By Douglas W. Lundy, M.D., MBA, FACS
From ATLANTA Medicine, Vol. 86, No. 1
Orthopaedic surgery is a diverse specialty comprised of multiple subspecialties focused on anatomic areas or pathologic processes (degenerative disease, developmental or trauma). Although the origins of orthopaedic surgery stem from treatment of children affected by polio, a tremendous portion of orthopaedic surgery throughout the world today involves the treatment of injuries to the bones, joints and surrounding tissues of the musculoskeletal system. Orthopaedic trauma surgery has advanced significantly over the last 50 years, with massive strides in the understanding of injury and the techniques to successfully return these patients to a functional level of living.
The subspecialty of orthopaedic trauma is an underrepresented discipline in orthopaedic surgery that has benefited greatly from the conflict in Iraq and Afghanistan. It is a very unfortunate truth that the treatment of injury always increases greatly in the time of war. It is especially unfortunate that many young American men and women must be injured in battle for funding to become available for these very important initiatives.
Through the aggressive lobbying efforts of orthopaedic surgeons, hundreds of millions of dollars have been directed by Congress to fund research on the treatment of extremity injuries during war. The valuable lessons learned from the suffering of American combatants will further improve the treatment of American citizens now and in the years to come.
Trauma continues to be a major problem in the state of Georgia. Although trauma is the No. 1 killer of Georgians between the ages of six months to age 44, the state continues to underfund efforts to improve the trauma system and establish a truly effective trauma network.
Trauma costs this country $406 billion a year, including both healthcare costs and lost productivity. Studies by the Georgia Trauma Care Network demonstrate that fatality rate from motor vehicle crashes doubles as the distance from a verified trauma center increases.
At 13.2/100,000, the death rate in Georgia from trauma is higher than the national average of 11.3. Nonetheless, when Georgia Trauma Care Funding, Amendment 2, an effective constitutional amendment to fund trauma care in the state, was placed on the ballot four years ago, the initiative was defeated 52.6 percent to 47.4 percent. Ironically, the sections of the state that would have benefitted the most from this funding actually voted en masse to defeat the effort.
Treatment of Mangled Extremities
Significant improvement techniques and a better understanding of severe extremity trauma has occurred over the last several years. The use of vacuum-assisted devices in the treatment of severe soft tissue trauma has dramatically decreased the morbidity of the treatment of these injuries. Improvements in the surgical and pharmacologic care of these injuries have resulted in lower rates of infection and other complications. Once again, much of this learning resulted from the horrific injuries sustained by our soldiers as they served valiantly in Iraq and Afghanistan.
The Lower Extremity Assessment Project (LEAP) was a tremendous effort by orthopaedic trauma surgeons to better understand the outcomes and ideal treatment of mangled extremities. I contributed some of the patients to this study during my fellowship 15 years ago, and this project resulted in over three dozen publications describing best practices in patients with these injuries.
The main findings of this study were sobering. Patients with severe lower extremity injuries did equally poorly whether their extremities are reconstructed or amputated, and the worse news is that the patients actually deteriorated in function between two and seven years after injury. This finding highlights that although we can reconstruct the bone structure and often gain healing, the extent of the soft tissue injury often determines the eventual functional outcome of the patient. Even though we have made significant strides in the treatment of these injuries, we still have a long way to go.
Pelvic and Acetabular Fractures
Pelvic and acetabular fractures with their associated injuries are some of the most catastrophic injuries affecting patients injured from motor vehicle crashes or falls. Increased understanding of the mechanisms leading to hypovolemic shock and death from pelvic injuries has resulted in a decrease in death rates and improvements in surgical techniques and functional outcomes. Minimally invasive techniques have resulted in faster returns to work and decreased morbidity for these badly injured patients.
Damage Control Orthopaedic Surgery
One of the biggest advances in orthopaedic trauma is the increased understanding of the contribution of major fractures to the overall stability of badly injured patients. With increased collaboration of orthopaedic surgeons with trauma surgeons and the trauma service, critically injured patients that would have died not too long ago now survive to live productive lives. Carefully timed and tactical emergent treatment of femoral and pelvic fractures, compartment syndromes and mangled extremities help optimize the patient’s condition during the critical hours after injury. After the patients have stabilized, we then return to surgery to anatomically reduce and stabilize articular fractures and accomplish definitive stabilization.
Advances in the care of patients with severe extremity injuries continue to develop, and these patients are enjoying much greater functional outcomes than they would have in the not too distant past. Although there is still much to accomplish in the care of these patients, we have come a long way. Atlanta has fellowship-trained orthopaedic trauma surgeons on staff at Grady Memorial Hospital, Kennestone Hospital, North Fulton Hospital and Gwinnett Medical Center trauma centers ready to care for patients presenting with severe injuries.
