Medical lessons learnt from the US and Canadian experience of treating combat casualties from Afghanistan and Iraq

Abstract

The Winston Churchill Memorial Trust, established in 1965, funds Travelling Fellowships and both authors visited hospitals in Germany, Canada and the USA regarded as centres of excellence with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies, as recipients of these Fellowships. This article presents some of the lessons learnt in the field of musculoskeletal trauma and rehabilitation from the Canadian and US military medical systems. In trauma, there were significant differences in wound debridement policy, use of external fixators for fractures, primary use of circular frames for open tibial fractures and a far more liberal use of bone morphogenetic protein in fracture treatment. Differences in soft tissue reconstruction policy regarding flaps for soft tissue cover over exposed bone, near-universal usage of topical negative pressure dressings and use of Allgöwer-Donati suture pattern to close all wounds were noted. Ertl amputation osteoplasty, a modified form of transtibial amputation, had also been reintroduced. In rehabilitation, the management of heterotopic ossification, in particular with imaging techniques and excision surgery, was identified. For the upper limb, we observed the patient training required to use a myoelectric hand and the future possibility of targeted muscle re-innervation to make controlling these myoelectric prostheses more natural using innate motor patterns. For the lower limb, we found we used identical above knee prostheses. For patients who have had limb reconstruction and have poor function, an energy-storing orthosis was demonstrated to compensate for the loss of range of motion and muscle power.

Functional and Mental Health Status of United Kingdom Military Amputees Postrehabilitation

“…It is beyond the scope of this article to complete a detailed comparison of different North Atlantic Treaty Organization amputee care pathways. Combat casualty care for the United States (US), Canadian, and UK military has previously been described, 2 along with a detailed analysis of US combat amputee care. 3 The paradigm of UK military rehabilitation at the Defence Medical Rehabilitation Centre (DMRC) is given in figure 1.…”

Bioengineered human skeletal muscle capable of functional regeneration

“…In severe muscle traumas such as volumetric muscle loss (VML), surgical trauma or partial muscles tears, the regenerative capacity of skeletal muscle can be overcome, leading to non-regenerative defects such as fibrosis [18][19][20][21], interstitial adipose accumulation [13,22,23] and heterotopic bone formation [24,25]. In these circumstances, individuals are left with complications such as reduced function, increased chance of reinjury and debilitating pain [26][27][28]. In animal models of severe traumas, there has been limited success in manipulating the regenerative process to promote muscle regeneration and reduce non-regenerative defects.…”

Functional regeneration of tissue engineered skeletal muscle in vitro is dependent on the inclusion of basement membrane proteins

“…The severity of muscle wounds seen in clinical settings is highly varied, ranging from minor strains to significant muscle traumas such as volumetric muscle loss. Typically, wounds caused by military trauma or severe sports injury, do not retain full regenerative capacity and complete recovery is not observed (Belmont, McCriskin, Sieg, Burks, & Schoenfeld, 2012;Dharm-Datta & McLenaghan, 2013;Wheatley et al, 2015). In addition, individuals with genetic conditions, collectively termed myopathies, also experience a lack of regeneration following injury (Dimachkie & Barohn, 2014;Flanigan, 2014;Nigro & Piluso, 2015;Shieh, 2013).…”