“In the early years we boarded planes for Afghanistan and Iraq with a copy of Rockwood and Green and Hoppenfield’s Surgical Exposures, only to find that none of the improvised explosive device (IED) blasts we were seeing resembled those hallowed texts. There is a loneliness one feels when faced with such cases where there is so little to guide one’s hand. But one learns.” — LtCol John M. Tickis, M.D., Mc USAF
Oh yes they learned.
LTC Brett D. Owens, M.D.How to treat the chaos of an IED blast wound as well as the other unconventional traumas encountered in Afghanistan and Iraq was little more than oral tradition until two Army surgeons LTC Brett D. Owens, M.D. and LTC Philip J. Belmont, M.D. decided to convert that institutional memory into a comprehensive reference book. Fifty-one combat physicians from the U.S. Army, Navy/Marine and Air Force joined the project and their enthusiastic participation allowed the entire project to be completed in just 12 months.
Combat Orthopedic Surgery: Lessons Learned from Iraq and Afghanistan is a 320-page, 29-chapter powerhouse of a reference book that was published last month. It is the first reference book for orthopedic surgeons emerging from the two wars of the past decade. It was published by SLACK, Incorporated and the two authors were at AAOS—which is where we sat down to discuss their landmark book.
Combat care in Afghanistan and Iraq is a paradigm shift from Vietnam, Korea and World War II. No training or education program adequately prepared these physicians for missions they faced. How they learned to treat IED wounds, improve the processes of limb salvage, amputation, tourniquet use, infection reduction, prosthetic design, and how to employ regenerative medicine techniques in front line care are the subjects of this remarkable book.
Considering how orthopedic therapies have vaulted forward during war time, this book reads like a skeleton key into the future. It is, in fact, the first orthopedic combat reference book to emerge from these two wars.
This book also exemplifies the culture of duty, honor, fidelity, patriotism, and collaboration which defines the U.S. professional military services today.
“When the country sounded a call to arms, these men and women responded. For me, working on this book was my way to honor their service, ” said 42-year-old co-author LTC Philip J. Belmont Jr., M.D. when we asked him why he committed roughly 1, 500 hours of evening and weekend time over two years to assemble this book.
Said his 38-year-old co-author LTC Brett D. Owens, M.D. “When we started to treat these wounded soldiers we weren’t handed anything, no books. We wrote this book because it had to be written.”
Musculoskeletal Combat Wounds in OIF/OEF
More than 65% of all operative cases at combat support hospitals are orthopedic in nature. Owens and his colleagues collected data from these orthopedic injuries during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) from October 2001 to January, 2005. He found that explosions were responsible for 75% of all extremity combat wounds, the highest percentage in U.S. military history. Gunshot wounds only accounted for 16% of extremity wounds.
Explosions create distinctive patterns of injuries including severely traumatized limbs, open fractures, disproportionately large zones of injury, frequent bone and volumetric soft tissue loss which is usually accompanied by gross foreign body and bacterial contamination. The three large and largely novel problems that these warrior physicians confronted in OIF/OEF were:
- Wound healing
- Infection
- Heterotopic ossification
As we noted earlier, when these physicians went scrambling back to their text books, they found significant gaps in the knowledge base. Open injury rates in these conflicts were 40% compared to 10% in civilian trauma. Transfusion rates are three times higher—yet combat mortality rates are at a historically low rate of 3%.
The authors, the collaborators and their editors organized their reference book into three major sections.
Section One: Principles
This section describes the history of combat orthopedic surgery from 1700 BCE to the modern day (MAJ Andrew J. Schoenfeld, M.D. author), today’s combat environment and the epidemiology of musculoskeletal combat injuries (LTC Philip J. Belmont Jr. M.D. and CPT Gens P. Goodman, D.O. authors), the military’s echelons of care (LTC Mark Pallis, D.O. and COL Tad Gerlinger, M.D. authors), the Forward Surgical Team (MAJ Andrew Schoenfeld, M.D., MAJ Dirk L. Slade, M.D. and LTC Belmont authors), Combat Support Hospitals (COL James R. Ficke, M.D. author) and finally a fascinating description of the Landstuhl Regional Medical Center (COL Joachim Jude Tenuta, M.D. author) which has treated so many service men and women over the years.
Section Two: Advancements
Here is where the authors and their collaborators collected the institutional knowledge of battle field innovation from hundred of physician warriors. There is so much in this section that is, on its own merit, fascinating but also provocative in the classic sense of stimulating new ideas and insights. The section begins with a clearly written chapter on ballistic, blast and burn injuries (COL (Ret) Roman Hayda, M.D. author) and then picks up speed with Management of Complex Combat-Related Soft Tissue Wounds/Negative Pressure Wound Therapy (MAJ Brett A. Freedman, M.D. and MAJ Leon J. Nesti, M.D., Ph.D. authors) and Basic Science of War Wounds (LCDR Jonathan Agner Forsberg, M.D., Trevor S. Brown, Ph.D. and MAJ Benjamin K. Potter, M.D. authors).
Heterotopic ossification is covered brilliantly by MAJ Potter and LCDR Forsberg. This topic may be one of the most provocative since it pulls in fundamental concepts of healing and protein signaling. For this reader, this was one of the most interesting and thought provoking of all chapters.
MAJ Scott Waterman, M.D., CDR Mark E. Fleming, D.O. and LTC Owens put together a special chapter on irrigation and debridement—the keys to successful wound repair. That chapter is followed by a detailed overview of the advancements in Tissue Engineering and Regeneration that have come from treating these combat injuries (LCDR Jared A. Vogler, D.O., Wesley Jackson, Ph.D. and MAJ Nesti M.D., Ph.D. authors), Infection in Orthopedic Extremity Injuries (LTC Clinton K. Murray, M.D. author), Tourniquets (COL John F. Kragh, Jr., M.D. author) and External Fixation Principles (LCDR Joseph Carney, M.D. and CAPT D.C. Covey, M.D. authors).
Section Three: Upper Extremity, Lower Extremity and Spine/Pelvis Injury Care
The last 14 chapters take the general principles and advancements of the previous two sections and apply them in a detailed reference section which give the combat surgeon and, yes, the civilian surgeon a comprehensive field manual and definitive reference for all orthopedic surgeons. As the authors put it, this is the nuts and bolts section.
Buy This Book
What, we asked the two lead authors, were the scientific advances that impressed them the most as they collected these articles? Dr. Belmont was most focused on the ways in which soldiers are better protected from injury:
- Advances in individual and vehicular body armor
- Much better limb salvage techniques and, therefore, reduced amputation
- More rapid evacuation to combat support hospitals
- Significant prosthesis advances—specifically for above-the-knee amputations where computer chip technologies offer the soldier more efficient ambulation and more normal gait.
Dr. Belmont also mentioned the major advances in pushing advanced care down to the most forward surgical units. Orthopedic surgeons treating wounded combat soldiers find that while they will certainly be working in their “zones of comfort, ” they will also be working in their “zones of ability.” That means that the surgeon whose residency may have been in large joint reconstruction will be also called upon to address hand, foot or spine cases.
Dr. Owens recommended these three topics from the book:
- The advancements in tourniquet use and design
- The excellent discussion of basic science of how wounds heal, the functional relationships of cytokines and chemokines.
- Heterotopic ossification and the cellular mechanisms, unique to the types of wounds encountered in OIF/OEF, that cause them.
Every practicing orthopedic surgeon should have this valuable new reference book in their library. To order call or write:
SLACK Incorporated
6900 Grove Road
Thorofare, NJ 08086 USA
Telephone: 856-848-1000
