Orthopedic Surgery in the United States Army: A Historical Review

Transcription

1 MILITARY MEDICINE, 176, 6:689, 2011 Orthopedic Surgery in the United States Army: A Historical Review MAJ Andrew J. Schoenfeld, MC USA ABSTRACT The contribution of American military surgeons to the development of orthopedic surgery has not previously been explored. The experiences of American military surgeons in conflicts from the Civil War to Iraq and Afghanistan have advanced the orthopedic discipline, resulting in important developments within the field, as well as scientific discoveries that have benefited both the civilian and military communities. From advances in wound care, to spinal surgery, intramedullary nailing of long bone fractures, and external fixation, American military surgeons have been pioneers of orthopedic surgery. The goal of this review was to survey the American military orthopedic experience from the American Revolution to the wars in Iraq and Afghanistan. INTRODUCTION Although only recognized as an independent discipline at the end of the 19th century, orthopedic surgery had developed over the course of millennia with many significant developments engendered during times of war. Although this association between military surgery and what we presently accept as orthopedics reaches back to the ancient period, the contributions of American military practitioners to the development of orthopedic surgery cannot be overlooked. Arguably, the experiences of American military surgeons in conflicts from the Civil War to the present have continued to reinvigorate the orthopedic discipline, resulting in important developments within the field, as well as scientific discoveries that have gone on to benefit the civilian and military communities. Before the technological advancements that potentiated the modern surgical specialties, it is even possible to maintain that the majority of what constituted American military combat surgery, from the Revolution to the First World War, was orthopedic in nature: removal of bullets and shrapnel, soft tissue care, setting of fractures, and extremity amputation. The goal of this review is to survey the U.S. Army s orthopedic experience from the period of the American Revolution to the current conflicts in Iraq and Afghanistan. It is hoped that, through this report, the reader may gain a better appreciation for the significant contributions American combat orthopedics has made to the development of the field as a whole. EARLY BEGINNINGS: THE AMERICAN REVOLUTION (1775) TO 1860 The United States Army Medical Department and the Medical Corps trace their origins to the founding of the United States Army Hospital department on July 27, 1775, only 10 days after the Battle of Bunker Hill. 1 The department, under the direction of Surgeon General Benjamin Church, was charged Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, 5005 North Piedras Street, El Paso, TX with supplying the fledgling units of the Continental Army with military surgeons who could provide battlefield care and administer to the wounded. Each Army regiment was authorized 1 surgeon. At the time, medical education within the United States was not standardized and the vast majority of physicians obtained their education through an apprentice system. Almost none of the American military surgeons had prior combat experience, including the Surgeon General. The surgeons of the Continental Army had limited resources, as well as a truncated understanding of the pathophysiological mechanisms of trauma, infection, and wound healing. These individuals were most effective at removing bullet fragments or shrapnel from superficial wounds, debriding devitalized tissue, and setting fractured limbs. 1 4 The fear of sepsis led to a substantial reliance on extremity amputations, particularly in the event of soft-tissue compromise or comminuted fractures. In most instances, wounds were not cleansed at all or they were irrigated with what standing water was available. During the Battle of Harlem Heights (1776), however, Continental Army Surgeon Charles Gillman used alcohol to treat combat wounds and later reported on the benefits of this process. His practices, however, were not adopted by other practitioners in the Continental Army. 3 In an effort to standardize some of the practices used to treat American war wounded, Continental Army Surgeon John Jones ( Fig. 1 ) authored the first American surgical text [O]n the Treatment of Wounds and Fractures: Designed for the Use of Young Military Surgeons in North America. 5 The text, devoted almost entirely to what would now be considered the purview of an orthopedic surgeon, cautioned army surgeons to respect the soft tissue envelope, remove bone fragments and foreign bodies as atraumatically as possible, and use bark emollients as a means of cautery. Amputations, unless needed to save a soldier s life, were to be delayed until the individual was determined to be stable from a medical standpoint. Open fractures were to be treated with debridement and an attempt at reduction. 5 Although other surgeons expounded principles from the standpoint of medical theory, Jones was one of the few military MILITARY MEDICINE, Vol. 176, June

2 FIGURE 1. John Jones, MD. Arguably America s first military surgeon. Jones trained under Percival Pott and John Hunter and composed On the Treatment of Wounds and Fractures: Designed for the Use of Young Military Surgeons in North America during the American Revolution. Courtesy of the National Library of Medicine. surgeons who could speak from prior experience. Formally trained in medicine in Europe, Jones had apprenticed under famed surgeons such as Percival Pott and John Hunter. He had also served as a British Army surgeon during the French and Indian War ( ). Interestingly, the revolutionary conflict now pitted Jones against his former mentor, John Hunter, who was serving as Surgeon General of the British Armed Forces.4 At the end of the revolution, the Army Medical Corps was dissolved and would only be reconstituted during times of war until 1818, when it was officially mandated as a standing portion of the peacetime Armed Forces. 1 The lack of a professional military medical service retarded the development of combat casualty care in the nascent U.S. Army. Nonetheless, advancements continued to be made by enterprising physicians serving within the ranks. For example, during the War of 1812, American surgeons advocated the performance of emergent extremity fasciotomies to treat elevated compartment pressures in the setting of fractures, burns, or severe combatrelated soft-tissue damage. 4 THE CIVIL WAR ( ) The medical departments of both the Federal American forces, as well as the Confederacy, at the start of the Civil War were grossly understaffed and unprepared for the shear number of casualties that were to arise from the conflict. 6 8 At FIGURE 2. Assistant Surgeon William W. Keen of the 5th Massachusetts Infantry. Keen served in the Federal Army Medical Corps during all 4 years of the Civil War and performed an emergent surgical decompression on a wounded soldier at Gettysburg (1863). Courtesy of the National Library of Medicine. the start of the Civil War, less than 100 physicians staffed the U.S. Army and some of these resigned their commissions to serve in the Confederate Medical Corps. 7,8 Most medical personnel on both sides were recruited from the civilian ranks of what was still a rudimentary, nonstandardized, medical education system. Even medical students were considered worthy of appointments as full-fledged combat surgeons. 6 Assistant Surgeon William W. Keen ( Fig. 2 ), of the 5th Massachusetts Infantry, had less than 1 month of formal medical school training before he was pressed into service. 6 His experiences at the Battle of Bull Run (1861), the first major Civil War battle, are extremely telling of the orthopedic nature of combat surgery at the time. Within the first hours of the battle, Keen was asked to perform a shoulder amputation and set a fracture of the upper extremity. 6 Over the course of the 4-year conflict, the ranks of the Medical Corps of the U.S. Army, as well as the Confederacy, burgeoned to over 15,000 surgeons Both sides produced 690 MILITARY MEDICINE, Vol. 176, June 2011

3 medical texts attempting to inform the treatment of war wounded, and A Manual of Military Surgery for the Use of Surgeons in the Confederate Army even provided an algorithm for performing amputations. 8 With approximately 70% of survivable Civil War injuries involving the extremities, the combat medical experience of this conflict provided ample exposure to fracture care. 9,10 Although popular conception associates the Civil War surgeon with the rapid performance of extremity amputations (indeed more than 60,000 amputations were performed by Federal surgeons alone 3 ), some practitioners pioneered novel approaches to fracture care and wound management. The aforementioned Dr. Keen performed an emergent decompression of the cervical spine in the setting of a gunshot wound at the Battle of Gettysburg (1863) successfully reversing an incomplete spinal cord injury. 11 Benjamin Howard, of the New York militia, performed open reduction and internal fixation of femur fractures using metal wire, 7,9,10 and some Confederate surgeons attempted to fix fractures with brass pins, 6 whereas others experimented with external fixation. 12 George Otis, a staff surgeon with Surgeon General Joseph Barnes, avoided extremity amputations by performing resection arthroplasty on damaged shoulder and hip joints. 10 The American medical experience during the Civil War galvanized the recognition of orthopedics as an independent field from general surgery. Within 20 years of the conflict, independent orthopedic societies, such as the American Orthopedic Association (AOA), were being founded across the country. Indeed, a substantial portion of the AOA s membership, as well as 2 of its first 6 presidents, were medical veterans of the Civil War. 6 A GROWING SERVICE: THE INDIAN WARS TO WORLD WAR I ( ) Although after the Civil War orthopedics was recognized as an independent medical specialty, no dedicated orthopedic surgeons existed within the Army Medical Corps. The medical service in the American West consisted of surgeons who administered all facets of medical care to the soldiers they served. However, orthopedic-related injuries comprised a sizable portion of combat wounds, particularly during the Indian Wars ( ). Throughout the Indian conflicts in the American West, 2 assistant surgeons were typically assigned to each military formation and service could be hazardous. In addition to performing battlefield amputations, care of gunshot wounds, and managing a soldier with a spinal cord injury from gunshot associated fracture, 2 of the 3 surgeons assigned to the 7th Cavalry lost their lives at the Battle of the Little Bighorn (1876). 13 During this period, the use of Listerian antiseptic techniques were adopted by the Medical Corps and applied to all military surgeries. 4 Hospital barges were utilized for the rapid evacuation and treatment of wounded personnel during the Spanish American War (1898). 3 These hospital ships also contained X-ray machines that allowed surgeons to precisely localize bullet fragments, as well as fractures, and treat such injuries more expeditiously, as well as precisely. These advances contributed to a remarkable decrease in the mortality and amputation rates during this conflict. 2,3 Among the 1,990 American servicemen injured during the Spanish American War, only 29 extremity amputations were performed and the mortality rate was 7.4%. 3 During World War I, 3 years of observation as a neutral country allowed the Army Medical Corps the time to anticipate the orthopedic needs of combat-injured soldiers. As a result, once American involvement in the conflict appeared imminent, the Army War Department petitioned the AOA to assist in the development of an Orthopedic Section within the American Expeditionary Force (AEF). 4,14 The Department of Military Orthopedic Surgery was formed within the Office of the Surgeon General in 1916 under MAJ Brackett EG. 15 The responsibility for orthopedic services in the combat zone, however, fell to the Division of Orthopedic Surgery of the AEF, under the command of COL Joel Goldthwait and COL Nathaniel Allison (Fig. 3 ). 14,15 Both Goldthwait and Allison were Harvard-trained surgeons, as were many members of the initial orthopedic cadre of the AEF. The division comprised 42 orthopedic surgeons, almost entirely from Harvard or Johns Hopkins, and 12 nurse assistants. 14,15 The unit did not operate as a specific entity but rather was spread across the entire Western Front, where physicians applied splints in the front line trenches and performed surgical interventions at hospitals in the rear. Military experiences in World War I resulted in the transformation of orthopedic surgery from a discipline focused on splinting and amputation as surgical mainstays to a service that actively sought to surgically intervene in fracture care. Open injuries were irrigated with Dakin s solution, debrided, and left open for a minimum of 24 to 48 hours. 16 The mortality rate for open femur fractures in the American forces remained below 20%, whereas it approached 80% for similarly injured servicemen in the armies of other combatants. 14 Following the experiences of World War I, the American Academy of Orthopaedic Surgeons (AAOS) was formed and residency training for the orthopedic specialty was standardized. Similar to the situation after the Civil War, many of the leaders of orthopedic surgery in the interwar period were veterans of the AEF, including 4 of the first 9 presidents of the AAOS. 14 WORLD WAR II AND KOREA ( ) A number of factors culminated to engender significant advances in the field of orthopedic surgery during, and immediately following, World War II ( ). 2,3,15,17,18 Chief among these were technical developments, such as the discovery of antibiotics and blood replacement that enabled orthopedic surgeons to more aggressively intervene in their manner of fracture care and internal fixation. 18 Second, the Army Surgeon General during World War II, MG Norman Kirk ( Fig. 4 ), was himself an orthopedic surgeon and strongly promoted the benefits of his specialty to American combat-injured. 3,17 MILITARY MEDICINE, Vol. 176, June

4 FIGURE 4. Major General Norman T. Kirk, MD (seated, second from right) and his staff during World War Two ( ). Major General Kirk was responsible for several initiatives which advanced the field of orthopedic surgery during, and after, the war. Courtesy of the National Library of Medicine. FIGURE 3. Colonel Nathaniel Allison of the American Expeditionary Force. Colonel Allison was the Assistant Director of the Division of Orthopaedic Surgery during World War I ( ). Courtesy of the National Library of Medicine. MG Kirk was instrumental in the development of special Army orthopedic hospitals and amputee centers and galvan ized the development of hand surgery when he charged Dr. Sterling Bunnell with the task of training young military surgeons in hand microsurgical and reconstructive techniques. 17,18 During World War II, American military surgeons experimented with the use of bone grafting, limb salvage, and surgical debridement for the treatment of osteomyelitis External fixation, a technique initially described by American surgeons during the Civil War 12, was refined and its application was established in the aftermath of Pearl Harbor. 18 The Army was very interested in facilitating the widespread use of external fixators but the devices fell out of favor with practitioners because of a high infection rate and a propensity to cause pseudarthrosis. 18 Particularly poor outcomes in the European theater resulted in the complete removal of external fixators from field hospitals. 18 Internal fixation was used sparingly, but with some remarkable success. 17,18 In 71 instances of open reduction and internal fixation performed at the 46th General Hospital, no cases of significant postoperative infection were reported. 18 At the end of the war, the experience of American POWs who had been treated in Germany with Gerhard Kuntscher s intramedullary devices, led to the acceptance of this technology as an approach to the treatment of combat-related long bone fractures. 2,17 The orthopedic experience during World War II also resulted in a revolution in the manner in which amputations were performed. At the start of the conflict, both guillotine and open circular amputations were advocated as equivalent techniques. However, based on the experience of large hospital sections, such as that of the 3rd Army, the decision was made to abandon the guillotine in favor of the circular technique, 18 a variant of which is still in use today. This was because the guillotine technique resulted in difficulties with soft-tissue coverage and often necessitated revision surgery. 18 During the Korean War ( ), the use of the helicopter enabled rapid evacuation of wounded soldiers to medical treatment facilities. For the first time in the history of military medicine, fixed military hospitals allowed soldiers to receive rapid medical and surgical intervention similar to that which they could receive in a civilian setting. 2,3 This facilitated relatively rapid surgical intervention for the treatment of fractures, traumatic amputations, and spinal cord injury. Orthopedic surgeons were a core component of cadre at Mobile Army Surgical Hospitals (MASHs). 3 All soldiers with penetrating cervical wounds received decompressive laminectomies during the Korean conflict 11 and the use of intramedullary fixation became standard among soldiers with lower extremity long-bone injuries. 2, MILITARY MEDICINE, Vol. 176, June 2011

5 THE VIETNAM CONFLICT ( ) The capabilities of fixed army hospitals and MASHs were further expanded during the Vietnam era and the treatment of war wounded was doctrinally refined, approaching the modern echelons of care system used in the military today. 2,21 Wounded soldiers were treated emergently and stabilized in smaller medical units close to the combat zone, then successively evacuated to larger military medical facilities that contained more robust resources and were capable of definitive intervention.22,23 Orthopedic surgeons were integral to the treatment of servicemembers at the large military centers, but many could also be found among the medical teams serving near the front lines. 22 Combat injuries to the extremities were treated with wound exploration, debridement, and open packing. Pulsatile lavage was used to treat contaminated war injuries, and primary closure was avoided in country. 22 Although previously injuries to major and collateral vessels were considered absolute indications for amputations, surgeons of the Vietnam era attempted to salvage limbs by performing vascular repair or reconstruction. Primary amputations were avoided and, if deemed necessary, were performed at the most distal site possible. 22 Approximately 55% of all combat-related injuries in Vietnam involved the extremities 23 and relatively modern approaches to internal fixation and limb reconstruction were utilized in their treatment. 22 Surgical exploration of the spine was also performed in instances of wounds caused by gunshot or explosive mechanisms. 11 THE MODERN ERA: GRENADA TO 9/11 ( ) In the 10-year period from the end of Vietnam to the invasion of Grenada, the American military underwent a transformation to a more mobile, rapidly deployable fighting force. 2,3,21 Unfortunately, the doctrinal approach of the Medical Corps was not revised to reflect this fact. As a result, the first MASH was not operational in Grenada until 4 days following the start of hostilities.24 This led to a reconsideration of the way the Army deployed its medical assets and a revolution in the administration of combat-related healthcare that continues to this day. 21 Following Grenada, the Army began to train highly mobile airborne surgical squads, which could be parachuted behind assault teams to provide close medical support. 24,25 One orthopedic surgeon was assigned to each of these 20-man surgical squads, which would eventually develop into the Forward Surgical Teams (FSTs) employed in combat today. 21,24,25 The first forward surgical squads made combat jumps during the Panama invasion (1989), which represented the first major American conflict to transpire during the period of modern orthopedic instrumentation and the largest nighttime airborne assault since World War II. In total, U.S. forces sustained 252 casualties during this operation with more than 80% of injuries considered orthopedic in nature. 26 Many injuries occurred during the initial jump and a high proportion of these included spinal fractures. 11,26 The concomitant use of Kevlar helmets and individual body armor on a large scale at the start of the Persian Gulf War ( ) significantly increased the proportion of orthopedic injuries encountered on the field of battle. 3,27 Additionally, advances in medical capabilities combined with military technology to create situations where soldiers were able to survive previously lethal combat-related injuries, but still endure devastating extremity wounds that posed substantial challenges to orthopedic specialists. 27,28 The fast-paced, and rapidly mobile, realities of desert warfare also led to the effective elimination of MASH units from the Army s medical doctrine. 3,21,24,25 Following the Gulf War, these hospitals, whose history extended back to the Korean War, were replaced by the more versatile FSTs and Combat Support Hospitals (CSHs) developed during the 1980s. 3,21 THE UNITED STATES CURRENT CONFLICTS: IRAQ AND AFGHANISTAN (2001 PRESENT) At the start of the Afghanistan invasion, the 274th and 250th FSTs were the first medical units to deploy in direct support of American forces in Operation Enduring Freedom (OEF). 24,25 Eventually, these units were followed by larger CSHs, who established fixed facilities in country. Doctrinally, 1 orthopedic surgeon is assigned to an FST, whereas up to 3 orthopedic practitioners may support a CSH. 21 Orthopedic interventions at an FST are limited to those necessary to save life and/ or limb, such as emergent amputation, irrigation and debridement, and/or application of external fixation. 21,24,25 More robust medical capabilities are present at a CSH, but orthopedic interventions remain similar to those performed at an FST. 21 For American military personnel, definitive orthopedic intervention is reserved until wounded soldiers arrive at facilities in Germany or within the continental United States. 21,28 Reports from the 274th and 250th FSTs in the initial phases of OEF revealed a high proportion of cases fell to the orthopedic surgeon on the team, including external fixation of fractures, amputations, and fasciotomies. 24,25 At the 250th FST, extremity procedures represented 65% of all cases performed from October 2001 April In 2003, the 250th FST redeployed to Operation Iraqi Freedom (OIF) and actively supported the 173rd Airborne Brigade in its invasion of Northern Iraq. 24 Here, 51% of all combat injuries were found to involve the extremities. 24 During the initial invasion of Iraq, the 555th and 745th FSTs traveled in the wake of the 3rd Infantry Division, which was responsible for spearheading the assault. 29 Of all the military conflicts in which the United States has previously been engaged, we possess the greatest knowledge regarding the orthopedic experience in both OIF and OEF because of the publication of recent prospective reports and the Joint Theater Trauma Registry Publications regarding the spectrum of orthopedic injuries in OIF/OEF reveal a prevalence of 54% among all those injured. 30,31 Owens et al 30,31 found that explosions were the cause of 75% of all orthopedic injuries, whereas gunshot wounds were responsible for only 16%. Similar findings were endorsed in the work of Belmont et al. 32 Here, approximately 50% of all injuries involved the MILITARY MEDICINE, Vol. 176, June

6 remain to be defined, if American military medical history can be used as an indicator, the advancements will no doubt be significant. ACKNOWLEDGMENTS This work is dedicated to my esteemed colleagues in the Department of Orthopedic Surgery at William Beaumont Army Medical Center and the men of the 1st Squadron, 13th Cavalry Regiment. Warhorse! FIGURE 5. Distribution of wounds by body region for casualties in major American military conflicts since extremities, whereas nearly 78% of all wounds were caused by explosive devices. 32 These represent injury distributions similar to those encountered in prior 20th century American conflicts (Fig. 5 ). New orthopedic wounding patterns and associated complications have also been identified in the present engagements, ranging from a predilection to develop heterotopic ossification in traumatic amputations 28 to lumbosacral dissociations. 11 Spine injuries have also increased relative to other injuries in OIF/OEF. A recent investigation estimates spine injuries to comprise 7.4% of all wounds sustained by American military personnel. 11 This figure represents the highest incidence of combat-related spine injuries in American military medical history. 11 CONCLUSION From humble beginnings in the Continental Army, the U.S. Army Medical Corps has evolved into a rapidly deployable and integral component of the modern military, performing life and limb saving procedures at the battle front and preserving the fighting force within the United States. During the revolution, much of American combat-related surgery consisted of orthopedic interventions, and the orthopedic specialist remains a vital component of the Army medical team today. Developments that transpired during major American conflicts, from the Civil War to World War II, helped fashion the discipline we know as orthopedic surgery. Orthopedic surgeons are now present at nearly every level of military medical care from the FST only a few miles behind the combat zone to the CSH and military treatment facilities within the United States. Currently, new challenges are presenting themselves to the field of orthopedics within the wars in Iraq and Afghanistan. Although the contributions of these engagements to the further development of the orthopedic profession REFERENCES 1. Gillette MC : The Army Medical Department Washington, DC, Center of Military History, United States Army, Noe A : Extremity injury in war: a brief history. J Am Acad Orthop Surg 2006 ; 14 (10) : S1 S6. 3. Manring MM, Hawk A, Calhoun JH, Andersen RC : Treatment of war wounds: a historical review. Clin Orthop Relat Res 2009 ; 467 (8) : Cozen LN : Military orthopedic surgery. 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