The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003–2011

Investigating Research Hotspots of Combat-related Spinal Injuries: A 30-year Bibliometric Analysis Study

INTRODUCTION

Spinal cord injuries often lead to significant motor and sensory deficits, as well as autonomic dysfunction. Compared with normal spinal injuries, combat-related spinal injuries (CRSIs) are usually more complex and challenging to treat because of multiple traumas, firing-line treatments, and arduous initial treatments on a battlefield. Yet numerous issues remain unresolved about clinical treatment and scientific research. The enhancement of CRSI diagnosis and treatment quality by military surgeons and nurses is imperative. The objective of this study is to identify the frontiers, hotspots, and trends among recent research, summarize the development process of clinical trials, and visualize them systematically.

MATERIALS AND METHODS

We collected publications from CRSI based on the Core Collection of Web of Science for 30 years from January 1, 1993 to May 1, 2023.Visualizations of the knowledge maps were produced using VOSviewer and CiteSpace software. We examined annual trends of publications and distribution patterns, the number of publications, as well as the research hotspots.

RESULTS

Among 201 documents, it was found that there was a stable upward trend in publications. There were 2 rapid growth stages during the 30 years. Among all countries, the USA contributed the most publications, along with the highest influence and the most international cooperation. Military Medicine was the journal of the maximum publications, whereas the Spine journal was the most influential one. Keyword co-occurrence analysis and trend topics analysis revealed that these articles focused 5 distinct categories for CRSI.

CONCLUSIONS

As the first bibliometric study focused on CRSI, we demonstrated the evolution of the field and provided future research directions. We summarized the hotspots and 5 clusters published. This would serve as a useful guide for clinicians and scientists regarding CRSI global impacts.

Impact of injury mechanism on early wound closure in patients with acute conflict-related extremity wounds: A prospective cohort analysis from two civilian hospitals in Iraq and Jordan

BACKGROUND

Gunshots and bomb blasts are important causes of extremity injuries in conflict zones, yet little research exists on the characteristics and outcomes of these injuries in civilian populations.

METHODS

We performed a prospective cohort analysis utilizing data from a randomized trial conducted at two civilian hospitals in Jordan and Iraq in 2015-2019. Adults who presented ≤72 h of sustaining an extremity injury were included. We used mechanism of injury (gunshot/bomb blast) as the exposure and wound closure by day 5 as the primary outcome measure.

RESULTS

The population predominantly comprised young men (n = 163, 94% male, and median age 29 years) injured by gunshots (61%) or bomb blasts (39%). Compared with the gunshot group, more participants in the bomb blast group had concomitant injuries (32/63 [51%] vs. 11/100 [11%], p < 0.001) and vascular injuries (9/63 [14%] vs. 4/100 [4%], p = 0.02). The wounds were larger in the bomb blast group compared with the gunshot group (median area 86 cm2 [IQR 24-161] vs. 21 cm2 [IQR 7-57], p < 0.001). Compared with the bomb blast group, significantly more participants in the gunshot group achieved wound closure by day 5 (74/100 [74%] vs. 16/63 [25%], p < 0.001). This difference remained after controlling for confounding factors (odds ratio 4.7, 95% confidence interval 1.6-13.7).

CONCLUSIONS

In civilians with conflict-related extremity injuries, bomb blast wounds had a lower likelihood of achieving closure within 5 days than gunshot wounds, independent of other factors, such as wound size and vascular injuries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02444598. Registered 14-05-2015, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT02444598.

Combat-related peripheral nerve injuries

Active-duty service members (ADSM) and military Veterans represent a population with increased occupational risk for nerve injuries sustained both during training operations and wartime. Mechanisms of war-related nerve injuries have evolved over time, from the musket ball-related traumas described by S.W. Mitchell to complex blast injuries and toxic exposures sustained during Middle East conflicts in the 21st century. Commonly encountered nerve injury etiologies in this population currently include compression, direct trauma, nutritional deficits, traumatic limb amputation, toxic chemical exposures, or blast-related injuries. Expeditious identification and comprehensive, interdisciplinary treatment of combat-associated neuropathies, as well as prevention of these injuries whenever possible is critical to reduce chronic morbidity and disability for service members and to maintain a well-prepared military. However, diagnosis of a combat-associated nerve injury may be particularly challenging due to comorbid battlefield injuries or delayed presentation of neuropathy from military toxic exposures. Advances in imaging for nerve injury, including MRI and ultrasound, provide useful tools to compliment EMG in establishing a diagnosis of combat-associated nerve injury, particularly in the setting of anatomic disruption or edema. Surgical techniques can improve pain control or restoration of function. In all cases, comprehensive interdisciplinary rehabilitation provides the best framework for optimization of recovery. Further work is needed to prevent combat-associated nerve injuries and promote nerve recovery following injury.

The effect of combat deployments on veteran opioid abuse

Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.

Combat Injury Profile in Urban Warfare

INTRODUCTION

Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield.

MATERIALS AND METHODS

IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part.

RESULTS

Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group.

CONCLUSIONS

The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.

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.

[War wounds and ballistics]

Ballistic wounds, which historically concerned military populations, now also affect civilian practice. Terrorist attacks, urban violence and certain accidents have brought them into the daily routine of some French hospitals. Their frequency fully justifies the need for every health-care professional to be aware of the major issues involved in their management. In this section, we will describe the various penetrating ballistic wounds and their specific features. We will also rectify certain preconceived ideas that should not be peddled by healthcare professionals, in order to maintain a high standard of care.

Human pelvis injury risk curves from underbody blast impact

INTRODUCTION

Underbody blast loading can result in injuries to the pelvis and the lumbosacral spine. The purpose of this study was to determine human tolerance in this region based on survival analysis.

METHODS

Twenty-six unembalmed postmortem human surrogate lumbopelvic complexes were procured and pretest medical images were obtained. They were fixed in polymethylmethacrylate at the cranial end and a six-axis load cell was attached. The specimens were aligned in a seated soldier posture. Impacts were applied to the pelvis using a custom vertical accelerator. The experimental design consisted of non-injury and injury tests. Pretest and post-test X-rays and palpation were done following non-injury test, and after injury test medical imaging and gross dissections were done. Injuries were scored using the Abbreviated Injury Scale (AIS). Axial and resultant forces were used to develop human injury probability curves (HIPCs) at AIS 3+ and AIS 4 severities using survival analysis. Then ±95% CI was computed using the delta method, normalised CI size was obtained, and the quality of the injury risk curves was assigned adjectival ratings.

RESULTS

At the 50% probability level, the resultant and axial forces at the AIS 3+ level were 6.6 kN and 5.9 kN, and at the AIS 4 level these were 8.4 kN and 7.5 kN, respectively. Individual injury risk curves along with ±95% CIs are presented in the paper. Increased injury severity increased the HIPC metrics. Curve qualities were in the good and fair ranges for axial and shear forces at all probability levels and for both injury severities.

CONCLUSIONS

This is the first study to develop axial and resultant force-based HIPCs defining human tolerance to injuries to the pelvis from vertical impacts using parametric survival analysis. Data can be used to advance military safety under vertical loading to the seated pelvis.

Long-term Mental Health Trajectories of Injured Military Servicemembers: Comparing Combat to Noncombat Related Injuries

OBJECTIVE

We sought to quantify the impact of injury characteristics and setting on the development of mental health conditions, comparing combat to noncombat injury mechanisms.

BACKGROUND

Due to advances in combat casualty care, military service-members are surviving traumatic injuries at substantial rates. The nature and setting of traumatic injury may influence the development of subsequent mental health disorders more than clinical injury characteristics.

METHODS

TRICARE claims data was used to identify servicemembers injured in combat between 2007 and 2011. Controls were servicemembers injured in a noncombat setting matched by age, sex, and injury severity. The rate of development, and time to diagnosis [in days (d)], of 3 common mental health conditions (post-traumatic stress disorder, depression, and anxiety) among combat-injured servicemembers were compared to controls. Risk factors for developing a new mental health condition after traumatic injury were evaluated using multivariable logistic regression that controlled for confounders.

RESULTS

There were 3979 combat-injured servicemember and 3979 matched controls. The majority of combat injured servicemembers (n = 2524, 63%) were diagnosed with a new mental health condition during the course of follow-up, compared to 36% (n = 1415) of controls ( P < 0.001). In the adjusted model, those with combat-related injury were significantly more likely to be diagnosed with a new mental health condition [odds ratio (OR): 3.18, [95% confidence interval (CI): 2.88-3.50]]. Junior (OR: 3.33, 95%CI: 2.66-4.17) and senior enlisted (OR: 2.56, 95%CI: 2.07-3.17) servicemem-bers were also at significantly greater risk.

CONCLUSIONS

We found significantly higher rates of new mental health conditions among servicemembers injured in combat compared to service-members sustaining injuries in noncombat settings. This indicates that injury mechanism and environment are important drivers of mental health sequelae after trauma.

Exoskeletal solutions to enable mobility with a lower leg fracture in austere environments

The treatment and evacuation of people with lower limb fractures in austere environments presents unique challenges that assistive exoskeletal devices could address. In these dangerous situations, independent mobility for the injured can preserve their vital capabilities so that they can safely evacuate and minimize the need for additional personnel to help. This expert view article discusses how different exoskeleton archetypes could provide independent mobility while satisfying the requisite needs for portability, maintainability, durability, and adaptability to be available and useful within austere environments. The authors also discuss areas of development that would enable exoskeletons to operate more effectively in these scenarios as well as preserve the health of the injured limb so that definitive treatment after evacuation will produce better outcomes.

The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018)

OBJECTIVE

We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries.

SUMMARY OF BACKGROUND DATA

US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown.

METHODS

We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs.

RESULTS

The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel.

CONCLUSION

This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.

Operation "NeuroTeam": rendering the absolute best care for the most deserving patients under the most difficult conditions

The tenets of neurosurgery worldwide, whether in the civilian or military sector, espouse vigilance, the ability to adapt, extreme ownership, and, of course, an innate drive for developing a unique set of technical skills. At a time in history when the complexity of battlefield neurotrauma climaxed coupled with a chronic shortage of military neurosurgeons, modernized solutions were mandated in order to deliver world-class neurological care to our servicemen and servicewomen. Complex blast injuries, as caused by an increased incidence of improvised explosive devices, yielded widespread systemic inflammatory responses with multiorgan damage. In response to these challenges, the "NeuroTeam," originally a unit of two neurosurgeons as deployed during Operation Desert Storm, was redesigned to instead pair a neurosurgeon with a neurointensivist and launched itself during two specialized missions in Operations Iraqi Freedom and Enduring Freedom. Representing a hybridized version of present-day neurocritical care teams, the purpose of this unit was to optimize neurosurgical care by focusing on interdisciplinary collaboration in an Echelon III combat support hospital. The NeuroTeam provided unique workflow capabilities never seen collectively on the battlefield: downrange neurosurgical capability by a board-certified neurological surgeon within 60 minutes from the point of injury paired with a neurocritical care–trained intensivist. This also set the stage for intraoperative telemedicine infrastructure for neurosurgery and optimized the ability to evaluate, triage, and stabilize patients prior to medical evacuation. This novel military partnership ultimately allowed the neurosurgeon to focus on the tenets of the craft and thereby the dynamic needs of the patient first and foremost.

Since the success of these missions, the NeuroTeam has evolved into a detachable unit, the "Head and Neck Team," comprising neurosurgeons, otolaryngologists, and ophthalmologists, supported by a postinjury hospital unit, which includes an embedded neurocritical care physician. The creation and evolution of the NeuroTeam, necessitated by a shortage of military neurosurgeons and the dangerous shift in military wartime tactics, best exemplifies multidisciplinary collaboration and military medicine agility. As neurocritical care continues to evolve into a highly complex, distinct specialty, the lessons learned by the NeuroTeam ultimately serve as a reminder for civilian and military physicians alike. Despite the conditions and despite one’s professional ego, patients with highly complex morbid neurological disease deserve expert, multidisciplinary management for survival.

Long-Term Effects of Repeated Blast Exposure in United States Special Operations Forces Personnel: A Pilot Study Protocol

Emerging evidence suggests that repeated blast exposure (RBE) is associated with brain injury in military personnel. United States (U.S.) Special Operations Forces (SOF) personnel experience high rates of blast exposure during training and combat, but the effects of low-level RBE on brain structure and function in SOF have not been comprehensively characterized. Further, the pathophysiological link between RBE-related brain injuries and cognitive, behavioral, and physical symptoms has not been fully elucidated. We present a protocol for an observational pilot study, Long-Term Effects of Repeated Blast Exposure in U.S. SOF Personnel (ReBlast). In this exploratory study, 30 active-duty SOF personnel with RBE will participate in a comprehensive evaluation of: 1) brain network structure and function using Connectome magnetic resonance imaging (MRI) and 7 Tesla MRI; 2) neuroinflammation and tau deposition using positron emission tomography; 3) blood proteomics and metabolomics; 4) behavioral and physical symptoms using self-report measures; and 5) cognition using a battery of conventional and digitized assessments designed to detect subtle deficits in otherwise high-performing individuals. We will identify clinical, neuroimaging, and blood-based phenotypes that are associated with level of RBE, as measured by the Generalized Blast Exposure Value. Candidate biomarkers of RBE-related brain injury will inform the design of a subsequent study that will test a diagnostic assessment battery for detecting RBE-related brain injury. Ultimately, we anticipate that the ReBlast study will facilitate the development of interventions to optimize the brain health, quality of life, and battle readiness of U.S. SOF personnel.

IDCRP Combat-Related Extremity Wound Infection Research

INTRODUCTION

Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses.

METHODS

Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors.

RESULTS

Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moderate/severe skin/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis.

CONCLUSIONS

Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health/social factors.

Injury mechanisms and injury severity scores as determinants of urban terrorism-related thoracoabdominal injuries

Objective: Improving the care of injuries resulting from terrorist attacks requires understanding injury mechanisms in armed conflicts. The aim of this study was to identify injury characteristics in military personnel with thoracoabdominal combat injuries resulting from terrorist attacks in urban settings.

Material and Methods: A retrospective study of military personnel with thoracoabdominal injuries who were referred to a tertiary center after treating and stabilizing at a primary healthcare organization due to terror-related injuries in various urban regions of Turkey between June 2015 and December 2016 was performed.

Results: A total of 70 patients were included in this study, of whom 87.1% were injured by explosives and 12.9% (n= 9) had gunshot wounds (GSWs). Mean injury severity score (ISS) was 21, blood transfusion amount was 3.7 units, and mortality rate was 8.5%. Patients injured by explosives had most commonly abdominal and extremity injuries (31.1%), whereas isolated abdominal injuries (55.6%) were observed among patients with GSWs. There were no significant differences between the mechanisms of injuries and the ISS, blood transfusion, and mortality (p= 0.635, p= 0.634, and p= 0.770, respectively). A significant correlation was observed between the ISS and transfusion amounts (r= 0.548, p< 0.001). Mortality was significantly higher in those with a high ISS and those undergoing massive blood transfusions (p= 0.004 and p< 0.001, respectively).

Conclusion: Explosive injuries, concomitant vascular injuries, high ISS, and the need for massive transfusions increased the mortality rate in urban combat injuries. To quickly identify high-risk patients and improve the care of injuries, it is essential to use predictive models or scoring systems.

Intrepid Spirit Centers: Considerations for Active Duty, National Guard, Reserves, and Retirees

BACKGROUND

Traumatic brain injury (TBI) is a significant concern to the military health system (MHS) and a signature wound of America's current conflict. To address the influx of patients with military-related TBI, the Department of Defense has partnered with the Fisher Foundation and the Intrepid Fallen Heroes Fund to establish the National Intrepid Center of Excellence and satellite network of Intrepid Spirit Centers. The purpose of this study is to review the prevalence of disease and geographic density of TBI among active duty, National Guard, reservist, and retired military populations in order to inform decision-making around the development of additional Intrepid Spirit Centers.

METHODS

We used the MHS Data Repository to perform a cross-sectional examination to assess the prevalence of TBI among active duty, National Guard, reservist, and retired military personnel from fiscal years (FY) 2016 to 2019. Statistical analyses included descriptive statistics on patient demographics and the prevalence of TBI.

RESULTS

We identified a total of 3,221,682 active duty, National Guard, reservists, and retired military personnel in the U.S. Army, Air Force, Navy, and Marine Corps during FY 2016 to 2019; 59.5% were active duty personnel, 23.1% were Retirees, and 17.4% were National Guard and reservists. A total of 72,002 were found to have a TBI-related diagnosis. Texas, North Carolina, and California had the highest case counts for TBI. High prevalence of TBI was found in Bexar County, TX, Muscogee County, GA, Okaloosa County, FL, San Diego County, CA, and Virginia Beach City, VA.

CONCLUSIONS

Additional Intrepid Spirit Centers are warranted to better meet the needs of active duty, active and inactive National Guard and reservists, and retired military personnel in locations including San Antonio, TX, and Columbus, GA. These locations currently have the medical infrastructure necessary to facilitate the care of wounded warriors and return to duty ensuring the health of the Nation's fighting force and veterans.

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.

Estimating the Number of Civilian Casualties in Modern Armed Conflicts-A Systematic Review

Objective: To examine the possibility of estimating the number of civilian casualties in modern armed conflicts. Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Scopus, and Web of Science search engines. The outcome was analyzed using a qualitative inductive thematic analysis. The scientific evidence of selected article was assessed, using the Health Evidence Quality Assessment Tool. Findings: The review of 66 included articles in this study indicates that with an increasing number of public health emergencies and the lack of vital elements of life such as water and food, emerging armed conflicts seem to be inevitable. In contrast to military-led cross-border traditional wars, modern armed conflicts affect internally on local communities and take civilian lives. Consequently, the measures and tools used in traditional military-led cross-border wars to adequately tally wounded and dead for many decades under the mandates of the International Humanitarian Law, is insufficient for modern warfare. While casualty counting during modern conflicts is deficient due to organizational, political or strategic reasons, the international organizations responsible for collecting such data (the International Federation of Red Cross and Red Crescent and International Institute of Humanitarian Law) face difficulties to access the conflict scene, resulting in under-reported, unreliable or no-reported data. Conclusion: There are challenges in estimating and counting the number of civilian casualties in modern warfare. Although the global need for such data is evident, the risks and barriers to obtaining such data should be recognized, and the need for new international involvement in future armed conflicts should be emphasized.

Therapeutic Potential of Mesenchymal Stromal Cell-Derived Extracellular Vesicles in the Prevention of Organ Injuries Induced by Traumatic Hemorrhagic Shock

Severe trauma is the principal cause of death among young people worldwide. Hemorrhagic shock is the leading cause of death after severe trauma. Traumatic hemorrhagic shock (THS) is a complex phenomenon associating an absolute hypovolemia secondary to a sudden and significant extravascular blood loss, tissue injury, and, eventually, hypoxemia. These phenomena are responsible of secondary injuries such as coagulopathy, endotheliopathy, microcirculation failure, inflammation, and immune activation. Collectively, these dysfunctions lead to secondary organ failures and multi-organ failure (MOF). The development of MOF after severe trauma is one of the leading causes of morbidity and mortality, where immunological dysfunction plays a central role. Damage-associated molecular patterns induce an early and exaggerated activation of innate immunity and a suppression of adaptive immunity. Severe complications are associated with a prolonged and dysregulated immune–inflammatory state. The current challenge in the management of THS patients is preventing organ injury, which currently has no etiological treatment available. Modulating the immune response is a potential therapeutic strategy for preventing the complications of THS. Mesenchymal stromal cells (MSCs) are multipotent cells found in a large number of adult tissues and used in clinical practice as therapeutic agents for immunomodulation and tissue repair. There is growing evidence that their efficiency is mainly attributed to the secretion of a wide range of bioactive molecules and extracellular vesicles (EVs). Indeed, different experimental studies revealed that MSC-derived EVs (MSC-EVs) could modulate local and systemic deleterious immune response. Therefore, these new cell-free therapeutic products, easily stored and available immediately, represent a tremendous opportunity in the emergency context of shock. In this review, the pathophysiological environment of THS and, in particular, the crosstalk between the immune system and organ function are described. The potential therapeutic benefits of MSCs or their EVs in treating THS are discussed based on the current knowledge. Understanding the key mechanisms of immune deregulation leading to organ damage is a crucial element in order to optimize the preparation of EVs and potentiate their therapeutic effect.

Long-Term Healthcare Expenditures Following Combat-Related Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is one of the most common injuries resulting from U.S. Military engagements since 2001. Long-term consequences in terms of healthcare utilization are unknown. We sought to evaluate healthcare expenditures among U.S. military service members with TBI, as compared to a matched cohort of uninjured individuals.

METHODS

We identified service members who were treated for an isolated combat-related TBI between 2007 and 2011. Controls consisted of hospitalized active duty service members, without any history of combat-related injury, matched by age, biologic sex, year of hospitalization, and duration of follow-up. Median total healthcare expenditures over the entire surveillance period represented our primary outcome. Expenditures in the first year (365 days) following injury (hospitalization for controls) and for subsequent years (366th day to last healthcare encounter) were considered secondarily. Negative binomial regression was used to identify the adjusted influence of TBI.

RESULTS

The TBI cohort consisted of 634 individuals, and there were 1,268 controls. Healthcare expenditures among those with moderate/severe TBI (median $154,335; interquartile range [IQR] $88,088-$360,977) were significantly higher as compared to individuals with mild TBI (median $113,951; IQR $66,663-$210,014) and controls (median $43,077; IQR $24,403-$83,590; P < .001). Most expenditures were incurred during the first year following injury.

CONCLUSION

This investigation represents the first continuous observation of healthcare utilization among individuals with combat-related TBI. Our findings speak to continued consumption of health care well beyond the immediate postinjury period, resulting in total expenditures approximately six to seven times higher than those of service members hospitalized for noncombat-related reasons.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020

PURPOSE

Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs.

METHODS

This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis.

RESULTS

During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed.

CONCLUSIONS

Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

Lower Extremity Combat Sustained Peripheral Nerve Injury in US Military Personnel

Background:

Since the civil war, combat sustained peripheral nerve injuries (CSPNI) have been documented during wartime. Warfare has evolved and current combat involves a greater severity of blast injuries secondary to increased use of improvised explosive devices. The purpose of this study was to describe CSPNI and report outcomes after evaluation and treatment. We hypothesize that a shorter time to evaluation will improve outcomes.

Methods:

A database including all active duty service members who sustained a CSPNI and were treated by the PNC between 2004 and 2009 was used. Service member demographic information, injury mechanism, CSPNI description, and Medical Research Council (MRC) final motor and sensory outcomes were queried from this database.

Results:

One hundred and four military service members sustained 144 PNIs. The average age was 26.7 years, and nearly all were men (98.1%). There was no correlation between Sunderland classification and age, specific PNI, injury type, or time to evaluation. Higher Sunderland classifications were found to be correlated with worse final motor (r = 0.51, P < 0.001) and final sensory (r = 0.41, P < 0.001) scores. Final motor and sensory scores were not associated with specific nerve injury, mechanism of injury, initial EMG, or surgical procedure. Shorter time to initial assessment was associated with improved final motor and sensory scores, but was not found to be statistically significant.

Conclusions:

As the complexity of CSPNIs progress as combat weaponry evolves, a firm understanding of treatment factors is important. Our study demonstrates in recent conflict that military service members’ initial injury severity is a key factor in expected outcome.

Combat injuries sustained by troops on counter terrorism and counter-insurgency operations in North east Nigeria: Implications for intervention

Background

Understanding the epidemiology of battlefield casualties is required for plans and coordinated efforts towards improved combat trauma care (CTC) performance and outcome. The engagement of the Armed Forces of Nigeria (AFN) in containing Boko Haram Terrorism (BHT) and insurgency in Northeast Nigeria has increased the risk of combat injuries to the troops. This study determined the characteristics of combat injuries sustained by soldiers on counter terrorism and counter-insurgency operations to contain BHT.

Methods

A retrospective cross-sectional study of combat casualties managed in 7 Division (Field) Hospital, [an equivalent of UN Level 2 facility] Maiduguri, Northeast Nigeria between November 2013 and October 2014. Using data obtained from a designed Operational Casualty Card that contains their sociodemographic characteristics, categorization (as Combat Arm, Combat Support Service, Civ-JTF), nature, mechanism and sites of injury as well as inpatients records. The data were collated and analysed using SPSS version 20.

Results

A total of 209 casualties were treated. The age of the casualties ranged from 18 to 57 years with a mean of 30.6 ± 7.7 years and males constituting 99%. Over two-third (71.3%) casualties had gunshot injuries while 14.3% and 8.1% sustained improvised explosive device (IED) and fragments injuries respectively. Over three-quarter (77.5%) sustained injuries on the upper and lower extremities while 17 (7.7%) and 12 (5.7%) had injuries on thorax/abdomen and head/neck respectively. Nineteen (9.1%) casualties resulted from friendly forces/colleagues.

Conclusion

The study revealed that gunshot and IED/blasts on the extremities were the most frequent mechanism and pattern of injuries sustained with less than a tenth of the casualties resulting from friendly forces. Training health personnel on CTC, deployment of combat lifesavers to improve pre-hospital CTC, employment of skilled Orthopaedic Surgeon and other relevant surgical subspecialties and timely air evacuation of critical cases from the Field Hospital to the Base Hospital are recommended.

Combat-Sustained Peripheral Nerve Injuries in the United States Military

PURPOSE

Combat-sustained peripheral nerve injuries (CSPNIs) are often the result of high-energy blast mechanisms and are increasing in frequency and severity among US forces engaged in contemporary warfare. The purpose of this study was to describe CSPNIs and report outcomes after evaluation in a military multidisciplinary peripheral nerve clinic. We hypothesized that a shorter time to evaluation by a multidisciplinary peripheral nerve team would improve outcomes.

METHODS

The Peripheral Nerve Consortium (PNC) maintains an electronic database of all active duty service members who sustained a peripheral nerve injury (PNI) and were treated by the PNC between 2004 and 2009. This database was queried for service member demographic information, injury characteristics, wounding patterns, CSPNI description, surgical procedures, and Medical Research Council final motor and sensory outcome.

RESULTS

Among the 104 service members treated by the PNC in the 6-year period reviewed, there were 138 PNIs. Average age was 27 years, time to initial evaluation by the PNC was 4 (±7) months, and average follow-up was 18 (±18) months. Associated injuries included fractures (31.1%), multiple PNIs (76.8%), vascular injury (30.4%), and traumatic brain injury (34.1%). There was no association between Sunderland classification and time to evaluation, mechanism of injury, or nerve injured. However, Sunderland classification was correlated with final motor and final sensory scores. Service members with better final sensory score (S1 or S2) had shorter time to initial evaluation than did patients with a final sensory score of S0 (<0.05). This did not hold true for final motor score.

CONCLUSIONS

Service members with more severe initial injuries had worse final outcomes. Although timely referral does not occur for most CSPNIs, a shorter time to presentation also led to improved sensory recovery. Complex combat-sustained PNIs may be best understood and treated within a multidisciplinary team.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Epidemiology of Blast Neurotrauma: A Meta-analysis of Blast Injury Patterns in the Military and Civilian Populations

BACKGROUND

Mass casualty incidents (MCIs) due to bombing-related terrorism remain an omnipresent threat to our global society. The aim of this study was to elucidate differences in blast injury patterns between military and civilian victims affected by terrorist bombings.

METHODS

An analysis of the Global Terrorism Database (GTD) and a PubMed literature search of casualty reports of bombing attacks from 2010-2020 was performed (main key words: blast injuries/therapy, terrorism, military personnel) with key epidemiological and injury pattern data extracted and statistically analyzed.

RESULTS

Demographic analysis of casualties revealed that military casualties tend to be younger and predominantly male (P < 0.05) compared with civilians. Military casualties also reported higher amounts of head/neck injury (P < 0.01) compared with civilians. The proportion of instantaneous fatalities along with injuries affecting the thoracoabdominal and extremity regions remained approximately equal across both groups.

CONCLUSIONS

Though the increased number of head/neck injuries was unexpected, we also found that the number of nonlethal head injuries also increased, predicating that more military blast neurotrauma patients survived their injuries. These data can be used to increase blast MCI preparation and education throughout the international neurosurgical community.

A decade in the battlefield (2004-2014): A French military perspective on the high mortality associated with non-exclusively orthopedic or brain combat injuries

BACKGROUND

During the last few decades, French armed forces have regularly deployed in asymmetric conflicts. Surgical support for casualties of these conflicts occurs in NATO role 2 and 3 medical treatment facilities (MTF); definitive surgical care occurs in France following a strategic medical evacuation. The aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or brain injuries.

METHODS

This descriptive study is a retrospective analysis of the surgical management of French casualties performed in role 2 or 3 MTF in Afghanistan, Mali, Niger, Djibouti and the Central African Republic between January 2004 and December 2014.

RESULTS

One hundred patients were included. Forty had fragment wounds. The most severe lesions were of the head, neck or thorax. The average injury severity score (ISS) was 34.9 (IC 95% 29.8-40). 17 damage control procedures were performed. Thirty patients died with a mean ISS of 61 (IC 95% 56-67); 5 deaths were considered as preventable. The most frequent surgical procedures in the MTF were digestive (n=31) and thoracic surgery (n=19). Thirty patients needed second-look surgery in France; eleven had severe complications. No patient died following medical evacuation to France.

CONCLUSIONS

Results from this study indicated that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. Level of Evidence IV.

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs-Walter Reed National Medical Center

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.

How the US Army Forged Hand Surgery

As the United States plunged into World War II, the surgeon general, Norman T. Kirk, scrambled to care for the complex hand injuries sustained in combat. To remedy this problem, Major General Kirk appointed Sterling Bunnell, a general surgeon and a World War I veteran with a keen interest in hand injuries, to serve as the consultant to the Secretary of War. Kirk and Bunnell formed 9 US military hand centers that treated 22,000 hand injuries in World War II. Bunnell and his pupils would later form the nucleus of the American Society for Surgery of the Hand. Through Dr. Bunnell's expertise, skillful care, dedication to teaching, and love of country, US hand surgery was born.

Tree of Life Synagogue Shooting in Pittsburgh: Preparedness, Prehospital Care, and Lessons Learned

On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers. The injured had wounds often seen in war-settings, with the signature of high velocity weaponry. We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.

Antibiotic Practice Patterns for Extremity Wound Infections among Blast-Injured Subjects

INTRODUCTION

We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012).

METHODS

Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment.

RESULTS

Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones.

CONCLUSIONS

Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship.

Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan

Background

Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients’ care.

Methods

We reviewed the records of all patients admitted at the Lashkargah “Emergency” hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death.

Results

We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries.

Conclusions

Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.

Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities

BACKGROUND

Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers.

MATERIALS AND METHODS

We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes.

RESULTS

We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98).

CONCLUSIONS

EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.

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.

Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention

PURPOSE OF REVIEW

To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts.

RECENT FINDINGS

Over 44% OEF/OIF/OND veterans are obese (BMI > 30 kg/m2), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.

Combat-Related Extremity Wounds: Injury Factors Predicting Early Onset Infections

We examined risk factors for combat-related extremity wound infections (CEWI) among U.S. military patients injured in Iraq and Afghanistan (2009-2012). Patients with ≥1 combat-related, open extremity wound admitted to a participating U.S. hospital (≤7 days postinjury) were retrospectively assessed. The population was classified based upon most severe injury (amputation, open fracture without amputation, or open soft-tissue injury defined as non-fracture/non-amputation wounds). Among 1271 eligible patients, 395 (31%) patients had ≥1 amputation, 457 (36%) had open fractures, and 419 (33%) had open soft-tissue wounds as their most severe injury, respectively. Among patients with traumatic amputations, 100 (47%) developed a CEWI compared to 66 (14%) and 12 (3%) patients with open fractures and open soft-tissue wounds, respectively. In a Cox proportional hazard analysis restricted to CEWIs ≤30 days postinjury among the traumatic amputation and open fracture groups, sustaining an amputation (hazard ratio: 1.79; 95% confidence interval: 1.25-2.56), blood transfusion ≤24 hours postinjury, improvised explosive device blast, first documented shock index ≥0.80, and >4 injury sites were independently associated with CEWI risk. The presence of a non-extremity infection at least 4 days prior to a CEWI diagnosis was associated with lower CEWI risk, suggesting impact of recent exposure to directed antimicrobial therapy. Further assessment of early clinical management will help to elucidate risk factor contribution. The wound classification system provides a comprehensive approach in assessment of injury and clinical factors for the risk and outcomes of an extremity wound infection.

Late immune consequences of combat trauma: a review of trauma-related immune dysfunction and potential therapies

With improvements in personnel and vehicular body armor, robust casualty evacuation capabilities, and damage control resuscitation strategies, more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system. As such, medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system. In this review, we aim to highlight these late consequences and identify areas for future research and therapeutic strategies. Trauma leads to the dysregulation of both the innate and adaptive immune responses, which places the injured at risk for several late consequences, including delayed wound healing, late onset sepsis and infection, multi-organ dysfunction syndrome, and acute respiratory distress syndrome, which are significant for their association with the increased morbidity and mortality of wounded personnel. The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses, triggered by the presence of damage-associated molecules and other immune-modifying agents following trauma. Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable, fluid and difficult to determine. As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated, it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma, which are known to lead to significant morbidity and mortality.

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.

Negative-Pressure Wound Therapy Versus Standard Treatment of Adult Patients With Conflict-Related Extremity Wounds: Protocol for a Randomized Controlled Trial

Background

In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.

Objective

The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.

Methods

This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.

Results

The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.

Conclusions

To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.

Trial Registration

ClinicalTrials.gov NCT02444598; http://clinicaltrials.gov/ct2/show/NCT02444598 (Archived by WebCite at http://www.webcitation.org/72hjI2XNX)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12334

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

OBJECTIVES

We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009).

METHODS

Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed.

RESULTS

A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006.

CONCLUSIONS

Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use).

LEVEL OF EVIDENCE

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

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.

Heterotopic ossification and lessons learned from fifteen years at war: A review of therapy, novel research, and future directions for military and civilian orthopaedic trauma

Heterotopic ossification, the formation of bone in soft tissues, is a common complication of the high-energy extremity trauma sustained in modern armed conflict. In the past 15years, military treatment facilities and aligned laboratories have been in a unique position to study and treat this process due to the high volume of patients with these injuries secondary to blast trauma. The devastating nature of these wounds has limited traditional therapeutic options, necessitating alternative solutions to prophylaxis and initial treatment producing substantial advances in modeling, prophylaxis, detection, and therapy. Specific developments include establishment of an animal model that reproduces the systemic and local tissue injury of blast injuries, the use of molecular assays and predictive modeling in clinical decision making, advances in early detection including Raman spectroscopy, and investigation of prophylactic and therapeutic pharmacotherapy targeting the molecular pathways of aberrant bone formation. In this review article, we will present the literature to date, ongoing studies, and future directions for investigation of heterotopic ossification, with a focus on military-specific research.