Approximately 33,000 American service members have been wounded in the wars in Iraq and Afghanistan during the past six years1. Providing treatment as soon as possible after injury has saved lives and preserved optimal function for most of the personnel wounded in the conflicts. Forward surgical teams have performed this life and limb-saving work. Orthopaedic surgeons are essential members of these teams because the majority of service members who are wounded in action sustain musculoskeletal injuries2. From the onset of the military actions in Iraq and Afghanistan, orthopaedic surgeons from the Army, Navy, and Air Force have served in the surgical units providing this care. These facilities range in size from two-surgeon resuscitative surgical teams near forward combat operations (Figs. 1-A and 1-B) to sophisticated field hospitals (Fig. 2)3. Continuously manning these battlefield surgical teams and caring for the large numbers of service members with musculoskeletal injuries have created many logistic and personnel challenges for the armed forces.
The goal of this article is to provide an overview of some of the background, challenges, and rewards relevant to service as an orthopaedic surgeon in today's armed forces. It includes a limited historical perspective on the important advances that have improved care for injured service members, some unique aspects affecting caregivers in the high operational tempo of present-day combat areas, and a description of how current military operations impact orthopaedic surgeons and their families.
The role of military orthopaedic surgeons differs from that of their civilian colleagues in a number of ways. The military orthopaedic surgeons treat military families, retirees, and active-duty personnel. They are expected to provide care for members of our armed services who are wounded in combat. This care frequently occurs under harsh, austere, and dangerous conditions. Therefore, U.S. military orthopaedic surgeons must meet many of the mandatory, general military requirements of all of the armed forces. These include service-specific physical fitness standards, small-arms training, physical as well as mental health requirements, and Geneva Convention Rules of War training. Military orthopaedic surgeons must also possess knowledge regarding tropical medicine and public health issues in present-day, far-flung, combat zones.
It has been said that, "The military profession is more than an occupation; it is a style of life."4 There are various reasons why orthopaedic surgeons voluntarily serve in the armed forces when the financial rewards, family stability, and freedom to run one's own life are potentially much different in civilian practice. Given the military lifestyle, the reasons why orthopaedic surgeons remain in uniform beyond any educational obligation are diverse and may include patriotism, professional growth, the opportunity to be part of a team involved with something larger than one's self, and a sense of duty. This call to duty has been frequently addressed, and encouraged, from the Commander-in-Chief on down. Speaking to midshipmen at the U.S. Naval Academy, President John F. Kennedy said, "What you have chosen to do for your country by devoting your life to the service of your country is the greatest contribution any man could make."5
In my opinion, there may be another, more fundamental reason why some orthopaedic surgeons remain in uniform—their patients. We are fortunate to have the best patients one can imagine. There is an axiom that one of the keys to successful orthopaedic surgery is proper patient selection. The strong bonds of loyalty and esprit de corps among military service members, especially at the small-unit levels, contribute to this sense of commitment6. Many of our patients who sustain devastating war injuries often express profound regret at leaving their comrades behind and want to return to their units as soon as possible. As a result, they exert extraordinary efforts to return to optimal function during their recovery. While the severity of their wounds may prevent some from ever returning to their units, most do not lose the determination to reach that goal. That unit cohesiveness mindset, coupled with the resilience of their physically fit youthful bodies, augurs for optimal recovery of the majority of our patients.
As devastating as many battlefield wounds are, military orthopaedic surgeons are often impressed by some of the outcomes. A case in point: a senior Marine officer was severely wounded in the early evening hours by a 122-mm rocket that also killed and wounded others (Figs. 3-A and 3-B). Because this attack occurred only 200 meters from the Fallujah surgical team, surgeons were able to operate on him within minutes after he was wounded. Despite further surgery and challenging rehabilitation, this Marine eventually returned to service in Iraq.
History has shown that advances in patient care often occur during wartime6. To reduce the overall morbidity of combat injuries, the U.S. military medical system has made effective changes in the strategies and systems of battle care in recent years7,8. However, with improved protection afforded the thorax and abdomen by modern body armor9, orthopaedic surgeons are now treating many severe extremity injuries sustained on the battlefield that were infrequently seen in survivors of past conflicts.
Historically, war has played an important role in the development of orthopaedic surgery, but it was not until World War I that orthopaedics developed as an independent surgical discipline10. Orthopaedic surgeons in the armed forces today benefit from those who served before them, some of whom made great contributions to our specialty. Although war's influence on the advancement of our specialty would itself be a lengthy dissertation, it is appropriate to mention a few outstanding contributions that have made a substantial mark on orthopaedics.
Important Organizational Events and Individuals Who Improved Care for Injured Service Members
In 1862, with the American Civil War producing thousands of casualties from single battles, Major Jonathan Letterman, an Army physician, was appointed Medical Director of the Army of the Potomac. He devised a system that included mobile field hospitals near battlefields, a stratified organization of combat care, principles of triage, specially outfitted boats and railroad cars for patient transportation in relative comfort and safety, and careful record keeping11. The system was supported by an efficient ambulance corps that was under the direction of the medical service. This infrastructure was subsequently adopted worldwide, and its basic tenets still exist. Letterman's principles are seen in today's echeloned levels of care, combat trauma registries, and rapid aeromedical evacuation of wounded personnel from battlefields in Iraq and Afghanistan back to the United States for definitive treatment.
Major General Norman T. Kirk, an orthopaedic surgeon and the Army Surgeon General during much of World War II, was a proponent of specialty hospitals to treat complex problems. He supported the idea of concentrating specialty services in military hospitals, where the complex wounds of military personnel could be treated more comprehensively and efficiently. His efforts resulted in the establishment of military hospitals for the care of service members with hand wounds and amputations. Initially, he designated five centers for amputees, where the resources of physicians with expertise in these conditions, physical therapists, and prosthetists were concentrated. The teams at these sites were responsible for performing revision surgery, prosthetic fitting, and rehabilitation for soldiers with such wounds. Within a year, the success of these centers created such a workload that two additional centers were started12.
With thousands of service members who had had a major limb amputated during the war, Major General Kirk turned to the National Academy of Sciences (NAS) for advice on how to improve the performance of artificial limbs13. In 1945, the NAS sponsored a conference on this issue, which ultimately led to federal funding for a prosthetics research program. The Veterans Administration assumed responsibility for this program in 1947, and affiliated amputee research centers were established at New York University, Northwestern University, and the University of California at Los Angeles14,15.
During the Vietnam War, the efficient and rapid transport of wounded personnel from the battlefield to waiting surgical teams with use of helicopters became commonplace. This improved medical evacuation of casualties enabled the concentration of surgical teams in trauma centers where trained specialists provided improved intensive care for wounded service members. As a result, a service member's survival from battlefield wounds was greater than that in any previous conflict.
Innovations in Equipment and Individuals Who Profoundly Affected the Care of Injured Service Members
In 1851, shortly before the Crimean War, a Dutch military surgeon, Antonius Mathijsen, worked on devising a better means of treating battlefield fractures, many of which were caused by gunshots16. By rubbing dry gypsum into coarse linen, he developed the plaster-of-Paris bandage, which continues to be a mainstay of fracture treatment.
The field of orthopaedic surgery made important advances in World War I, especially in the treatment of trauma. Additionally, improved principles of wound débridement that decreased the prevalence of infection were developed. During World War I, British orthopaedic surgeon Sir Robert Jones was appointed Major General Inspector for orthopaedics in the British Armed Forces. He was an advocate for tendon transplantation and bone-grafting as well as for conservative restorative procedures. Jones set up numerous orthopaedic centers throughout the country—a novel idea at the time—and their efficiency was a testament to his organizational skills17. His introduction of the Thomas splint for fractures of the middle and lower third of the femur markedly decreased the mortality from these injuries18. In 1917, he wrote Notes on Military Orthopaedics, which at the time was indispensable to other surgeons throughout the United Kingdom who were not as proficient at fracture care19. Sir Robert Jones' accomplishments during the war provided him with the stature to found the British Orthopaedic Association in 1918.
In 1939, near the outset of World War II in Europe, Gerhard Küntscher introduced a method of intramedullary nailing for the stabilization of femoral fractures20. As a medical officer in the German Army from 1942 to 1945, he pursued refinements of the procedure, despite the German military's initial disapproval of this perceived radical technique. This method eventually revolutionized the stabilization of long-bone fractures, especially the femur, throughout the world.
During the same period in the United States, Sterling Bunnell was appointed as Consultant to the Secretary of War to guide, integrate and develop the special field of hand surgery.10 He helped to establish centers in ten general hospitals to treat hand injuries. For two years, he traveled from one hand center to another teaching young army surgeons and performing surgery21. Important advances were made, and the subspecialty of hand surgery came into its own during this period10. After the war, Dr. Bunnell edited Surgery in World War II. Hand Surgery, a text describing many of the techniques and principles that were developed22.
During the 1930s, Roger Anderson refined external fixation as a method to stabilize fractures23. During the early part of World War II, American casualties treated with this technique in a stable environment had favorable outcomes12. Although this technique was not used to any extent during World War II, it is a mainstay of stabilization of osseous injuries in the present-day Iraq and Afghanistan wars24.
The events of World War II brought into focus the need to establish criteria for determining when a traumatic wound could be closed in relative safety. These principles were based on the clinical appearance of the wound, and they included the absence of drainage, erythema, or foreign material and the presence of healthy-appearing tissue. These principles were a major advancement in wound care and remain in use today12. Also, various methods were developed to treat the many fracture nonunions incurred during the war. Among them was the posterolateral approach for bone-grafting of the tibia to treat nonunion, which was reported by Paul Harmon25.
Transportation Changes That Substantially Improved the Time to Care and Survival Chances of Wounded Service Members
Although motorized ambulances were used in World War I, as opposed to the horse-drawn ambulances of previous conflicts, patients often did not receive care until twelve to twenty-four hours after injury26. During World War II, it took twelve to fifteen hours for service members wounded on the battlefield in Italy to reach a hospital for care27. This delay in the care of wounded personnel was addressed by the introduction of the helicopter for patient transport during the Korean War. The method revolutionized medical evacuation, as it decreased the time of casualty transport to a definitive care facility by four to six hours27. Improvements in the system during the Vietnam War further decreased the time to initial treatment of wounded soldiers to one or two hours11.
Intermingling of Changes in Administration, Treatment, and Transportation Improved Military and Civilian Survival and Preservation of Function
Modern organized care of injured patients has its roots in military models of trauma care, and many of the advances in treating patients with major trauma can be attributed to the lessons learned during past military conflicts27. During World War II, Letterman's principles were expanded to accommodate the evacuation of wounded service members through tiers of increasingly capable medical care. This system was further refined during the Korean and Vietnam conflicts to take advantage of concentrated trauma care resources for more effective life and limb-saving surgery. For example, the rapid helicopter transport that began in Korea and improved in Vietnam allowed for much greater success in the earlier repair of extremity vascular injuries compared with the methods of World War II28. The principles learned during wartime were not automatically, or easily, implemented at home. However, the military's success in dealing with severe injuries led to heightened public expectations about trauma care and provided an impetus for the development of civilian trauma systems29. As a result, many of the military concepts for emergency trauma care were subsequently introduced in the civilian sector.
Athletic Injuries
A number of improved methods for the treatment of patients with athletic trauma have also evolved in the military setting. Many sports injuries are treated by military orthopaedic surgeons on a daily basis because of the military lifestyle30. Most service members are young, physically active adults who pursue a wide range of sports activities. A number of these pursuits are also used to promote teamwork and fitness. For example, in the Marine Corps, all members are required to participate in martial arts training that can progress through various levels of proficiency—and risk. Many service members have military duties and off-duty physical pursuits that are often at the level of accomplished or elite athletes. The injuries sustained by service members from these activities create a large pool of patients who can be treated, and followed, in a more controlled environment than in the civilian setting. This opportunity has helped to better define certain outcomes in the care of patients with sports injuries and has provided substantial contributions to the field of orthopaedic sports medicine31. Landmark studies on anterior cruciate ligament injuries by Feagin and Curl32 and on shoulder dislocations by DeBerardino et al.33 at the United States Military Academy are but two examples.
Each branch of the armed forces is unique, and orthopaedic surgeons in the Army, Navy, and Air Force are imbued with the distinctive traditions and heritage of their respective services. However, there are common attributes of military orthopaedics that extend across service lines despite the specific needs of each military branch.
Humanitarian Missions
Participation in humanitarian missions that have spanned the globe is one distinctive aspect of military orthopaedics. These duties range from being part of larger operations, such as those in the Balkans34 or Haiti35, to stand-alone missions as in Sri Lanka36. These missions are epitomized by the Navy hospital ship U.S.N.S. Mercy mission to Southeast Asia for disaster relief stemming from the tsunami and earthquake that occurred close together in 2004 and 200537. Such assignments require orthopaedic ingenuity and an ability to adapt to, and use, the resources that are available. Today, these missions often occur as part of our nation's overarching foreign policy and are viewed as an important aspect of the global war on terror. The one-on-one diplomacy of individual military orthopaedic surgeons is invaluable38. This can include meeting with American and foreign diplomats on a wide range of issues related to health care, teaching the medical personnel of the host nation, and helping to establish medical infrastructure.
Combat Deployments
Some of the most challenging assignments faced by military orthopaedic surgeons are lengthy wartime deployments. This type of service requires subjugation of one's self-interest in the interest of others39. Deployments of orthopaedic surgeons to Iraq and Afghanistan have varied by service branch since the current wars began, and they have been as long as fifteen months. In Vietnam, the deployments were typically twelve months. Currently, most deployment lengths for Army, Navy, and Air Force orthopaedic surgeons are in the range of six, seven, and four months, respectively. Many orthopaedic surgeons have deployed more than once.
Preparing for a combat deployment begins weeks before the actual departure, with field or shipboard training, war surgery courses, mass casualty drills, small-arms qualifications, convoy training, intelligence briefings, and, in some cases, predeployment mission surveys to the destination country. Orthopaedic surgeons are not uncommonly selected for key leadership roles in the combat theater. In Iraq, for example, this has ranged from being in charge of far-forward surgical teams to the command of field hospitals. Given that most wounded personnel have musculoskeletal injuries, the clinical and surgical skills possessed by orthopaedic surgeons provide them with a valuable perspective on patient care when in positions of leadership.
Long or repeated combat tours can be hard on both service personnel and their families. Although each branch of the military has support systems in place to help families to deal with the stresses of wartime deployments, military members and their families still face many challenges. These may include solo parenting issues, financial concerns, and intense family emotions about the safety of the active duty member. Deployed personnel may have feelings that range from apprehension regarding combat zone service to loneliness from being separated from family for extended periods. While there are no data pertaining specifically to military orthopaedic surgeons, they and their families face many of the same stresses borne by others in the military community.
Troops deployed to Iraq and Afghanistan generally have had more morale-enhancing services available to them compared with previous wars. These range from small exchanges that sell comfort, hygiene, and other items to tent or building-based gyms to maintain physical fitness. Some camps are visited by USO (United Service Organizations) troupes or other entertainers. Advances in deployed telecommunications capabilities have made it easier than ever before to keep in touch with family, friends, and others by telephone, e-mail, and the World Wide Web. Most personnel on twelve to fifteen-month deployments have had an opportunity to return home for two weeks during the deployment.
Messing and berthing arrangements for surgical teams have varied by location and by the time period when the teams were deployed. Tents, buildings of opportunity, and containerized living units (or so-called cans) have all been used for berthing, and living accommodations have generally improved over time. Messing has also varied but generally has improved since 2003. Initially, Meals-Ready-to-Eat (MREs) and tray rations were commonplace, but, as the combat theater has matured, cafeteria-style dining facilities staffed by contract personnel were established on many of the larger camps or bases.
Surgically capable units in the combat theater are classified as either Level II or Level III, depending on their inherent capabilities. Small far-forward surgical teams are termed Level II and are exemplified by the ten-person Marine Corps Forward Resuscitative Surgical System or the twenty-person Army Forward Surgical Team3. Since a substantial subset (20% to 35%) of patients die from uncontrolled hemorrhage within minutes after being wounded and before reaching medical care, some of them are now being saved by these small, highly mobile surgical units that are placed on the battlefield to provide expedient treatment40. Known as tactical surgical intervention, the extent of this care depends on the physiologic status of the patient, the numbers and types of casualties, the resources available, and the tactical situation40. Level-III facilities, such as the Army Combat Support Hospital in Baghdad and the Air Force Theater Hospital in Balad, Iraq, are in essence combat zone trauma centers with advanced surgical capabilities, blood-banking, intensive care units, and excellent ancillary support including physical therapy.
The experience of serving with a surgical team in Iraq, for example, is based on many factors that may include the team's location, its capabilities, and the type and extent of ongoing military operations. The actual number of wounded personnel who are treated by an orthopaedic surgeon on any given day depends on enemy and coalition activity in the team's area of responsibility. At Level II, there is usually one orthopaedic surgeon per team and thus he or she must be continually available around the clock to see casualties. Level III may have two or more orthopaedic surgeons, thus allowing for some division of labor when not in a mass casualty situation. Typically, 60% to 70% of combat casualties have musculoskeletal injuries. The most intense combat, and thus the highest number of monthly casualties to date, were sustained during combat operations in Fallujah in 200441. In addition to treating those injured in combat, orthopaedic surgeons also provide a large amount of garrison care. This includes U.S. service members, other coalition personnel, and contractors with problems that vary from athletic trauma and overuse to industrial injuries. The in-theater care provided to many of these injured patients obviates the need for medical evacuation and conserves valuable human and material resources.
Most orthopaedic surgery performed on personnel wounded in combat in Iraq and Afghanistan today can be categorized as damage control orthopaedics42, similar to that performed in other modern conflicts. This treatment concept includes early, rapid, temporary fracture stabilization to minimize blood and heat loss, followed by physiologic stabilization43. Secondary definitive orthopaedic management is then provided at the most capable echelon. Definitive surgery is also sometimes done for Iraqi nationals, particularly at Level-III facilities44. To provide some perspective regarding patient numbers, over 56,000 patients, including coalition forces, Iraqi military, Iraqi civilians, and contractors, were seen at Marine Corps forward medical and surgical units in Al Anbar Province alone from March 2004 through October 200745.
The combat setting is challenging for all who serve in Iraq. The desert environment is harsh, with temperatures soaring to 130°F. Severe sandstorms can markedly reduce visibility for days and can ground aircraft on occasion. The current war in Iraq is an insurgency with shifting allegiances, no uniformed enemy, and no front lines. Most casualties never see their attacker. Improvised explosive devices, or so-called roadside bombs, have been responsible for >60% of American casualties in Iraq (Fig. 4)46. Vehicle-borne improvised explosive devices driven by suicide drivers and suicide bombers wearing explosive vests have also caused U.S. and coalition casualties. The possibility of injury or death from these weapons is always present for any unit, including forward surgical teams, who are on the move. In addition, Army, Navy, and Air Force orthopaedic surgeons have come under indirect fire on many occasions (Fig. 5).
Battlefield injuries are seldom encountered by orthopaedic surgeons outside the military47. They are characteristically caused by high-energy weapons and are often catastrophic in the scope of bone and soft-tissue injury48. Patients injured by improvised explosive devices can be particularly difficult to manage since they often have combined penetrating, blunt, and burn injuries7. The energized fragments from these weapons include casing components, nails, dirt, clothing, and even bone. This mixture produces an unprecedented degree of mangled extremities and makes the decision to amputate more complex7.
Today, nearly nine of ten service members wounded in Iraq survive—the highest survival rate in history. This is reflected by a 10.1% case fatality rate, which is a measure of the overall lethality of the battlefield for those who are wounded49,50. The case fatality rates for ground troops in World War II and Vietnam were 19.1% and 15.8%, respectively49. However, the use of these comparative statistics to show that the historically low case fatality rate in Iraq is due to improved medical care can be ambiguous. This is because data from different conflicts were not always collected uniformly51.
There are probably multiple factors that have contributed to the decline in the case fatality rate for the Iraq War. These include lessened battlefield lethality, better personal protective equipment, improved battlefield first-aid training, far-forward placement of surgical teams, more sophisticated surgical care, and markedly decreased medical evacuation times49. Today, most patients arrive in Germany for Level-IV care within twelve to forty-eight hours after injury, and they are back in the United States in four to five days52. During the Vietnam era, this took forty-five days51.
A more accurate measure of the effectiveness of medical care than case fatality rate may be the percentage of patients—about 5% in Iraq—who die of their wounds after reaching a medical facility8,49. Paradoxically, this rate is significantly higher than in either World War II or Vietnam (p < 0.05), although the care today is much more sophisticated49. It is not exactly clear why there are differences in the rate of patients who die of their wounds nor is it clear what impact has been made by medical care. Although it is possible that the increased rate of patients who die of their wounds might reflect worse medical care compared with previous conflicts, there may be a better explanation. Improved hemorrhage control on the battlefield, enhanced corpsman and/or medic training, and faster evacuation could increase the number of casualties who die of severe wounds in a medical treatment facility rather than on the battlefield. This percentage of patients who die of their wounds would likely be greater if not for improvements in surgical management with use of damage control principles, the liberal use of fresh whole blood, the availability of recombinant factor VII, and improved intensive-care techniques49.
Early irrigation and débridement, fracture stabilization, shunting of arterial injuries, vacuum-assisted closure, frequent use of flaps for coverage, better options for osseous stabilization, and advances in prosthetics may contribute to improved outcomes compared with previous wars. These methods are being addressed by a large multicenter trial termed the Military Extremity Trauma and Amputation-Limb Salvage (METALS) study that will provide a uniform protocol for long-term follow-up to better define the clinical, functional, and quality-of-life outcomes following major orthopaedic extremity trauma in military personnel53.
In order to institutionalize lessons of combat casualty care, several formal courses have been established to educate military surgeons. These include the Navy's Emergency War Surgery course, the Army's Extremity War Surgery Course, and the Society of Military Orthopaedic Surgeons Combat Extremity Surgery Course. Also, since 2006, the American Academy of Orthopaedic Surgeons, the Orthopaedic Trauma Association, and the Society of Military Orthopaedic Surgeons have jointly sponsored annual symposia on Extremity War Injuries. This landmark program has brought together civilian orthopaedic trauma experts with military orthopaedic surgeons who have extensive battlefield surgery experience to develop, record, and disseminate treatment principles that are based on the best available evidence54. It is hoped that this program will fill knowledge gaps that are apparent when attempts are made to apply the principles of civilian trauma care to the treatment of combat casualties.
In conclusion, military orthopaedic surgery is a unique aspect of our specialty that can markedly differ from civilian practice and often requires special sacrifices of both the surgeon and his or her family. However, the opportunity to work with and treat the many dedicated members of the armed forces is itself very rewarding and provides an important service to the nation.