sacra using insertional torque and bone mineral density was conducted to determine the optimal sagittal trajectory of S1 pedicle screws. Objective To measure the maximal insertional torque of sacral promontory versus bicortical pedicle screw fixation. Summary of background data Fixation of instrumentation to the sacrum is commonly accomplished using S1 pedicle screws, with previous studies reporting biomechanical advantages of bicortical over unicortical S1 screws. The biomechanical effect of bicortical screws (paralleling the endplate) versus screws directed into the apex of the sacral promontory is unknown. Methods For this study, 10 fresh frozen cadaver sacra were harvested and evaluated with dual-energy radiograph absorptiometry to assess bone mineral density. Matched 7.5-mm monoaxial stainless steel pedicle screws then were randomly assigned by side (left versus right) and placed bicortically or into the apex of the sacral promontory under direct visualization. Maximum insertional torque was recorded for each screw revolution with a digital torque wrench (TQJE1500, Snap-On Tools, Kenosha, WI). Results Maximum bicortical S1 screw insertional torque averaged 5.22 +/- 0.83 inch-pounds, as compared with the maximum sacral promontory S1 screw insertional torque of 10.34 +/- 1.94 inch-pounds. This resulted in a 99% increase in maximum insertional torque (P = 0.005) using the "tricortical" technique, with the screw directed into the sacral promontory. Mean bone mineral density was 940 +/- 0.25 mg/cm2 (range, 507-1428 mg/cm2). The bone mineral density correlated with maximal insertional torque for the sacral promontory technique (r = 0.806; P = 0.005), but not for the bicortical technique (r = 0.48; P = 0.16). Conclusions The screws directed into the apex of the sacral promontory of the S1 pedicle resulted in an average 99% increase in peak insertional torque (P = 0.005), as compared with bicortical S1 pedicle screw fixation. Tricortical pedicle screw fixation correlates directly with bone mineral density.

OBJECTIVE To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. DESIGN Retrospective review. SETTING Tertiary (Level/Role V) Military Treatment Facility. PATIENTS Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. INTERVENTION Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. MAIN OUTCOME MEASURES Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. RESULTS The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of

Intracompartmental pressure measurements are frequently used in the diagnosis of compartment syndrome, particularly in patients with equivocal or limited physical examination findings. Little clinical work has been done to validate the clinical use of intracompartmental pressures or identify associated false-positive rates. We hypothesized that diagnosis of compartment syndrome based on one-time pressure measurements alone is associated with a high false-positive rate.Forty-eight consecutive patients with tibial shaft fractures who were not suspected of having compartment syndrome based on physical examinations were prospectively enrolled. Pressure measurements were obtained in all four compartments at a single point in time immediately after induction of anesthesia using a pressure-monitoring device. Preoperative and intraoperative blood pressure measurements were recorded. The same standardized examination was performed by the attending surgeon preoperatively, postoperatively, and during clinical follow-up for 6 months to assess clinical evidence of acute or late compartment syndrome.No clinical evidence of compartment syndrome was observed postoperatively or during follow-up until 6 months after injury. Using the accepted criteria of delta P of 30 mm Hg from preoperative diastolic blood pressure, 35% of cases (n = 16; 95% confidence interval, 21.5-48.5%) met criteria for compartment syndrome. Raising the threshold to delta P of 20 mm Hg reduced the false-positive rate to 24% (n = 11; 95% confidence interval, 11.1-34.9%). Twenty-two percent (n = 10; 95% confidence interval, 9.5-32.5%) exceeded absolute pressure of 45 mm Hg.A 35% false-positive rate was found for the diagnosis of compartment syndrome in patients with tibial shaft fractures who were not thought to have compartment syndrome by using currently accepted criteria for diagnosis based solely on one-time compartment pressure measurements. Our data suggest that reliance on one-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies.Diagnostic study, level II.

The 2013 Extremity War Injury symposium focused on the sequelae of combat-related injuries, including posttraumatic osteoarthritis, amputations, and infections. Much remains to be learned about posttraumatic arthritis, and there are few circumstances in which a definitive arthroplasty should be performed in an acutely injured and open joint. Although the last decade has seen tremendous advances in the treatment of combat upper extremity injuries, many questions remain unanswered, and continued research focusing on improving reconstruction of large segmental defects remains critical. Discussion of infection centered on the need for novel methods to reduce the bacterial load following the initial debridement procedures. Novel methods of delivering antimicrobial therapy and anti-inflammatory medications directly to the wound were discussed as well as the need for near real-time assessment of bacterial and fungal burden and further means of prevention and treatment of biofilm formation and the importance of animal models to test therapies discussed. Moderators and lecturers of focus groups noted the continuing need for improved prehospital care in the management of junctional injuries, identified optimal strategies for both surgical repair and/or reconstruction of the ligaments in multiligamentous injuries, and noted the need to mitigate bone mineral density loss following amputation and/or limb salvage as well as the necessity of developing better methods of anticipating and managing heterotopic ossification.

There is no commonly seen parallel in the civilian trauma setting that can prepare one for the instant you see your first patient with traumatic amputations caused by an explosive device. Your ATLS training will serve as your backstop. The airway must be effectively secured, if it is not already. In a mature theatre, it is likely that field medics have already taken several steps, to include endotracheal intubation and control of catastrophic hemorrhage with tourniquets. If this hasn’t been done, apply a tourniquet to stop major hemorrhage immediately. Begin resuscitation with blood products the instant intravenous or intraosseous access is obtained. It is quite conceivable that as an orthopedic surgeon, you will be supervising the resuscitation. Know the transfusion protocols for your theater.

A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combat-related open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion-extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries.

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors’ knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors’ early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

Background: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. Conclusions: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

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.

Hip fractures in the young are exceedingly rare and are usually seen in instances of high energy trauma or metabolically altered bone states. In this case report, we present an occult femoral neck fracture, diagnosed by magnetic resonance imaging, in an otherwise healthy, young, active duty male patient with an isolated vitamin D deficiency treated using cannulated percutaneous screws.

BACKGROUND: Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. METHODS: We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. RESULTS: One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly associated with amputation, revision operation, and prolonged time to union. Surveillance cultures were positive in 64% of extremities and 93% of these cultures isolated gram-negative species. In contrast, infecting organisms were predominantly gram-positive. CONCLUSIONS: Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops.

The objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat between 2007 and 2010 was conducted. Data analyzed included age, injury mechanism, amputated limbs, number and type of associated injuries, blood products utilized, intensive care unit length of stay (ILOS), hospital length of stay (HLOS) and the Injury Severity Score (ISS). Patients were stratified based on the number of amputations. Sixty-three patients comprised the multiple extremity amputation (MEA) group. Ninety-eight percent sustained injuries from an improvised explosive device (IED) and 96% were dismounted. The ISS, number of surgical encounters, blood products utilized and ILOS were all clinically significantly different than controls. Care of multiple extremity amputees involves the utilization of significant resources. This knowledge may better help surgeons and administrators allocate assets at hospitals, both military and civilian, who care for this complex and challenging patient population.

Injuries involving the sternoclavicular region resulting in posterior displacement of the medial clavicle are rare, and those that occur prior to fusion of the medial epiphyseal growth plate are more often a result of physis fracture, rather than sternoclavicular joint dislocation. Medial clavicular physis fractures initially are treated by closed reduction with the expectation of normal osseous repair and remodeling. We report a case of a previously fractured medial clavicle physis that abnormally remodeled, was reinjured, and resulted in posterior displacement with superior vena cava impingement and brachioplexopathy. Our case report describes the patient's initial injury and repair, the reinjury and discovery of abnormal remodeling, and the outcome of surgical intervention. We also include a review of recent literature on sternoclavicular joint injuries and treatment options. To our knowledge, this is the first reported case of an abnormally remodeled medial clavicle resulting in superior vena cava compression.

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.