Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Research Advances After a Decade of War 21 articles


What Risk Factors Are Associated With Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study

Deydre S. Teyhen PT, PhD, Scott W. Shaffer PT, PhD, Robert J. Butler PT, PhD, Stephen L. Goffar PT, PhD, Kyle B. Kiesel PT, PhD, Daniel I. Rhon PT, DSc, Jared N. Williamson DPT, Phillip J. Plisky PT, DSc

Musculoskeletal injury is the most common reason that soldiers are medically not ready to deploy. Understanding intrinsic risk factors that may place an elite soldier at risk of musculoskeletal injury may be beneficial in preventing musculoskeletal injury and maintaining operational military readiness. Findings from this population may also be useful as hypothesis-generating work for particular civilian settings such as law enforcement officers (SWAT teams), firefighters (smoke jumpers), or others in physically demanding professions.

Can Cytoprotective Cobalt Protoporphyrin Protect Skeletal Muscle and Muscle-derived Stem Cells From Ischemic Injury?

Heather-Marie P. Wilson PhD, Robert E. Welikson PhD, Jun Luo MD, PhD, Thomas J. Kean PhD, Baohong Cao MD, PhD, James E. Dennis PhD, Margaret D. Allen MD

Extremity trauma is the most common injury seen in combat hospitals as well as in civilian trauma centers. Major skeletal muscle injuries that are complicated by ischemia often result in substantial muscle loss, residual disability, or even amputation, yet few treatment options are available. A therapy that would increase skeletal muscle tolerance to hypoxic damage could reduce acute myocyte loss and enhance preservation of muscle mass in these situations.

Does Coordinated, Multidisciplinary Treatment Limit Medical Disability and Attrition Related to Spine Conditions in the US Navy?

Gregg Ziemke PT, MS, MHA, OCS, CAPT, MSC, USN, Marco Campello PT, PhD, Rudi Hiebert ScM, Shira Schecter Weiner PT, PhD, Chris Rennix ScD, Margareta Nordin DrMedSci

Musculoskeletal conditions account for the largest proportion of cases resulting in early separation from the US Navy. This study evaluates the impact of the Spine Team, a multidisciplinary care group that included physicians, physical therapists, and a clinical psychologist, for the treatment of active-duty service members with work-disabling, nonspecific low back pain at the Naval Medical Center, Portsmouth, VA, USA. We compared the impact of the introduction of the Spine Team in limiting disability and attrition from work-disabling spine conditions with the experience of the Naval Medical Center, San Diego, CA, USA, where there is no comparable spine team.

Osteoblasts Have a Neural Origin in Heterotopic Ossification

ZaWaunyka W. Lazard BS, Elizabeth A. Olmsted-Davis PhD, Elizabeth A. Salisbury PhD, Zbigniew Gugala MD, PhD, Corrine Sonnet PhD, Eleanor L. Davis, Eric Beal BS, Eroboghene E. Ubogu MD, Alan R. Davis PhD

Heterotopic ossification (HO) is the process of bone formation at a nonskeletal site. Recently, we showed that the earliest steps occur in sensory nerves. We now extend these studies by identifying unique osteogenic progenitors within the endoneurial compartment of sensory nerves.

Whole-body Vibration at Thoracic Resonance Induces Sustained Pain and Widespread Cervical Neuroinflammation in the Rat

Martha E. Zeeman MS, Sonia Kartha BS, Nicolas V. Jaumard PhD, Hassam A. Baig MS, Alec M. Stablow, Jasmine Lee, Benjamin B. Guarino BS, Beth A. Winkelstein PhD

Whole-body vibration (WBV) is associated with back and neck pain in military personnel and civilians. However, the role of vibration frequency and the physiological mechanisms involved in pain symptoms are unknown.

Hydrogel-based Delivery of rhBMP-2 Improves Healing of Large Bone Defects Compared With Autograft

Laxminarayanan Krishnan PhD, Lauren B. Priddy MS, Camden Esancy BS, Mon-Tzu Alice Li PhD, Hazel Y. Stevens BS, Xi Jiang BS, Lisa Tran MD, David W. Rowe PhD, Robert E. Guldberg PhD

Autologous bone grafting remains the gold standard in the treatment of large bone defects but is limited by tissue availability and donor site morbidity. Recombinant human bone morphogenetic protein-2 (rhBMP-2), delivered with a collagen sponge, is clinically used to treat large bone defects and complications such as delayed healing or nonunion. For the same dose of rhBMP-2, we have shown that a hybrid nanofiber mesh-alginate (NMA-rhBMP-2) delivery system provides longer-term release and increases functional bone regeneration in critically sized rat femoral bone defects compared with a collagen sponge. However, no comparisons of healing efficiencies have been made thus far between this hybrid delivery system and the gold standard of using autograft.

Preventing Heterotopic Ossification in Combat Casualties—Which Models Are Best Suited for Clinical Use?

Keith A. Alfieri MD, Benjamin K. Potter MD, Thomas A. Davis PhD, Matthew B. Wagner PhD, Eric A. Elster MD, Jonathan A. Forsberg MD

To prevent symptomatic heterotopic ossification (HO) and guide primary prophylaxis in patients with combat wounds, physicians require risk stratification methods that can be used early in the postinjury period. There are no validated models to help guide clinicians in the treatment for this common and potentially disabling condition.

Immunomodulatory Peptide IDR-1018 Decreases Implant Infection and Preserves Osseointegration

Hyonmin Choe MD, PhD, Arvind S. Narayanan MS, Deep A. Gandhi, Aaron Weinberg DMD, PhD, Randall E. Marcus MD, Zhenghong Lee PhD, Robert A. Bonomo MD, Edward M. Greenfield PhD

Innate defense regulator peptide-1018 (IDR-1018) is a 12-amino acid, synthetic, immunomodulatory host defense peptide that can reduce soft tissue infections and is less likely to induce bacterial resistance than conventional antibiotics. However, IDRs have not been tested on orthopaedic infections and the immunomodulatory effects of IDR-1018 have only been characterized in response to lipopolysacharide, which is exclusively produced by Gram-negative bacteria.

Rifamycin Derivatives Are Effective Against Staphylococcal Biofilms In Vitro and Elutable From PMMA

Carlos J. Sanchez PhD, Stefanie M. Shiels PhD, David J. Tennent MD, Sharanda K. Hardy BS, Clinton K. Murray MD, Joseph C. Wenke PhD

Local antimicrobial delivery through polymethylmethacrylate beads (PMMA), commonly vancomycin, is used for the treatment of contaminated open fractures but has limited activity againstbiofilms, which occur commonly in such fractures. Rifamycins have activity against biofilms and are an effective treatment for osteoarticular infections involving staphylococcal biofilms, but there are limited studies evaluating the activity of rifamycin derivatives, other than rifampin, against biofilms ofand evaluating incorporation of these drugs into PMMA for treatment of contaminated open fractures.

Porphyrin-adsorbed Allograft Bone: A Photoactive, Antibiofilm Surface

Sana S. Dastgheyb PhD, Cyrus B. Toorkey PhD, Irving M. Shapiro BDS, PhD, Noreen J. Hickok PhD

Allograft bone is commonly used to augment bone stock. Unfortunately, allograft is prone to bacterial contamination and current antimicrobial therapies are inadequate. Photoactivated porphyrins combat bacterial growth by production of reactive oxygen species (ROS); however, to our knowledge, they have not been tested in the setting of allograft bone.

Blast Injury in the Spine: Dynamic Response Index Is Not an Appropriate Model for Predicting Injury

Edward Spurrier BM, FRCS(Tr+Orth), James A. G. Singleton MRCS, RAMC, Spyros Masouros PhD, Iain Gibb FRCS Ed, FRCR, RAMC, Jon Clasper DM, DPhil

Improvised explosive devices are a common feature of recent asymmetric conflicts and there is a persistent landmine threat to military and humanitarian personnel. Assessment of injury risk to the spine in vehicles subjected to explosions was conducted using a standardized model, the Dynamic Response Index (DRI). However, the DRI was intended for evaluating aircraft ejection seats and has not been validated in blast conditions.

Cathodic Electrical Stimulation Combined With Vancomycin Enhances Treatment of Methicillin-resistant Staphylococcus aureus Implant-associated Infections

Scott Nodzo MD, Menachem Tobias MS, Lisa Hansen MS, Nicole R. Luke-Marshall PhD, Ross Cole BS, Linda Wild MD, Anthony A. Campagnari PhD, Mark T. Ehrensberger PhD

Effective treatments for implant-associated infections are often lacking. Cathodic voltage-controlled electrical stimulation has shown potential as a treatment of implant-associated infections of methicillin-resistant(MRSA).

Bioburden Increases Heterotopic Ossification Formation in an Established Rat Model

Gabriel J. Pavey MD, Ammar T. Qureshi PhD, Donald N. Hope MD, Rebecca L. Pavlicek PhD, Benjamin K. Potter MD, Jonathan A. Forsberg MD, Thomas A. Davis PhD

Heterotopic ossification (HO) develops in a majority of combat-related amputations wherein early bacterial colonization has been considered a potential early risk factor. Our group has recently developed a small animal model of trauma-induced HO that incorporates many of the multifaceted injury patterns of combat trauma in the absence of bacterial contamination and subsequent wound colonization.

Botulinum Toxin-induced Muscle Paralysis Inhibits Heterotopic Bone Formation

Brandon J. Ausk PhD, Ted S. Gross PhD, Steven D. Bain PhD

Short-term muscle atrophy induced by botulinum toxin A (BTxA) has been observed to impair osteogenesis in a rat closed femur fracture model. However, it is unclear whether the underlying mechanism is a direct effect of BTxA on muscle-bone interactions or an indirect effect that is driven by skeletal unloading. Because skeletal trauma in the closed fracture model also leads to disuse atrophy, we sought to mitigate this confounding variable by examining BTxA effects on muscle-bone interactions in two complementary in vivo models in which osteogenesis is induced in the absence of skeletal unloading. The overall aim of this study was to identify a potential strategy to inhibit pathological bone formation and heterotopic ossification (HO).

What Risk Factors Predict Recurrence of Heterotopic Ossification After Excision in Combat-related Amputations?

Gabriel J. Pavey MD, Elizabeth M. Polfer MD, Kyle E. Nappo MD, Scott M. Tintle MD, Jonathan A. Forsberg MD, Benjamin K. Potter MD

Heterotopic ossification (HO) is common after combat-related amputations and surgical excision remains the only definitive treatment for persistently symptomatic HO. There is no consensus in the literature regarding the timing of surgery, and recurrence frequency, reexcision, and complications have not been reported in large numbers of patients.

What Is the Magnitude and Long-term Economic Cost of Care of the British Military Afghanistan Amputee Cohort?

D. S. Edwards FRCS(Tr&Orth), Rhodri D. Phillip FRCP, Nick Bosanquet MSc, Anthony M. J. Bull PhD, Jon C. Clasper FRCS(Tr&Orth)

Personal protection equipment, improved early medical care, and rapid extraction of the casualty have resulted in more injured service members who served in Afghanistan surviving after severe military trauma. Many of those who survive the initial trauma are faced with complex wounds such as multiple amputations. Although costs of care can be high, they have not been well quantified before. This is required to budget for the needs of the injured beyond their service in the armed forces.

Analysis of Orthopaedic Research Produced During the Wars in Iraq and Afghanistan

George C. Balazs MD, Jonathan F. Dickens MD, Alaina M. Brelin MD, Jared A. Wolfe MD, John-Paul H. Rue MD, Benjamin K. Potter MD

Military orthopaedic surgeons have published a substantial amount of original research based on our care of combat-wounded service members and related studies during the wars in Iraq and Afghanistan. However, to our knowledge, the influence of this body of work has not been evaluated bibliometrically, and doing so is important to determine the modern impact of combat casualty research in the wider medical community.

Early Characterization of Blast-related Heterotopic Ossification in a Rat Model

Ammar T. Qureshi PhD, Erica K. Crump BA, Gabriel J. Pavey MD, Donald N. Hope MD, Jonathan A. Forsberg MD, Thomas A. Davis PhD

Heterotopic ossification (HO) affects the majority of combat-related lower extremity wounds involving severe fracture and amputation. Defining the timing of early osteogenic-related genes may help identify candidate prophylactic agents and guide the timing of prophylactic therapy after blast and other combat-related extremity injuries.

Percutaneous Distraction Pinning for Metacarpophalangeal Joint Stabilization After Blast or Crush Injuries of the Hand

Matthew A. Langford MD, Kevin Cheung BS, Zhongyu Li MD, PhD

Unstable, severely comminuted fractures of the metacarpophalangeal (MCP) joint are difficult to treat. Closed treatment and casting of these fractures often fail to maintain proper alignment and impede wound care where concomitant open injuries such as gunshot wounds are present. Conventional pinning or plating techniques are not feasible if extensive bone loss and comminution are present. A distraction pinning technique represents a potential alternative, but results with this approach, to our knowledge, have not been reported.