The nature and incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009)

Chiropractic management of acute low back pain in a U.S. veteran with unilateral transtibial amputation: A case report

OBJECTIVE

The purpose of this case report is to describe chiropractic management of acute low back pain for a patient with a unilateral transtibial amputation.

CLINICAL FEATURES

A 39-year-old male veteran presented to the VA Puget Sound chiropractic clinic with acute low back pain. The patient had a history of a left transtibial amputation secondary to a blast injury sustained during combat. He presented wearing a prosthesis, walking with a left trunk antalgia, and utilizing a cane for ambulation assistance due to low back pain severity. The PEG patient-reported outcome was scored 7.3/10. Lumbar range of motion produced severe pain with flexion and mild pain with extension and right lateral flexion. Repetitive lumbar extension reduced the low back pain intensity without peripheralization of symptoms. Orthopedic testing was provocative for low back pain, but not radicular symptoms.

INTERVENTION AND OUTCOME

A trial of care was completed with six visits over six weeks and included high-velocity, low-amplitude spinal manipulative therapy spinal manipulative therapy, spinal end-range loading, and exercise prescription. Following the first visit, there was an immediate reduction in pain, and the patient was able to ambulate without the use of his cane. A resolution of the complaint was achieved by the sixth visit, with a final PEG mean score of 1/10, and he was released from care to self-management.

CONCLUSION

This is only the third case report to describe the chiropractic management of a patient with comorbid transtibial amputation. Our case highlights the necessary modification of the examination and a positive outcome following a trial of care. There is currently limited guidance available for clinicians to aid the management of individuals with spinal complaints and lower limb amputations, suggesting a gap in the literature.

Recent Orthopedic Trauma Volume in the United States Military Health System

INTRODUCTION

As illustrated by the "Walker Dip," there is growing concern regarding the lack of combat casualty care during peacetime. Surgical volume and case complexity are paramount for training and skill sustainment. We sought to quantify the recent orthopedic trauma surgical case load of all military orthopedic surgeons across the Military Health System (MHS).

MATERIALS AND METHODS

We queried the United States MHS Data Repository for orthopedic trauma-related Current Procedural Terminology codes for which the Accreditation Council for Graduate Medical Education (ACGME) requires graduating residents to perform a minimum case volume: hip fracture, femur/tibia shaft fracture, pilon fracture, and ankle fracture. The search yielded all corresponding procedures performed between January 2017 and December 2023 within the MHS.

RESULTS

There were 15,873 total ACGME-minimum orthopedic trauma procedures performed across the MHS during the study period (2,268 cases per year) for the fixation of 3,283 hip fractures, 805 femoral shaft fractures, 1,455 tibial shaft fractures, and 10,330 ankle or pilon fractures. The sole level I trauma center in the MHS, which accepts civilian trauma, performed 21% of all cases. Civilian trauma made up 70% of this military treatment facility's volume. For another military treatment facility that began accepting civilian trauma in the middle of the study period, the volume increased from 49 to 123 cases per year.

CONCLUSION

Across the MHS, there was a low volume of ACGME-minimum orthopedic trauma procedures performed. These data help to frame the current orthopedic trauma surgical volume in the United States MHS in support of efforts to maximize military surgeon training and readiness, ultimately in preparation for future conflicts.

Biomaterial-Based Regenerative Strategies for Volumetric Muscle Loss: Challenges and Solutions

Significance: Volumetric muscle loss (VML) is caused by the loss of significant amounts of skeletal muscle tissue. VML cannot be repaired by intrinsic regenerative processes, resulting in permanent loss of muscle function and disability. Current rehabilitative-focused treatment strategies lack efficacy and do not restore muscle function, indicating the need for the development of effective regenerative strategies. Recent Advances: Recent developments implicate biomaterial-based approaches for promoting muscle repair and functional restoration post-VML. Specifically, bioscaffolds transplanted in the injury site have been utilized to mimic endogenous cues of the ablated tissue to promote myogenic pathways, increase neo-myofiber synthesis, and ultimately restore contractile function to the injured unit. Critical Issues: Despite the development and preclinical testing of various biomaterial-based regenerative strategies, effective therapies for patients are not available. The unique challenges posed for biomaterial-based treatments of VML injuries, including its scalability and clinical applicability beyond small-animal models, impede progress. Furthermore, production of tissue-engineered constructs is technically demanding, with reproducibility issues at scale and complexities in achieving vascularization and innervation of large constructs. Future Directions: Biomaterial-based regenerative strategies designed to comprehensively address the pathophysiology of VML are needed. Considerations for clinical translation, including scalability and regulatory compliance, should also be considered when developing such strategies. In addition, an integrated approach that combines regenerative and rehabilitative strategies is essential for ensuring functional improvement.

Biomechanical validation of the field-expedient pelvic splint

INTRODUCTION

Morbidity and mortality from pelvic ring injuries can be mitigated by early and effective external pelvic stabilisation. The field-expedient pelvic splint (FEPS) is a recently described technique to improvise an effective pelvic binder for an austere environment. This technique has not been biomechanically validated. We hypothesise that the FEPS will be biomechanically equivalent to a commercially available pelvic binder routinely used in the austere environment.

METHODS

Compressive force generation of the FEPS was measured using a commercial load frame. A SAM Pelvic Sling was used as a control. The FEPS was tested for initial force generation, persistence of force generation over a 6-hour longitudinal test period and force generation after repeated assembly/disassembly.

RESULTS

The FEPS generated 203N (±7N) with one windlass turn and 420N (±34N) with two windlass turns. The SAM Pelvic Sling generated 197N (±11N) of force. There was no significant difference between FEPS after one windlass crank and the SAM Pelvic Sling but the force generated by the FEPS with two windlass cranks was significantly higher than the SAM Pelvic Sling. Longitudinal testing showed that after 6 hours of continuous compression, the FEPS generated 189N (±19N) and the force generated at hour 6 was not significantly different from the initial force generated by SAM Pelvic Sling. Reusability testing showed no significant difference with force generation by the FEPS after repeated assembly/disassembly with one crank of the windlass but there was a significantly increased force generation by FEPS after repeated use trials with two cranks of the windlass.

CONCLUSION

The FEPS exerted equivalent pelvic compressive forces to its commercial equivalent and this force generation persists at effective levels over a 6-hour time course. The FEPS remained effective after repeated use. The FEPS is a viable alternative in the austere or resource-limited environment for temporary pelvic stabilisation.

The influence of microbial colonization on inflammatory versus pro-healing trajectories in combat extremity wounds

A combination of improved body armor, medical transportation, and treatment has led to the increased survival of warfighters from combat extremity injuries predominantly caused by blasts in modern conflicts. Despite advances, a high rate of complications such as wound infections, wound failure, amputations, and a decreased quality of life exist. To study the molecular underpinnings of wound failure, wound tissue biopsies from combat extremity injuries had RNA extracted and sequenced. Wounds were classified by colonization (colonized vs. non-colonized) and outcome (healed vs. failed) status. Differences in gene expression were investigated between timepoints at a gene level, and longitudinally by multi-gene networks, inferred proportions of immune cells, and expression of healing-related functions. Differences between wound outcomes in colonized wounds were more apparent than in non-colonized wounds. Colonized/healed wounds appeared able to mount an adaptive immune response to infection and progress beyond the inflammatory stage of healing, while colonized/failed wounds did not. Although, both colonized and non-colonized failed wounds showed increasing inferred immune and inflammatory programs, non-colonized/failed wounds progressed beyond the inflammatory stage, suggesting different mechanisms of failure dependent on colonization status. Overall, these data reveal gene expression profile differences in healing wounds that may be utilized to improve clinical treatment paradigms.

Novel muscle-derived extracellular matrix hydrogel promotes angiogenesis and neurogenesis in volumetric muscle loss

Volumetric muscle loss (VML) represents a clinical challenge due to the limited regenerative capacity of skeletal muscle. Most often, it results in scar tissue formation and loss of function, which cannot be prevented by current therapies. Decellularized extracellular matrix (DEM) has emerged as a native biomaterial for the enhancement of tissue repair. Here, we report the generation and characterization of hydrogels derived from DEM prepared from WT or thrombospondin (TSP)-2 null muscle tissue. TSP2-null hydrogels, when compared to WT, displayed altered architecture, protein composition, and biomechanical properties and allowed enhanced invasion of C2C12 myocytes and chord formation by endothelial cells. They also displayed enhanced cell invasion, innervation, and angiogenesis following subcutaneous implantation. To evaluate their regenerative capacity, WT or TSP2 null hydrogels were used to treat VML injury to tibialis anterior muscles and the latter induced greater recruitment of repair cells, innervation, and blood vessel formation and reduced inflammation. Taken together, these observations indicate that TSP2-null hydrogels enhance angiogenesis and promote muscle repair in a VML model.

Periarticular blast wounds without fracture a prospective case series

BACKGROUND

During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture.

METHODS

The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement.

RESULTS

Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01).

CONCLUSION

Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Recent Advances in Implantable Biomaterials for the Treatment of Volumetric Muscle Loss

BACKGROUND

Volumetric muscle loss (VML) causes pain and disability in patients who sustain traumatic injury from invasive surgical procedures, vehicle accidents, and battlefield wounds. Clinical treatment of VML injuries is challenging, and although options such as free-flap autologous grafting exist, patients inevitably develop excessive scarring and fatty infiltration, leading to muscle weakness and reduced quality of life.

SUMMARY

New bioengineering approaches, including cell therapy, drug delivery, and biomaterial implantation, have emerged as therapies to restore muscle function and structure to pre-injury levels. Of these, acellular biomaterial implants have attracted wide interest owing to their broad potential design space and high translational potential as medical devices. Implantable biomaterials fill the VML defect and create a conduit that permits the migration of regenerative cells from the intact muscle tissue to the injury site. Invading cells and regenerating myofibers are sensitive to the biomaterial's structural and biochemical properties, which can play instructive roles in guiding cell fate and organization into functional tissue.

KEY MESSAGES

Many diverse biomaterials have been developed for skeletal muscle regeneration with variations in biophysical and biochemical properties, and while many have been tested in vitro, few have proven their regenerative potential in clinically relevant in vivo models. Here, we provide an overview of recent advances in the design, fabrication, and application of acellular biomaterials made from synthetic or natural materials for the repair of VML defects. We specifically focus on biomaterials with rationally designed structural (i.e., porosity, topography, alignment) and biochemical (i.e., proteins, peptides, growth factors) components, highlighting their regenerative effects in clinically relevant VML models.

Evaluation of gunshot injuries to long bones from pneumatic weapons using a human thigh model. Part I. Introduction and assumptions. Discussion of shot ballistics. Human thigh model

Introduction

In accordance with the Polish law, pneumatic weapons are weapons that use compressed gas to set a bullet in motion and generate a discharge energy of more than 17J. In recent years, Poland has seen an increase in crimes committed with pneumatic weapons. The research aim of the present study was to measure the velocity of selected 5.5 mm and 6.35 mm caliber shot and to create a model of a human thigh using a pig femur.

Material and methods

This study used Air Arms Hi-Power Xtra FAC cal. 5.5 mm and FX Bobcat Mk II cal. 6.35 mm carbines and Haendler& Natterman's Spitzkugel, Hollow Point and Baracuda cal. 5.5 mm and 6.35 mm lead shot and Excite Apollo cal. 5.5 mm and Black Max Lead-Free cal. 6.35 mm lead-free shot. The velocity of the shot at a distance of 10 m was measured and its kinetic energy was calculated; pig femurs were measured and CT imaging was performed.

Results

The 5.5mm caliber shot reached velocities between 253 m/s and 278 m/s, obtaining energies between 27J and 44J. The 6.35 mm cal. shot reached velocities between 242 m/s and 254 m/s and energies between 52J and 59J. Pig femurs had an average weight of 410 g, a length of 239 mm, and a shaft diameter at mid-length of 30.6mm. The thickness of pig femur shaft walls was variable. A ballistic model of the human thigh was created using gelatin available in Poland.

Conclusions

1. The number of registered crimes with pneumatic weapons and the wide access to pneumatic devices with the possibility of design modifications justify the initiation of experimental studies on the assessment of gunshot injuries from pneumatic weapons. 2. The parameters of the shaft of a pig femur obtained from pigs weighing about 115 kg are similar to those of a human adult femur, which makes it possible to create a human thigh model. 3. Of the 5.5 mm cal. shot, the highest impact energies were generated by barracuda type shot, and of the 6.35 mm cal. shot, it was barracuda type and lead-free shot. 4. The thickness of the bony layer of the pig femur shaft is heterogeneous; the posterior wall of the shaft is the thickest, the lateral wall is the thinnest; however, it shows the greatest individual variability.

No pain, no gain: The military overtraining hypothesis of musculoskeletal stress and injury

The purpose of this manuscript is to present a model of military overtraining and subsequent injury, discharge, and disability. Military training and combat operations are physically and physiologically demanding, placing great strain on the musculoskeletal system of warfighters. Non-battle musculoskeletal injuries (MSKI) are common and present a serious threat to operational readiness in today's military. MSKI risk stratification and prevention are an active area of research and is steeped in the background of sports science. Here, a model is proposed that incorporates the theory of General Adaptation Syndrome to describe how military training stressors may exceed that of training in traditional athletics and may induce sub-optimal training stressors. Positive feedback loops are discussed to explain how military overtraining (MOT) creates a system of ever-increasing stressors that can only be fully understood in the greater context of all environmental factors leading to overtraining. The Military Overtraining Hypothesis (MOTH) is proposed as a model that encapsulates the elevated MSKI risk in combat arms and other operational military personnel as an effort to broaden understanding of multifactorial military MSKI etiologies and as a tool for researchers and commanders to contextualize MSKI research and risk mitigation interventions.

Supporting the Frontlines: A Scoping Review Addressing the Health Challenges of Military Personnel and Veterans

(1) Background: Military personnel and veterans meet unique health challenges that stem from the complex interplay of their service experiences, the nature of warfare, and their interactions with both military and civilian healthcare systems. This study aims to examine the myriad of injuries and medical conditions specific to this population, encompassing physical and psychological traumas. (2) Methods: A scoping review (systematic search and non-systematic review) was performed to evaluate the current landscape of military healthcare. (3) Results: A significant change in the injury profile over time is identified, linked to shifts in combat strategies and the integration of advanced technologies in warfare. Environmental exposures to diverse chemical or natural agents further complicate the health of service members. Additionally, the stressors they face, ranging from routine stress to traumatic experiences, lead to various mental health challenges. A major concern is the gap in healthcare accessibility and quality, worsened by challenges in the civilian healthcare system's capacity to address these unique needs and the military healthcare system's limitations. (4) Conclusions: This review underscores the need for holistic, integrated approaches to care, rigorous research, and targeted interventions to better serve the health needs of military personnel and veterans.

Immunopathological Alterations after Blast Injury and Hemorrhage in a Swine Model of Prolonged Damage Control Resuscitation

Trauma-related hemorrhagic shock (HS) remains a leading cause of death among military and civilian trauma patients. We have previously shown that administration of complement and HMGB1 inhibitors attenuate morbidity and mortality 24 h after injury in a rat model of blast injury (BI) and HS. To further validate these results, this study aimed to develop a swine model and evaluate BI+HS-induced pathophysiology. Anesthetized Yucatan minipigs underwent combined BI and volume-controlled hemorrhage. After 30 min of shock, animals received an intravenous bolus of PlasmaLyte A and a continuous PlasmaLyte A infusion. The survival rate was 80% (4/5), and the non-survivor expired 72 min post-BI. Circulating organ-functional biomarkers, inflammatory biomarkers, histopathological evaluation, and CT scans indicated evidence of multiple-organ damage, systemic innate immunological activation, and local tissue inflammation in the injured animals. Interestingly, a rapid and dramatic increase in plasma levels of HMGB1 and C3a and markedly early myocarditis and encephalitis were associated with early death post-BI+HS. This study suggests that this model reflects the immunopathological alterations of polytrauma in humans during shock and prolonged damage control resuscitation. This experimental protocol could be helpful in the assessment of immunological damage control resuscitation approaches during the prolonged care of warfighters.

Temporal corridors of forces and moments, and injuries to pelvis-lumbar spine in vertical impact simulating underbody blast

Pelvis and lumbar spine fractures occur in falls, motor vehicle crashes, and military combat events. They are attributed to vertical impact from the pelvis to the spine. Although whole-body cadavers were exposed to this vector and injuries were reported, spinal loads were not determined. While previous studies determined injury metrics such as peak forces using isolated pelvis or spine models, they were not conducted using the combined pelvis-spine columns, thereby not accounting for the interaction between the two body regions. Earlier studies did not develop response corridors. The study objectives were to develop temporal corridors of loads at the pelvis and spine and assess clinical fracture patterns using a human cadaver model. Vertical impact loads were delivered at the pelvic end to twelve unembalmed intact pelvis-spine complexes, and pelvis forces and spinal loads (axial, shear and resultant and bending moments) were obtained. Injuries were classified using clinical assessments from post-test computed tomography scans. Spinal injuries were stable in eight and unstable in four specimens. Pelvis injuries included ring fractures in six and unilateral pelvis in three, sacrum fractures in ten, and two specimens did not sustain any injuries to the pelvis or sacrum complex. Data were grouped based on time to peak velocity, and ± one standard deviation corridors about the mean of the biomechanical metrics were developed. Time-history corridors of loads at the pelvis and spine, hitherto not reported in any study, are valuable to assess the biofidelity of anthropomorphic test devices and assist validating finite element models.

The impact of bilateral injuries on the pathophysiology and functional outcomes of volumetric muscle loss

Volumetric muscle loss (VML)-defined as the irrecoverable loss of skeletal muscle tissue with associated persistent functional deficits-is among the most common and highly debilitating combat-related extremity injuries. This is particularly true in cases of severe polytrauma wherein multiple extremities may be involved as a result of high energy wounding mechanisms. As such, significant investment and effort has been made toward developing a clinically viable intervention capable of restoring the form and function of the affected musculature. While these investigations conducted to date have varied with respect to the species, breed, and sex of the chosen pre-clinical in-vivo model system, the majority of these studies have been performed in unilateral injury models, an aspect which may not fully exemplify the clinical representation of the multiply injured patient. Furthermore, while various components of the basal pathophysiology of VML (e.g., fibrosis and inflammation) have been investigated, relatively little effort has focused on how the pathophysiology and efficacy of pro-regenerative technologies is altered when there are multiple VML injuries. Thus, the purpose of this study was two-fold: (1) to investigate if/how the pathophysiology of unilateral VML injuries differs from bilateral VML injuries and (2) to interrogate the effect of bilateral VML injuries on the efficacy of a well-characterized regenerative therapy, minced muscle autograft (MMG). In contrast to our hypothesis, we show that bilateral VML injuries exhibit a similar systemic inflammatory response and improved muscle functional recovery, compared to unilateral injured animals. Furthermore, MMG treatment was found to only be effective at promoting an increase in functional outcomes in unilateral VML injuries. The findings presented herein add to the growing knowledge base of the pathophysiology of VML, and, importantly, reiterate the importance of comprehensively characterizing preclinical models which are utilized for early-stage screening of putative therapies as they can directly influence the translational research pipeline.

Metagenomic features of bioburden serve as outcome indicators in combat extremity wounds

Battlefield injury management requires specialized care, and wound infection is a frequent complication. Challenges related to characterizing relevant pathogens further complicates treatment. Applying metagenomics to wounds offers a comprehensive path toward assessing microbial genomic fingerprints and could indicate prognostic variables for future decision support tools. Wound specimens from combat-injured U.S. service members, obtained during surgical debridements before delayed wound closure, were subjected to whole metagenome analysis and targeted enrichment of antimicrobial resistance genes. Results did not indicate a singular, common microbial metagenomic profile for wound failure, instead reflecting a complex microenvironment with varying bioburden diversity across outcomes. Genus-level Pseudomonas detection was associated with wound failure at all surgeries. A logistic regression model was fit to the presence and absence of antimicrobial resistance classes to assess associations with nosocomial pathogens. A. baumannii detection was associated with detection of genomic signatures for resistance to trimethoprim, aminoglycosides, bacitracin, and polymyxin. Machine learning classifiers were applied to identify wound and microbial variables associated with outcome. Feature importance rankings averaged across models indicated the variables with the largest effects on predicting wound outcome, including an increase in P. putida sequence reads. These results describe the microbial genomic determinants in combat wound bioburden and demonstrate metagenomic investigation as a comprehensive tool for providing information toward aiding treatment of combat-related injuries.

Bioinks and Bioprinting Strategies for Skeletal Muscle Tissue Engineering

Skeletal muscles play important roles in critical body functions and their injury or disease can lead to limitation of mobility and loss of independence. Current treatments result in variable functional recovery, while reconstructive surgery, as the gold-standard approach, is limited due to donor shortage, donor-site morbidity, and limited functional recovery. Skeletal muscle tissue engineering (SMTE) has generated enthusiasm as an alternative solution for treatment of injured tissue and serves as a functional disease model. Recently, bioprinting has emerged as a promising tool for recapitulating the complex and highly organized architecture of skeletal muscles at clinically relevant sizes. Here, skeletal muscle physiology, muscle regeneration following injury, and current treatments following muscle loss are discussed, and then bioprinting strategies implemented for SMTE are critically reviewed. Subsequently, recent advancements that have led to improvement of bioprinting strategies to construct large muscle structures, boost myogenesis in vitro and in vivo, and enhance tissue integration are discussed. Bioinks for muscle bioprinting, as an essential part of any bioprinting strategy, are discussed, and their benefits, limitations, and areas to be improved are highlighted. Finally, the directions the field should expand to make bioprinting strategies more translational and overcome the clinical unmet needs are discussed.

RISK-ORIENTED ANALYSIS OF LIMB LOSS IN VICTIMS OF MODERN HOSTILITIES

OBJECTIVE

The aim: Identification, verification and analysis of clinically effective risks of limb amputation as a basis for the formation of risk-oriented treatment and diagnostic tactics in victims with limb injuries due to modern hostilities.

PATIENTS AND METHODS

Materials and methods: This research is based on a study of 1,072 cases of limb damage due to modern hostilities in eastern Ukraine in 2014-2020. All injuries were gunshot (bullet and mine injuries). According to the concept of Clinical Risk Management, Clinical Result Risk was chosen for evaluation and analysis. Risk factors - epidemiological and anatomical signs of damage.

RESULTS

Results: Quantitative indicators of the clinical effective risk of limb loss are generally small and range from minimal to significant values (0.01-0.24). In some cases - up to 0.4 (significant), and are not critical and catastrophic. Of practical importance are only the risk factors associated with the nature of participation in hostilities and the anatomical characteristics of the injury. Among the immediate causes of limb loss, only primary traumatic amputation matters. Damage to vascular and nerve structures is not critical for limb loss. The impact of other risk factors may be reduced or eliminated if adequate care is provided.

CONCLUSION

Conclusions: The risks of limb loss in victims of modern hostilities vary within the qualitative characteristics of the minimum-significant risk. The greatest importance in the clinical implementation of risks are risk factors related to the performance of functional duties of servicemen and anatomical features. he use of risk-based analysis must be taken into account in the formation of standards of medical care and treatment protocols for victims of modern hostilities.

Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY)

SUMMARY

Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.

A Combination of N-Terminal proB-Type Natriuretic Peptide and Myoglobin Can Predict Severe Complications After Major Non-Cardiac Surgery in Elderly Patients: A Prospective Observational Cohort Study

Background: Previous studies have demonstrated that serum N-terminal proB-type natriuretic peptide (NT-proBNP) was a predictor of adverse cardiovascular outcomes after surgery. We performed a prospective study to evaluate if NT-proBNP could be a sensitive marker of overall postoperative outcomes in older patients undergoing major elective non-cardiac surgery when combined with myoglobin (MYO).

Methods: Two hundred and three adults aged ≥65 years were enrolled in the study. The American Society of Anesthesiologists (ASA) physical status of patients were I to IV. Blood samples would be taken before and 2 h after the surgery for each patients and NT-proBNP and MYO concentrations (NT-proBNP baseline/ 2 h and MYO baseline/ 2 h) of these samples would be measured immediately. The primary outcome was moderate to severe complications, which were based on the Clavien–Dindo Classification (CDC) scheme (≥CDC grade 3), and the secondary outcomes were major complications within 30 days after surgery. This study was registered at China Clinical Trial Registry (ChiCTR1900026223, http://www.chictr.org.cn/).

Results: Overall, moderate to severe complications occurred in 15 patients (7.4%) and major complications occurred in 18 patients (8.9%). Both preoperative and postoperative NT-proBNP values were independent predictors of moderate to severe complications (area under the curve (AUC), 0.820; 95% CI: 0.728, 0.912, P < 0.001; AUC, 0.785; 95% CI: 0.685, 0.885, P < 0.001). When NT-proBNP baseline and MYO-2 h were combined (NT-proBNP baseline × MYO-2 h), the predictive power was improved (AUC 0.841, 95% CI: 0.758, 0.923, P < 0.001).

Conclusions: A combination of perioperative NT-proBNP and postoperative MYO concentrations was a good predictor of postoperative complications in elderly patients who underwent major non-cardiac surgery. Using fast and dynamic tests provided by point-to-care-testing, NT-proBNP and MYO concentration measurements provided useful guidance for therapy before or soon after surgery, thus helping to reduce postoperative complications in elderly patients.

Lower extremity reconstruction for limb salvage and functional restoration - The Combat experience

Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.

Gait biomechanics: A clinically relevant outcome measure for preclinical research of musculoskeletal trauma

Traumatic injuries to the musculoskeletal system are the most prevalent of those suffered by United States Military Service members and accounts for two-thirds of initial hospital costs to the Department of Defense. These combat-related wounds often leave survivors with life-long disability and represent a significant impediment to the readiness of the fighting force. There are immense opportunities for the field of tissue engineering and regenerative medicine (TE/RM) to address these musculoskeletal injuries through regeneration of damaged tissues as a means to restore limb functionality and improve quality of life for affected individuals. Indeed, investigators have made promising advancements in the treatment for these injuries by utilizing small and large preclinical animal models to validate therapeutic efficacy of next-generation TE/RM-based technologies. Importantly, utilization of a comprehensive suite of functional outcome measures, particularly those designed to mimic data collected within the clinical setting, is critical for successful translation and implementation of these therapeutics. To that end, the objective of this review is to emphasize the clinical relevance and application of gait biomechanics as a functional outcome measure for preclinical research studies evaluating the efficacy of TE/RM therapies to treat traumatic musculoskeletal injuries. Specifically, common musculoskeletal injuries sustained by service members-including volumetric muscle loss, post-traumatic osteoarthritis, and composite tissue injuries-are examined as case examples to highlight the use of gait biomechanics as an outcome measure using small and large preclinical animal models.

The War after War: Volumetric Muscle Loss Incidence, Implication, Current Therapies and Emerging Reconstructive Strategies, a Comprehensive Review

Volumetric muscle loss (VML) is the massive wasting of skeletal muscle tissue due to traumatic events or surgical ablation. This pathological condition exceeds the physiological healing process carried out by the muscle itself, which owns remarkable capacity to restore damages but only when limited in dimensions. Upon VML occurring, the affected area is severely compromised, heavily influencing the affected a person’s quality of life. Overall, this condition is often associated with chronic disability, which makes the return to duty of highly specialized professional figures (e.g., military personnel or athletes) almost impossible. The actual treatment for VML is based on surgical conservative treatment followed by physical exercise; nevertheless, the results, in terms of either lost mass and/or functionality recovery, are still poor. On the other hand, the efforts of the scientific community are focusing on reconstructive therapy aiming at muscular tissue void volume replenishment by exploiting biomimetic matrix or artificial tissue implantation. Reconstructing strategies represent a valid option to build new muscular tissue not only to recover damaged muscles, but also to better socket prosthesis in terms of anchorage surfaces and reinnervation substrates for reconstructed mass.

Strategic Orthopedic Evacuations to the Spanish Role 4 During a Decade (2009-2018)

INTRODUCTION

Casualty evacuation is a key point in medical support to military operations, sometimes being necessary to transfer them to National Territory for a definitive diagnosis and treatment. The aim of this work is to analyze the patients evacuated from Areas of Operations to the Orthopedic Surgery and Traumatology Unit of the Spanish Role 4 Medical Treatment Facility in the last 10 years.

MATERIAL AND METHODS

A cross-sectional, descriptive, and retrospective study carried out in the period between January 1, 2009 and December 31, 2018. The study population was all personnel evacuated from the Area of Operations to Spanish Role 4. For categorical variables, absolute and relative percent frequencies were used. Spanish military authorization was obtained to perform this study. This study has been approved by the Ethics and Clinical Research Committee of the Defense Central Hospital "Gómez Ulla" (code 12/17).

RESULTS

A total of 520 medical evacuations have been performed on Role 4, of which 227 were on the Orthopedic Surgery and Traumatology Unit. Seven percent of the evacuees were categorized as "combat" casualties. The areas of operations from which more patients have been evacuated were Afghanistan and Lebanon, 30.39% and 19.38%, respectively. The most frequent lesion pattern was the fracture affecting the extremities. Accidents (n = 98, 43.17%) and sport (n = 57; 25.3%) were the main causes of injury. Sixty-seven (29.51%) patients were treated surgically in Role 4. No deaths were recorded among patients in this series.

CONCLUSION

Evacuations because of trauma cause more than half of the medical repatriations carried out on the National Territory, of which the majority are due to fractures affecting the limbs, especially the bones of the hand. Sport was the first preventable cause of injury among evacuated patients. Our results are similar to the experience obtained by other allied armed forces. It is a moral imperative and a fundamental necessity for the Spanish military medical services to promote and maintain the Spanish Role 4 Medical Treatment Facility as an indispensable element in medical support for international missions.

Incidence and demographic characteristics of Syrian Civil War-related amputations: A multi-center study

Objectives

The aim of this study was to identify the causes, levels, and rates of amputations performed in civilians during the Syrian Civil War and to present epidemiological data of the amputees.

Patients and methods

Between August 2017 and February 2019, a total of 363 amputations of 307 amputees (266 males, 41 females; mean age 29.9±13.3 years; range, 6 to 86 years) were retrospectively analyzed in four prosthesis and orthosis centers managed by an international non-governmental organization and serving to individuals who experienced amputation during Syrian Civil War. Level, etiology, number of amputations and distribution of the amputations by years were investigated.

Results

Of the patients, 25.4% were under the age of 18 years. A total of 74% of all amputations were of the lower extremities. Transtibial and transfemoral amputations were the most common amputation levels. Of the amputees, 89.3% reported the cause of amputation as bombing.

Conclusion

Civil amputations during the Syrian Civil War are different from those in other civil wars due to the high rate of bombing-induced amputations and also the high rate of victims under the age of 18 years. Our study results show a high ratio of both lower and upper extremity amputations in these civilians.

Incident Musculoskeletal Conditions Among Men and Women Veterans Returning From Deployment

BACKGROUND

Military service confers an increased risk for musculoskeletal (MSK) injury among women and men Veterans.

OBJECTIVE

The objective of this study was to determine the prevalence of MSK conditions at first visit to Veterans Affairs (VA), and the incidence rates of new MSK conditions in women and men Veterans with and without a baseline MSK condition.

DESIGN

A cohort study including Veterans whose end of last deployment was between October 1, 2001 and October 1, 2015.

SUBJECTS

A total of 765,465 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans.

MAIN OUTCOME MEASURES

Prevalent and incident MSK conditions identified through the International Classification of Diseases, ninth Revision, Clinical Modification diagnostic codes.

RESULTS

Twenty-six percent of women and 29% of men present to the VA with a MSK condition. In those without an MSK diagnosis at baseline, the unadjusted rate of developing at least 1 MSK condition was 168 and 180 per 1000 person-year [hazard ratio (HR)=0.94; 95% confidence interval (CI)=0.92-0.95] in women and men. Women were more likely to develop newly diagnosed MSK conditions of the hip (HR=1.9; 95% CI=1.83-1.98) or the ankle/foot (HR=1.17; 95% CI=1.15-1.20) and less likely to develop MSK conditions of the upper extremity (HR=0.75; 95% CI=0.73-0.78), knee (HR=0.87; 95% CI=0.86-0.89), and spine (HR=0.94; 95% CI=0.93-0.96). In those with prevalent MSK conditions at baseline, the rate of developing a second MSK condition was higher in women than men (151 and 133/1000 person-year; HR=1.13; 95% CI=1.11-1.15).

CONCLUSIONS

A high proportion of Veterans present to the VA with MSK conditions. Women are less likely to develop conditions related to the upper extremities, spine or knee, and more likely to have conditions of the hip or ankle/foot.

Anatomic injury patterns in combat casualties treated by forward surgical teams

BACKGROUND

Role 2 forward surgical teams provide damage-control resuscitation and surgery for life- and limb-threatening injuries. These teams have limited resources and personnel, so understanding the anatomic injury patterns seen by these teams is vital for providing adequate training and preparation prior to deployment. The objective of this study was to describe the spectrum of injuries treated at Role 2 facilities in Afghanistan.

METHODS

Using Department of Defense Trauma Registry data, a retrospective, secondary data analysis was conducted. Eligible patients were all battle or non-battle-injured casualties treated by Role 2 forward surgical teams in Afghanistan from October 2005 to June 2018. Abbreviated Injury Scale (AIS) 2005 codes were used to classify each injury and Injury Severity Score (ISS) was calculated for each patient. Patients with multiple trauma were defined as patients with an AIS severity code >2 in at least two ISS body regions.

RESULTS

The data set included 10,383 eligible patients with 45,225 diagnosis entries (range, 1-27 diagnoses per patient). The largest number of injuries occurred in the lower extremity/pelvis/buttocks (23.9%). Most injuries were categorized as minor (39.4%) or moderate (38.8%) in AIS severity, while the largest number of injuries categorized as severe or worse occurred in the head (13.5%). Among head injuries, 1,872 injuries were associated with a cerebral concussion or diffuse axonal injury, including 50.6% of those injuries being associated with a loss of consciousness. There were 1,224 patients with multiple trauma, and the majority had an injury to the extremities/pelvic girdle (58.2%). Additionally, 3.7% of all eligible patients and 10.5% of all patients with multiple trauma did not survive to Role 2 discharge.

CONCLUSION

The injury patterns seen in recent conflicts and demonstrated by this study may assist military medical leaders and planners to optimize forward surgical care in future environments, on a larger scale, and utilizing less resources.

LEVEL OF EVIDENCE

Epidemiological, Level III.

Regenerative rehabilitation of catastrophic extremity injury in military conflicts and a review of recent developmental efforts

AIM OF THE REVIEW

This review aims to describe the current state of regenerative rehabilitation of severe military extremity injuries, and promising new therapies on the horizon.

DISCUSSION

The nature of warfare is rapidly shifting with information operations, autonomous weapons, and the threat of full-scale peer adversary conflicts threatening to create contested environments with delayed medical evacuation to definitive care. More destructive weapons will lead to more devastating injuries, creating new challenges for limb repair and restoration. Current paradigms of delayed rehabilitation following initial stabilization, damage control surgery, and prolonged antibiotic therapy will need to shift. Advances in regenerative medicine technologies offer the possibility of treatment along the continuum of care. Regenerative rehabilitation will begin at the point of injury and require a holistic, organ-systems approach.

CONCLUSIONS

Both technological improvements and a rapidly advancing understanding of injury pathophysiology will contribute to improved limb-salvage outcomes, and shift the calculus away from early limb amputation.

Rotator Cuff Fibro-Adipogenic Progenitors Demonstrate Highest Concentration, Proliferative Capacity, and Adipogenic Potential Across Muscle Groups

Fatty infiltration (FI) of rotator cuff (RC) muscles is common in patients with RC tears. Studies have demonstrated that fibro-adipogenic progenitors (FAPs), a population of resident muscle stem cells, are the main contributors of FI, which adversely affects muscle quality and RC repair success. Although FI is common in RC injuries, it is not frequently reported after other musculotendinous injuries. Additionally, studies have shown the development of different pathology patterns across muscle groups suggestive of intrinsic differences in cellular composition and behavior. This study evaluates FAP distribution and differentiation properties across anatomic locations in mice. Muscles from seven different anatomic locations were harvested from PDGFRα-eGFP FAP reporter mice. FAPs were quantified using histology and FACS sorting with BD Aria II with CD31^- /CD45^- /Integrinα7^- /Sca-1⁺ and PDGFRα reporter signal (n = 3 per muscle). The cells were analyzed for adipogenesis using immunocytochemistry and for proliferation properties with Brdu-Ki67 staining. In a separate group of mice, RC and tibialis anterior muscles received glycerol injection and were harvested after 2 weeks for FI quantification (n = 4). One-way analysis of variance was used for statistical comparisons among groups, with significance at p < 0.05. FAPs from the RC, masseter, and paraspinal muscles were more numerous and demonstrated greater proliferative capacity and adipogenic potency than those from the tibialis anterior and gastrocnemius. The RC demonstrated significantly greater levels of FI than the tibialis anterior after glycerol-injection injury. Clinical Significance: This study suggests differences in FAP distribution and differentiation characteristics may account for the propensity to develop FI in RC tears as compared with other musculotendinous injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1113-1121, 2020.

Osteomyelitis Risk Factors Related to Combat Trauma Open Upper Extremity Fractures: A Case-Control Analysis

OBJECTIVE

To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures.

DESIGN

Retrospective observational case-control study.

SETTING

US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009).

PATIENTS/PARTICIPANTS

Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Multivariable odds ratios (ORs; 95% confidence interval [CI]).

RESULTS

Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis.

CONCLUSIONS

Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Force Mitigation by Boots in Axial Impacts using a Lower Leg Finite Element Model

Lower extremity injuries caused by floor plate impacts through the axis of the lower leg are a major source of injury and disability for civilian and military vehicle occupants. A collection of PMHS pendulum impacts was revisited to obtain data for paired booted/unbooted test on the same leg. Five sets of paired pendulum impacts (10 experiments in total) were found using four lower legs from two PMHS. The PMHS size and age was representative of an average young adult male. In these tests, a PMHS leg was impacted by a 3.4 or 5.8 kg pendulum with an initial velocity of 5, 7, or 10 m/s (42-288 J). A matching LS-DYNA finite element model was developed to replicate the experiments and provide additional energy, strain, and stress data. Simulation results matched the PMHS data using peak values and CORA curve correlations. Experimental forces ranged between 1.9 and 12.1 kN experimentally and 2.0 and 11.7 kN in simulation. Combat boot usage reduced the peak force by 36% experimentally (32% in simulation) by compressing the sole and insole with similar mitigations for calcaneus strain. The simulated Von Mises stress contours showed the boot both mitigating and shifting stress concentrations from the calcaneus in unbooted impacts to the talus-tibia joint in the booted impacts, which may explain why some previous studies have observed shifts to tibia injuries with boot or padding usage.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma

BACKGROUND

Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference.

METHODS

This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18).

RESULTS

Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation.

CONCLUSIONS

Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteomyelitis Risk Factors Related to Combat Trauma Open Femur Fractures: A Case-Control Analysis

OBJECTIVES

To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures?

DESIGN

Retrospective observational case-control study.

SETTING

US military regional hospital in Germany and tertiary care hospitals in United States (2003-2009).

PATIENTS/PARTICIPANTS

One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI).

RESULTS

Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo-Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0-123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3-25.1) and dead muscle (OR: 32.9; CI: 5.4-199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors.

CONCLUSIONS

Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006-2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations).

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Bone Loss or Devascularization Associated With Recurrence of Osteomyelitis in Wartime Open Tibia Fractures?

BACKGROUND

During recent wars, 26% of combat casualties experienced open fractures and these injuries frequently are complicated by infections, including osteomyelitis. Risk factors for the development of osteomyelitis with combat-related open tibia fractures have been examined, but less information is known about recurrence of this infection, which may result in additional hospitalizations and surgical procedures.

QUESTIONS/PURPOSES

(1) What is the risk of osteomyelitis recurrence after wartime open tibia fractures and how does the microbiology compare with initial infections? (2) What factors are associated with osteomyelitis recurrence among patients with open tibia fractures? (3) What clinical characteristics and management approaches are associated with definite/probable osteomyelitis as opposed to possible osteomyelitis and what was the microbiology of these infections?

METHODS

A survey of US military personnel injured during deployment between March 2003 and December 2009 identified 215 patients with open tibia fractures, of whom 130 patients developed osteomyelitis and were examined in a retrospective analysis. No patients with bilateral osteomyelitis were included. Twenty-five patients meeting osteomyelitis diagnostic criteria were classified as definite/probable (positive bone culture, direct evidence of infection, or symptoms with culture and/or radiographic evidence) and 105 were classified as possible (bone contamination, organism growth in deep wound tissue, and evidence of local/systemic inflammation). Patients diagnosed with osteomyelitis were treated with débridement and irrigation as well as intravenous antibiotics. Fixation hardware was retained until fracture union, when possible. Osteomyelitis recurrence was defined as a subsequent osteomyelitis diagnosis at the original site ≥ 30 days after completion of initial treatment. This followup period was chosen based on the definition of recurrence so as to include as many patients as possible for analysis. Factors associated with osteomyelitis recurrence were assessed using univariate analysis in a subset of the population with ≥ 30 days of followup. Patients who had an amputation at or proximal to the knee after the initial osteomyelitis were not included in the recurrence assessment.

RESULTS

Of 112 patients meeting the criteria for assessment of recurrence, 31 (28%) developed an osteomyelitis recurrence, of whom seven of 25 (28%) had definite/probable and 24 of 87 (28%) had possible classifications for their initial osteomyelitis diagnosis. Risk of osteomyelitis recurrence was associated with missing or devascularized bone (recurrence, 14 of 31 [47%]; nonrecurrence, 22 of 81 [28%]; hazard ratio [HR], 3.94; 1.12-13.81; p = 0.032) and receipt of antibiotics for 22-56 days (recurrence, 20 of 31 [65%]; nonrecurrence: 37 of 81 [46%]; HR, 2.81; 1.05-7.49; p = 0.039). Compared with possible osteomyelitis, definite/probable osteomyelitis was associated with localized swelling at the bone site (13 of 25 [52%] versus 28 of 105 [27%]; risk ratio [RR], 1.95 [1.19-3.19]; p = 0.008) and less extensive skin and soft tissue injury at the time of trauma (9 of 22 [41%; three definite/probably patients missing data] versus 13 of 104 [13%; one possible patient missing data]; RR, 3.27 [1.60-6.69]; p = 0.001). Most osteomyelitis infections were polymicrobial (14 of 23 [61%; two patients with missing data] for definite/probable patients and 62 of 105 [59%] for possible patients; RR, 1.03 [0.72-1.48]; p = 0.870). More of the definite/probable patients received vancomycin (64%) compared with the possible patients (41%; p = 0.046), and the duration of polymyxin use was longer (median, 38 days versus 16 days, p = 0.018). Time to definitive fracture fixation was not different between the groups.

CONCLUSIONS

Recurrent osteomyelitis after open tibia fractures is common. In a univariate model, patients with an intermediate amount of bone loss and those treated with antibiotics for 22 to 56 days were more likely to experience osteomyelitis recurrence. Because only univariate analysis was possible, these findings should be considered preliminary. Osteomyelitis recurrence rates were similar, regardless of initial osteomyelitis classification, indicating that diagnoses of possible osteomyelitis should be treated aggressively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Modified Battlefield Acupuncture Does Not Reduce Pain or Improve Quality of Life in Patients with Lower Extremity Surgery

Introduction

This study seeks to determine if modified Battlefield Acupuncture is more effective at relieving acute extremity pain, reducing medication use, and improving quality of life than placebo acupuncture or standard care after lower extremity surgery.

Methods

We conducted a multi-site 3-arm randomized, double-blind controlled trial of standard care alone versus standard care + placebo auricular acupuncture with semi-permanent needles versus standard care + modified battlefield acupuncture with semi-permanent needles for lower extremity surgery at two Air Force hospitals. Subjects reported pain level immediately after acupuncture, 24, 48, 168, and 720 hours later to a blinded research associate. Additionally, subjects completed a PIQ-6 30 days post-operatively, and opioid use was tracked for 30 days post-operatively.

Results

Two hundred thiry-three subjects &gt;18 years old (92 females and 141 males) with a mean age of 44.5 years were randomized with 81 randomized to modified BFA, 74 randomized to placebo acupuncture, and 78 randomized to standard care. Overall pain levels were unchanged at each time point between groups. Outcomes showed unchanged pain, opioid and quality of life between groups.

Conclusion

The use of modified battlefield acupuncture protocol does not change pain opioid use or quality of life in those with lower extremity surgery.

Four years of orthopaedic activities in Chinese Role 2 Hospital of eastern Mali peacekeeping area

INTRODUCTION

The Chinese Role 2 Hospital (CHN-Role 2H) Medical Treatment Facility (MTF) was founded in July 2013 as part of the Chinese commitment to Multidimensional Integrated Stabilization Mission in Mali (MINUSMA). It provides medical care for approximately 5200 personnel of the whole Sector East of MINUSMA including UN military personnel, UN police and UN civilian staff. The aim of this study was to determine the orthopaedic surgical activity over a 4-year period to facilitate the training of future Chinese military surgical teams.

MATERIALS AND METHODS

Surgical records of all patients operated on at the CHN-Role 2H between 28 March 2014 to 28 March 2018 were identified, and all orthopaedic activity were analysed.

RESULTS

During this period, 1190 patients underwent 2024 surgical procedures. Orthopaedic procedures represented 961/2024 (47.5%) of all the procedures. Battle injury (BI) represented 43% of patients. Improvised explosive devices (IEDs) were responsible for 15.8 % casualties. Fractures (49%) and soft tissue injures (43%) were the most common injuries, with 61% of the fractures being open. Damage control surgery including debridement (23.52%) and external fixation (17.90%) were the most frequently performed interventions.

CONCLUSION

Orthopaedic surgery is the most frequently performed surgery in the CHN-Role 2H in Mali. The complexity and severity of injuries demonstrate the urgent need for tailored training and extended skill sets for deploying military orthopaedic surgeons.

The burden of gunshot wounding of UK military personnel in Iraq and Afghanistan from 2003-14

INTRODUCTION

Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts.

METHODS

This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death.

RESULTS

There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM.

CONCLUSION

These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries.

Palovarotene inhibits connective tissue progenitor cell proliferation in a rat model of combat-related heterotopic ossification

Heterotopic ossification (HO) develops in the extremities of wounded service members and is common in the setting of high-energy penetrating injuries and blast-related amputations. No safe and effective prophylaxis modality has been identified for this patient population. Palovarotene has been shown to reduce bone formation in traumatic and genetic models of HO. The purpose of this study was to determine the effects of Palovarotene on inflammation, progenitor cell proliferation, and gene expression following a blast-related amputation in a rodent model (n = 72 animals), as well as the ability of Raman spectroscopy to detect early HO before radiographic changes are present. Treatment with Palovarotene was found to dampen the systemic inflammatory response including the cytokines IL-6 (p = 0.01), TNF-α (p = 0.001), and IFN-γ (p = 0.03) as well as the local inflammatory response via a 76% reduction in the cellular infiltration at post-operative day (POD)-7 (p = 0.03). Palovarotene decreased osteogenic connective tissue progenitor (CTP-O) colonies by as much as 98% both in vitro (p = 0.04) and in vivo (p = 0.01). Palovarotene treated animals exhibited significantly decreased expression of osteo- and chondrogenic genes by POD-7, including BMP4 (p = 0.02). Finally, Raman spectroscopy was able to detect differences between the two groups by POD-1 (p < 0.001). These results indicate that Palovarotene inhibits traumatic HO formation through multiple inter-related mechanisms including anti-inflammatory, anti-proliferative, and gene expression modulation. Further, that Raman spectroscopy is able to detect markers of early HO formation before it becomes radiographically evident, which could facilitate earlier diagnosis and treatment. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1135-1144, 2018.

Management of Mangled Extremities and Orthopaedic War Injuries

In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.

Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection

BACKGROUND

Combat-related extremity wound infections can complicate the recovery of injured military personnel. The Enterococcus genus contains both commensal and pathogenic bacteria found in many combat wounds. We describe the patient population susceptible to Enterococcus infection, the characteristics of Enterococcus spp. isolated from combat-related wounds, and the microbiological profile of Enterococcus-positive wounds.

METHODS

Patient and culture data were obtained from the Trauma Infectious Disease Outcomes Study. Subjects were divided into a case group with enterococcal extremity wound infections and a comparator group with wound infections caused by other micro-organisms.

RESULTS

Case and comparator subjects had similar patterns of injury and infection. Case subjects had higher Injury Severity Scores (33 vs. 30; p < 0.001), longer hospitalization at U.S. facilities (55 vs. 40 days; p = 0.004), and required more large-volume blood transfusions (>20 units) within 24 h post-injury (53% vs. 30%; p < 0.001). Approximately 60% of case subjects had three or more infections, and 91% had one or more polymicrobial infections, compared with 43% and 50%, respectively, in the comparator group. The thigh was the most common site of Enterococcus spp. isolation, contributing 50% of isolates. Enterococcus faecium was the predominant species isolated from case-group infections overall (66%), as well as in polymicrobial infections (74%). Frequent co-colonizing microbes in polymicrobial wound infections with Enterococcus were other ESKAPE pathogens (64%) (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae [and Escherichia coli], Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and fungi (35%).

CONCLUSIONS

The specific pathogenicity of Enterococcus relative to other pathogens in polymicrobial wounds is unknown. Identifying strain-specific outcomes and investigating the interactions of Enterococcus strains with other wound pathogens could provide additional tools and strategies for infection mitigation in combat-related wounds.

Pathophysiology of Volumetric Muscle Loss Injury

Volumetric muscle loss (VML) injuries are prevalent in civilian and military trauma patients and are known to impart chronic functional deficits. The frank loss of muscle tissue that defines VML injuries is beyond the robust reparative and regenerative capacities of mammalian skeletal muscle. Given the nature of VML injuries, there is a clear need to develop therapies that promote de novo regeneration of skeletal muscle fibers, which can integrate with the remaining musculature and restore muscle strength. However, the pathophysiology of VML injuries is not completely defined, and, therefore, there may be other opportunities to improve functional outcomes other than de novo regeneration. Herein, clinical and preclinical studies of VML were reviewed to ascertain salient manifestations of VML injury that can impair limb function and muscle strength. The limited clinical data available highlighted proliferative fibrosis secondary to VML injury as a viable target to improve limb range of motion. Selected preclinical studies that used standardized neuromuscular functional assessments broadly identified that the muscle mass remaining after VML injury is performing suboptimally, and, therefore, percent VML strength deficits are significantly worse than can be explained by the initial frank loss of contractile machinery. Potential mechanisms of suboptimal strength of the remaining muscle mass suggested within the literature include intramuscular nerve damage, muscle architectural perturbations, and diminished transmission of force. Collectively, both clinical and preclinical data indicate a complex pathophysiology after VML that presents multiple therapeutic targets. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel.

Open Fracture Care During War: Opportunities for Research

Reported infection rates following severe open fractures of the lower extremity sustained in combat have varied widely, from 23% to 85%. The infection rates have been either similar to or higher than those reported in the civilian trauma literature. Deployed surgeons have increased the frequency of fasciotomy procedures for limbs with or at risk for clinical compartment syndrome. The long-term sequelae of compartment syndrome and fasciotomies are not clearly defined. The definition of the term late amputation has varied in the literature, and studies have not consistently included information on the causes of the amputations. Preclinical and clinical translational studies on the reduction of the rates of infection and other limb morbidities are needed to address the acute care of combat extremity wounds.