Jessica C. Rivera

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

&NA; The Army Physical Evaluation Board results for wounded warriors from a previously described cohort were reviewed to identify permanently disabling conditions and whether the conditions were preexisting or caused by battlefield injury. Arthritis was the most common unfitting condition in this cohort, with 94.4% of cases attributed to combat injury and only 5.6% attributed to preexisting conditions or documented in the health records prior to battle injury. The most common causes of injury that resulted in arthritis were intra‐articular fractures secondary to explosions, traumatic arthrotomies resulting from fragment projectiles, and gunshot wounds. Arthritis was recognized as a disabling condition an average of 19 ± 10 months after injury. Research is needed to enhance prevention and management of joint injuries in order to minimize the disabling effects of joint degeneration in this young patient population.

The Changing Face of Disability in the US Army: The Operation Enduring Freedom and Operation Iraqi Freedom Effect

&NA; Orthopaedic disorders account for significant disability among adults in the United States. Previous studies have demonstrated long‐term disability in military personnel with musculoskeletal conditions. However, these studies focused primarily on battlefield‐injured service members and did not evaluate the entire population. The goal of this study was to determine and compare the disabling conditions of the entire United States Army during peacetime and war. We identified the conditions leading to separation from military service before and during Operation Iraqi Freedom and Operation Enduring Freedom. During war, more soldiers are found to be unfit for duty, and they have more conditions per individual that make them unfit. Orthopaedic conditions account for the greatest number of soldiers separated from military service at both time points studied (ie, January through March 2001, January through March 2009). Back pain and osteoarthritis are the two most common causes of separation from military service; these conditions are responsible for the most disability during peacetime and war.

Volumetric muscle loss leads to permanent disability following extremity trauma.

Extremity injuries comprise the majority of battlefield injuries and contribute the most to long-term disability of servicemembers. The purpose of this study was to better define the contribution of muscle deficits and volumetric muscle loss (VML) to the designation of long-term disability in order to better understand their effect on outcomes for limb-salvage patients. Medically retired servicemembers who sustained a combat-related type III open tibia fracture (Orthopedic cohort) were reviewed for results of their medical evaluation leading to discharge from military service. A cohort of battlefield-injured servicemembers (including those with nonorthopedic injuries) who were medically retired because of various injuries (General cohort) was also examined. Muscle conditions accounted for 65% of the disability of patients in the Orthopedic cohort. Among the General cohort, 92% of the muscle conditions were identified as VML. VML is a condition that contributes significantly to long-term disability, and the development of therapies addressing VML has the potential to fill a significant void in orthopedic care.

Infection reduces return-to-duty rates for soldiers with Type III open tibia fractures.

BACKGROUND Infection is a potentially devastating complication following severe lower extremity trauma, but its impact on the outcomes of combat casualties remains unclear. We hypothesize that orthopedic infectious complications will have a negative impact on holistic patient outcome as measured by return-to-duty (RTD) and disability ratings among wounded soldiers. METHODS We reviewed the medical records for 115 wounded soldiers who sustained a Type III open tibia fracture and tabulated the prevalence of infectious complications. We searched the Physical Evaluation Board database to determine the disability ratings of soldiers with and without an infection and how many of each group was able to return to active duty service. The average percent disability rating and RTD rates between groups were compared using an unpaired t test and &khgr;2 test, respectively. RESULTS Overall, 40% of our cohort had an infectious complication of their fractured limb. Twenty-one soldiers were able to RTD, while 94 could not and were medically retired. Of those medically retired, 44% had an infection. The average percent disability among soldiers with infection was 55%, compared with 47% for those who were not infected (p = 0.1407). Soldiers who experienced any type of infectious complication (p = 0.0470) and having osteomyelitis (p = 0.0335) had a lower chance of RTD compared with those who had no infection. Having a deep soft tissue infection alone showed a strong trend toward decreased RTD rate (p = 0.0558). CONCLUSION Infectious complications following severe lower extremity trauma significantly decrease the rate of RTD. In addition, the presence of infectious complications demonstrates a trend toward higher disability ratings in the combat wounded. LEVEL OF EVIDENCE Prognostic study, level III.

Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients☆

INTRODUCTION Following severe lower extremity trauma, patients who undergo limb reconstruction and amputations both endure frequent complications and mental health sequelae. The purpose of this study is to assess the extent to which late amputation following a period of limb salvage impacts the evolution of the clinical variables that can affect the patients perception of his or her limb: ongoing limb associated complications and mental health conditions. PATIENTS AND METHODS A case series of US service members who sustained a late major extremity amputation from September 2001 through July 2011 were analysed. Pre- and post-amputation complications, mental health conditions, and reason(s) for desiring amputation were recorded. RESULTS Forty-four amputees with detailed demographic, injury and treatment data were identified. The most common reasons for desiring a late amputation were pain and being dissatisfied with the function of the salvage limb. An average of 3.2 (range 1-10) complications were reported per amputee prior to undergoing late amputation and an average of 1.8 (range 0-5) complications reported afterwards. The most common complication prior to and after late amputation was soft tissue infection (24 (17%) and 9 (22%), respectively). Twenty-nine (64%) late amputees were diagnosed with a mental health condition prior to undergoing their amputation and 27 (61%) late amputees were diagnosed with mental conditions after late amputation. Only three of the 15 patients who did not have a mental health condition documented prior to their late amputation remained free of a documented mental health condition after the amputation. DISCUSSION Ongoing complications and mental health conditions can affect how a patient perceives and copes with his or her limb following severe trauma. Patient dissatisfaction following limb reconstruction can influence the decision to undergo a late amputation. Patients with a severe, combat related lower extremity injury that are undergoing limb salvage may not have a reduction in their overall complication rate, a resolution of specific complications or an improvement of their mental health after undergoing late amputation. CONCLUSION Surgeons caring for limb salvage patients should counsel appropriately when managing expectations for a patient who desires a late amputation.

Characterisation and outcomes of upper extremity amputations

BACKGROUND The purpose of this study is to characterise the injuries, outcomes, and disabling conditions of the isolated, combat-related upper extremity amputees in comparison to the isolated lower extremity amputees and the general amputee population. METHODS A retrospective study of all major extremity amputations sustained by the US military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, and the Physical Evaluation Board Liaison Offices were queried in order to obtain injury characteristics, demographic information, treatment characteristics, and disability outcome data. RESULTS A total of 1315 service members who sustained 1631 amputations were identified; of these, 173 service members were identified as sustaining an isolated upper extremity amputation. Isolated upper extremity and isolated lower extremity amputees had similar Injury Severity Scores (21 vs. 20). There were significantly more non-battle-related upper extremity amputees than the analysed general amputation population (39% vs. 14%). Isolated upper extremity amputees had significantly greater combined disability rating (82.9% vs. 62.3%) and were more likely to receive a disability rating >80% (69% vs. 53%). No upper extremity amputees were found fit for duty; only 12 (8.3%) were allowed continuation on active duty; and significantly more upper extremity amputees were permanently retired than lower extremity amputees (82% vs. 74%). The most common non-upper extremity amputation-related disabling condition was post-traumatic stress disorder (PTSD) (17%). Upper extremity amputees were significantly more likely to have disability from PTSD, 13% vs. 8%, and loss of nerve function, 11% vs. 6%, than the general amputee population. DISCUSSION/CONCLUSION Upper extremity amputees account for 14% of all amputees during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts. These amputees have significant disability and are unable to return to duty. Much of this disability is from their amputation; however, other conditions greatly contribute to their morbidity.

Beyond osteogenesis: an in vitro comparison of the potentials of six bone morphogenetic proteins

Bone morphogenetic proteins (BMPs) other than the clinically available BMP-2 and BMP-7 may be useful for improving fracture healing through both increasing osteogenesis and creating a favorable healing environment by altering cytokine release by endogenous cells. Given the spectrum of potential applications for BMPs, the objective of this study was to evaluate various BMPs under a variety of conditions to provide further insight into their therapeutic capabilities. The alkaline phosphatase (ALP) activity of both C2C12 and human adipose-derived stem cells (hASCs) was measured after exposure of increasing doses of recombinant human BMP-2, -4, -5, -6, -7, or -9 for 3 and 7 days. BMPs-2, -4, -5, -6, -7, and -9 were compared in terms of their ability to affect the release of stromal derived factor-1 (SDF-1), vascular endothelial growth factor (VEGF), and basic fibroblast growth factor (b-FGF) from human bone marrow stromal cells (hBMSCs). Gene expression of ALP, osteocalcin, SDF-1, VEGF, and b-FGF following shRNA-mediated knockdown of BMP-2 and BMP-6 in hBMSCs or human osteoblasts under osteogenic differentiation conditions was also evaluated. Collectively, BMPs-6 and -9 produced the greatest osteogenic differentiation of C2C12 and hASCs as determined by ALP. The hBMSC secretion of SDF-1 was most affected by BMP-5, VEGF by BMP-4, and b-FGF by BMP-2. The knockdown of BMP-2 in BMSCs had no effect on any of the genes measured whereas BMP-6 knockdown in hBMSCs caused a significant increase in VEGF gene expression. BMP-2 and BMP-6 knockdown in human osteoblasts caused significant increases in VEGF gene expression and trends toward decreases in osteocalcin expression. These findings support efforts to study other BMPs as potential bone graft supplements, and to consider combined BMP delivery for promotion of multiple aspects of fracture healing.

Unwavering Pathobiology of Volumetric Muscle Loss Injury.

Volumetric muscle loss (VML) resulting from extremity trauma presents chronic and persistent functional deficits which ultimately manifest disability. Acellular biological scaffolds, or decellularized extracellular matrices (ECMs), embody an ideal treatment platform due to their current clinical use for soft tissue repair, off-the-shelf availability, and zero autogenous donor tissue burden. ECMs have been reported to promote functional skeletal muscle tissue remodeling in small and large animal models of VML injury, and this conclusion was reached in a recent clinical trial that enrolled 13 patients. However, numerous other pre-clinical reports have not observed ECM-mediated skeletal muscle regeneration. The current study was designed to reconcile these discrepancies. The capacity of ECMs to orchestrate functional muscle tissue remodeling was interrogated in a porcine VML injury model using unbiased assessments of muscle tissue regeneration and functional recovery. Here, we show that VML injury incites an overwhelming inflammatory and fibrotic response that leads to expansive fibrous tissue deposition and chronic functional deficits, which ECM repair does not augment.

Identifying obstacles to return to duty in severely injured combat-related servicemembers with amputation

The capacity of servicemembers with amputation to return to duty after combat-related amputation and the associated disabilities remains largely unknown. The purpose of this study was to examine the disabling conditions and return to duty rates of servicemembers with amputation across all service branches following major limb amputations from September 2001 through July 2011. Pertinent medical information, military occupation status, return to duty designation, disabling conditions, and disability ratings for each servicemember were obtained from the Physical Evaluation Board Liaison Office (PEBLO). Across all service branches, 16 (2%) servicemembers were found fit for duty (Fit) and allowed to continue with their preinjury occupation. Another 103 (11%) were allowed to continue on Active Duty (COAD) in a less physically demanding role. More than half (554, 56%) were determined fully disabled (PEBLO rating > 75); the average disability rating was 73. COAD and Fit Army servicemembers had lower Injury Severity Scores than other servicemembers (17.4, p = 0.009 and 11.2, p < 0.001, respectively). Despite improvements in their care and rehabilitation, only 13% of all servicemembers with amputation are able to return to Active Duty and many have multiple disabling conditions that contribute to a very high level of disability.

Orthopedic Trauma: Extremity Fractures

Fractures continue to account for a large proportion of combat-related injuries. The basic tenets of irrigation, debridement, soft tissue care, and vigilant monitoring/fasciotomy for acute compartment syndrome persist. Closed management of fractures with splinting or casting is acceptable. If time and facility allow, external fixation of fractures offer many advantages over closed treatment but require knowledge, experience and skill in the safe placement of pins. The care of host nationals presents unique challenges and deployed surgeons must be flexible and resourceful in these situations.