Military surgeons update management of high-energy knee injuries

The ongoing wars in Iraq and Afghanistan have resulted in uniquely destructive patterns of combat injuries, including limb-threatening injuries to the knee. In the March special issue of Techniques in Knee Surgery military surgeons serving in Operation Iraqi Freedom and Operation Enduring Freedom share their experience with managing these high-energy injuries of the knee. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, and pharmacy.

The special issue provides surgeons with an update on the challenges, strategies, and techniques of managing the new patterns of leg and knee injury seen in the war on terrorism. "A common theme…is the importance of the 'team' approach to these battlefield injuries by multiple services and personnel to achieve the optimal result," writes Dr. Charles B. Pasque, guest editor of the special issue.

Unique Injury Patterns Pose Special Challenges to Knee Surgery
With improvements in body armor and rapid evacuation of casualties, many service members are surviving with extensive injuries to the knee and surrounding area. Many of these injuries are caused by improvised explosive devices, with high-energy blasts producing injury patterns unlike those seen in civilians. In addition to severe destruction of blood vessels, soft tissue, and bone, the injuries are characterized by contaminating debris driven deep into the wound.

In the special issue, surgeons serving "downrange" in Iraq and Afghanistan share their insights into the surgical concepts and advances used to treat soldiers with these devastating injuries. The focus is on providing appropriate management as the patient advances through the echelons of military medical care: from emergency care at the point of injury, to forward surgical teams or combat support hospitals for stabilization procedures, through final transport for definitive surgical reconstruction. The articles address four critical issues:

•External fixation is critical for stabilizing the injured leg while the patient is evacuated for further medical care. External fixation hardware can be placed by forward surgical teams located close to combat units—often under "austere" operating conditions and sometimes without the benefit of x-rays. After transport, patients need extremely close monitoring and "second-look" surgeries to keep the injury clean and stable. (Co-authored by Dr. Neil C. Vining, along with Dr. Pasque.)
•Frontline treatment of blood vessel injuries is essential to have any chance of saving these severely injured limbs. New vascular shunting techniques can temporarily re-route the blood supply, keeping the leg viable for eventual reconstruction. The earlier blood supply can be restored, the better the chances of saving the limb. However, surgeons must often make difficult decisions as to which limbs are salvageable. (Lead author Dr. Mark E. Fleming.)
•Major advances in soft tissue care have been made in recent years. A variety of surgical techniques provide new options for replacing the skin of the leg and knee and reconstructing the ligaments and muscles responsible for knee motion. As the patient proceeds through the echelons of care, close co-operation among surgical specialists—including vascular, orthopaedic, and plastic surgeons—is essential to provide the best possible outcomes. (Lead author Dr. Joseph DuBose.)
•Once the "soft tissue envelope" of the injured limb is stable, fractures can be managed using advanced internal fixation devices. These techniques, such as new "locked plating" systems, make it possible to reconstruct even very severely fragmented fractures of the leg and knee. More research is needed to determine the long-term outcomes of these techniques, and to develop promising approaches to bone and tissue regeneration. (Lead author Dr. Romney C. Anderson.)

Dr. Pasque hopes that the updates in the special issue of Techniques in Knee Surgery "can help improve the care of future wounded warriors and help those of us who care for these injuries in civilian practice." Dr. Pasque spent a year as a mobilized Navy reservist, working at the Landstuhl Regional Medical Center in Germany. He found the experience inspirational, and offers his thanks to the authors for sharing their experience and expertise. "Your unselfish care for our country's wounded warriors is a shining example for all of us to follow on how to care for our patients," Dr. Pasque concludes.