James R. Ficke

Battlefield orthopaedic injuries cause the majority of long-term disabilities

&NA; Extremity injuries make up 54% of combat wounds sustained in Operation Iraqi Freedom and Operation Enduring Freedom. In a cohort of war‐wounded service members, we identified the conditions secondary to battle injury that result in disqualification from continued service. The Army Physical Evaluation Board records of 464 wounded service members who were injured between October 2001 and January 2005 were reviewed to determine the codes indicating unfitting conditions. Sixty‐nine percent of these conditions were orthopaedic. Fifty‐seven percent of the injured had unfitting conditions that were orthopaedic only. Of those evacuated from theater with a primary diagnosis of injury to the head, thorax, or abdomen and who suffered an orthopaedic injury as well, 76% had an orthopaedic diagnosis as the primary unfitting condition. Orthopaedic‐related disability has a significant impact on the affected patient, the health care system, and, in the case of wounded service members, on military strength and readiness.

Ten years at war: comprehensive analysis of amputation trends.

BACKGROUND While multiple studies have examined amputations that have occurred during the current conflicts in Iraq and Afghanistan, none of these studies have provided an overarching characterization of all of these injuries. METHODS A retrospective study of all major extremity amputations sustained by US Service Members from January 2001 through July 30, 2011, was performed. Data obtained from these amputees included amputation level(s), mechanism of injury, time to amputation, Injury Severity Score (ISS), age, rank, number of trauma admissions, and number of troops deployed. RESULTS There were 1,221 amputees who met inclusion criteria. These amputees sustained a total of 1,631 amputations. The number of amputations performed each year has increased dramatically in 2010 (196) and the first half of 2011 (160) from 2008 (105) and 2009 (94). The number of amputations performed per every 100 traumatic admissions (3.5–14) and the number of amputations per 100,000 deployed troops (2–14) has also increased in 2010 and the first half of 2011. Most amputations occurred at the transtibial (683, 41.8%) and transfemoral (564, 34.5%) levels. Thirty percent of the amputees (366) sustained multiple amputations, and 14% of all amputations (228) performed involved the upper extremity. There were 127 amputees (10%) who underwent their amputation more than 90 days after the date of injury. CONCLUSION The number of amputations occurring during the current Iraqi and Afghanistan conflicts has increased in 2010 and the first half of 2011. Most amputations involve the lower extremities, and there is a much higher percentage of amputees who have sustained multiple amputations during current operations than previous conflicts. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Prevention and management of infections associated with combat-related extremity injuries.

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.

Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom.

Objectives: Injuries are common during combat operations. The high costs of extremity injuries both in resource utilization and disability are well known in the civilian sector. We hypothesized that, similarly, combat-related extremity injuries, when compared with other injures from the current conflicts in Iraq and Afghanistan, require the largest percentage of medical resources, account for the greatest number of disabled soldiers, and have greater costs of disability benefits. Design: Descriptive epidemiologic study and cost analysis. Methods: The Department of Defense Medical Metrics (M2) database was queried for the hospital admissions and billing data of a previously published cohort of soldiers injured in Iraq and Afghanistan between October 2001 and January 2005 and identified from the Joint Theater Trauma Registry. The US Army Physical Disability Administration database was also queried for Physical Evaluation Board outcomes for these soldiers, allowing calculation of disability benefit cost. Primary body region injured was assigned using billing records that gave a primary diagnosis International Classification of Diseases Ninth Edition code, which was corroborated with Joint Theater Trauma Registry injury mechanisms and descriptions for accuracy. Results: A total of 1333 soldiers had complete admission data and were included from 1566 battle injuries not returned to duty of 3102 total casualties. Extremity-injured patients had the longest average inpatient stay at 10.7 days, accounting for 65% of the

Prevention of infections associated with combat-related extremity injuries

65.3-million total inpatient resource utilization, 64% of the 464 patients found “unfit for duty,” and 64% of the

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update endorsed by the infectious diseases society of America and the surgical infection society

170-million total projected disability benefit costs. Extrapolation of data yields total disability costs for this conflict, approaching

Return to Duty Rate of Amputee Soldiers in the Current Conflicts in Afghanistan and Iraq

2 billion. Conclusions: Combat-related extremity injuries require the greatest utilization of resources for inpatient treatment in the initial postinjury period, cause the greatest number of disabled soldiers, and have the greatest projected disability benefit costs. This study highlights the need for continued or increased funding and support for military orthopaedic surgeons and extremity trauma research efforts.

Guidelines for the prevention of infection after combat-related injuries.

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. 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.

Posttraumatic Osteoarthritis Caused by Battlefield Injuries: The Primary Source of Disability in Warriors

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.

Prevalence of Late Amputations During the Current Conflicts in Afghanistan and Iraq

BACKGROUND The purpose of this study was to determine the percentage of amputee soldiers who sustained their injury during the current conflicts in Afghanistan and Iraq and have returned to duty. In addition, the authors plan to identify the factors that influence the amputees likelihood to return to duty. METHODS The computerized records of amputee soldiers who presented to the Physical Evaluation Board between October 1, 2001 and June 1, 2006 were reviewed. This data were crossreferenced with the Military Amputee Database. The following variables were extracted: age, gender, pay grade, amputation level, and final disposition. RESULTS During the period reviewed, there were 395 major limb amputees that met inclusion criteria. Of those, 65 returned to active duty (16.5%). The average age of amputees returning to duty was more than 4 years older than those who separated from the service (31.4 vs. 27.2), p < 0.0001. Officers and senior enlisted personnel returned to duty at a higher rate (35.3% and 25.5%, respectively) when compared with junior enlisted personnel (7.0%), p < 0.0001. Those with multiple extremity amputations have the lowest return to duty rate at 3%, when compared with the overall return to duty rate for single extremity amputees (20%), p < 0.0001. CONCLUSION During the 1980s, 11 of 469 amputees returned to active duty (2.3%). The number of amputees returning to duty has increased significantly, from 2.3% to 16.5%, due to advancements in combat casualty care and the establishment of centralized amputee centers.