Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
Department of Orthopedics, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.
Mil Med. 2023 Aug 29;188(9-10):2924-2931. doi: 10.1093/milmed/usac219.
After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East.
A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes.
The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques.
These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.
在中东地区经历了 20 多年的战争后，骨科损伤成为最常见的与战斗相关的损伤之一，根据国防部创伤登记处的数据，占 R2/R3（二级/三级）设施所有手术的 14%。为了进一步阐明部署在战场上的骨科医生的角色，我们对中东地区的骨科医生进行了回顾性研究，重点分析了与中东战争期间骨科手术护理相关的定量和定性分析因素。
对 2001 年至 2021 年期间在中东地区的骨科医生进行了回顾性研究。使用两名审核员进行了综合文献检索，使用了 PubMed 和 Embase 数据库。使用 Covidence 对文章进行了编译和审查。纳入标准包括专注于在全球反恐战争（GWoT）期间发生的成年美国军人的骨科损伤的期刊文章。在发生冲突的情况下，第三位作者将确定文章的相关性。对于其余的文章，进行了全文审查以提取相关的预定定量数据，然后利用德尔菲共识方法突出相关的定性主题。
最初的搜索产生了 1226 篇可能相关的文章。最终，共有 40 项研究符合资格标准。在咨询了沃尔特·里德国家军事医学中心的以前部署的骨科医生后，对 40 项研究进行了回顾性主题分析，揭示了骨科医生在 GWoT 期间经历的五个主题。这些主题包括由于新型武器而导致与以前的战争损伤相比具有独特的骨科损伤机制，R2 与 R3 位置的干预措施不同，与平民环境中所见的损伤不同，维持对骨科医生使命的人道主义方面的重视，以及最后与部署前培训相关的与骨科医生的部署成功的感知。从这项广泛的研究中，我们发现爆炸物损伤机制大大增加，与以前的冲突相比，这是骨科损伤的主要病因。由于改进的身体装甲和整体存活率的复杂爆炸物损伤增加，R2/3 设施对骨科干预（包括清创术、截肢术和外固定术）的需求增加。与平民创伤相比，GWoT 期间发生的战斗损伤在并发症、管理和复杂性方面有所不同。“人道主义”病例构成了部署骨科医生的大量手术病例。最后，部署前提供了各种机会（进修、四肢手术课程和专门的部署前培训），骨科医生最常识别到的有用培训是学习更多的软组织覆盖技术。
这些主要主题表明，应强调部署前培训和骨科医生的战略定位，以反映肌肉骨骼创伤护理的不断变化的格局。作者建议，分析骨科医生在这些独特的军事环境中的舒适度和感知能力，以最好地为不断变化的作战模式和可能发生的未来同级冲突做好准备，这可能导致缺乏医疗后送和延长现场护理。
