Combat Orthopedic Surgery: Lessons Learned in Iraq and Afghanistan
Textbook cover co-edited by Lt. Cols. Brett D. Owens, M.D., and Philip J. Belmont Jr., M.D.

FORT KNOX, Ky. -- Lt. Cols. Brett D. Owens, M.D., and Philip J. Belmont Jr., M.D., first met more than a decade ago at Walter Reed Army Medical Center in Washington, D.C., where they served as a general surgery intern and an orthopedic surgery resident, respectively.

They collaborated on a research project early on, but it wasn’t until 2007 when they rekindled their partnership working at William Beaumont Army Medical Center in El Paso, Texas. Col. Owens was serving as director of Orthopedic Surgery Research, and Col. Belmont as the Orthopedic Surgery Residency Program director, when they began collaborating extensively on research projects focused on musculoskeletal injuries in U.S. military service members.

Through this work, they realized they shared a common interest in applying their training and military experience to medical research aimed at improving the state of the art in Soldier care. They both have similar education backgrounds as well: undergraduate school at the U.S. Military Academy at West Point (although not in the same class) and elite medical schools (Georgetown and Duke, respectively).

Drs. Belmont and Owens launched their medical careers during ten years of insurgency and irregular war in Iraq and Afghanistan, which have challenged military orthopedists with a very different injury profile than previous conflicts.

For example, explosions from improvised explosive devises (IED) are now responsible for three-quarters of combat wounds to the arms and legs, while gunshots account for only 16 percent. Sophisticated body armor to protect the torso and internal organs, and a highly integrated military trauma system have contributed to a higher percentage of Soldiers surviving serious injury; at the same time, evolving enemy tactics have resulted in far more injuries to the extremities.

Drs. Owens and Belmont have repeatedly accessed the Joint Theater Trauma Registry (JTTR) to study musculoskeletal injuries incurred by combat troops during Operation Iraqi Freedom and Operation Enduring Freedom, as a first step to better allocating Army resources and improving outcomes for injured soldiers. The JTTR is a comprehensive military database of medical records about combat injuries and outcomes through all levels of care for 40,000 U.S. military service members who have been wounded in action in the Iraq and Afghanistan Wars (more have been wounded, but not all cases have been recorded in the JTTR).

Last year, one of their studies based on JTTR data was published in The Journal of Trauma, a prestigious peer-reviewed medical journal. The study followed one 4,000-person Army Brigade Combat Team over 15 months during the surge in Iraq, and looked at the incidence and type of musculoskeletal injuries sustained. “Our research is designed to shed light on the impact of the evolving nature of America’s conflicts on our troops and provide recommendations for our military medical system,” explains Dr. Belmont.

Military orthopedists are innovating quickly

As orthopedic surgeons in the Army, Drs. Belmont and Owens spend the workday providing medical care to those in uniform. Dr. Owens specializes in Sports Medicine as chief of Orthopedic Surgery Service at Keller Army Hospital in West Point, N.Y., while Dr. Belmont is chief of Adult Reconstruction and Director of the Orthopedic Surgery Residency Program at William Beaumont Army Medical Center/Texas Tech University Health Sciences Center in El Paso, Texas. Both have deployed to Iraq to treat Soldiers during Operation Iraqi Freedom.

In their combat medical experiences, as well as caring for Soldiers here at home, Drs. Owens and Belmont are keenly aware of the unique challenges and paradigms military orthopedic surgeons face as a result of the current irregular warfare in Iraq and Afghanistan. Like many of their colleagues in the Army and orthopedic surgeons in other branches of service, they also appreciate the fact that the current conflicts have forced military orthopedic surgeons to innovate at lightning speed. Surgeons have been publishing their findings individually in various medical journals and sharing anecdotal information with each other, informally - but these findings and best practices for treating complex battlefield extremity wounds could not previously be found in one place.

In light of this widely recognized need, Dr. Owens and Dr. Belmont consulted a mentor, Col. (Ret.) John Feagin, M.D., to discuss how to encapsulate all of this complex and widespread information into a tangible, ‘one-stop shop’ for orthopedic surgeons.

“In all honesty, it seemed like a huge project,” recalls Dr. Owens. “Then Col. Feagin told us that if we didn’t tackle this, it was highly unlikely anyone would. After hearing those words, for us, it was basically a done deal. It just had to be done.”

Two years and approximately 2,000 hours of night and weekend work later, an unprecedented military orthopedic resource was born. Earlier this year, Dr. Owens and Dr. Belmont achieved their goal with the publication of "Combat Orthopedic Surgery: Lessons Learned in Iraq and Afghanistan." As the first orthopedic combat reference to emerge from the current conflicts, the book draws upon contributions from 50 military orthopedic surgeons and outlines challenges and clinical best practices for treating combat orthopedic injuries.

“This book is the first thing military orthopedic surgeons should pack when they deploy,” said Dr. Owens.

Carving out hours between time spent with patients, teaching, research and family, Dr. Owens and Dr. Belmont combed through existing orthopedic literature from the past decade and relied on a network of military orthopedic surgeons with an extensive array of expertise and experience to fill in gaps and create a more complete picture of combat orthopedic surgery today. The book is divided into three main sections: the ‘principles’ of combat orthopedic surgery, including an overview of the combat environment and different levels or ‘echelons’ of care; advances in specific treatments; and techniques for upper extremity, lower extremity, spine and pelvis injuries. As they compiled the information for the book, several advances stood out, including better limb salvage techniques and, therefore, reduced amputation rates, and significant prosthetic advances"specifically for above-the-knee amputations where computer chip technologies offer the soldier improved gait kinematics and energy efficiency.

“Advances in injury care almost always come around times of armed conflict, and unfortunately, the battlefield is an example of one of the least controlled environments in which clinicians work,” said Thomas Scalea, M.D., trauma surgeon and physician-in-chief, R Adams Cowley Shock Trauma/University of Maryland. “It is difficult to catalogue radiographs and even more difficult to obtain good operative photos. Additionally, follow up care can be fragmented, making the ability to follow a single patient from injury to recovery extraordinarily difficult. This book addresses all of these issues and is a must read for any young surgeon who is interested in a comprehensive view of battlefield injuries.”

Drs. Belmont and Owens continue their work on medical research to provide the best possible orthopedic care for the men and women serving our country. They both currently teach at Uniformed Services University of the Health Sciences.

“After nearly a decade of combat, it is our sincere hope there isn’t the need for a second edition of this book,” says Dr. Belmont. “That being said, we feel good that the orthopedic community now has a definitive reference for combat surgery to save more limbs and lives and get the best outcomes for our Soldiers.”

Page last updated Thu July 21st, 2011 at 00:00