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Military Medicine

International Journal of AMSUS

RAISING THE BAR: EXTREMITY TRAUMA CARE

GUEST EDITORS

Fred A. Cecere, MD

Steven J. Stanhope, PhD

Kenton R. Kaufman, PhD

Bill W. Oldham, MBA

COL John C. Shero, MS USA (Ret)

COL James A. Mundy, MS USA (Ret)

SPECIAL ISSUE – Supplement to Military Medicine, Volume 181, Number 11/12

November/December 2016



 Raising the Bar: Extremity Trauma Care

“Raising the Bar” in Extremity Trauma Care: A Story of Collaboration and Innovation 

1

Fred A. Cecere, Bill W. Oldham



The Extremity Trauma and Amputation Center of Excellence: Overview of the Research and 

Surveillance Division 

Christopher A. Rábago, Mary Clouser, Christopher L. Dearth, Shawn Farrokhi, Michael R. Galarneau, 

M. Jason Highsmith, Jason M. Wilken, Marilynn P. Wyatt, Owen T. Hill

The Bridging Advanced Developments for Exceptional Rehabilitation (BADER) Consortium: 

Reaching in Partnership for Optimal Orthopaedic Rehabilitation Outcomes 

13

Steven J. Stanhope, Jason M. Wilken, Alison L. Pruziner, Christopher L. Dearth, Marilynn Wyatt, Gregg W. Ziemke, 

Rachel Strickland, Suzanne A. Milbourne, Kenton R. Kaufman

The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for 

Service Members With Complex Trauma 

20

Brad M. Isaacson, Brad D. Hendershot, Seth D. Messinger, Jason M. Wilken, Christopher A. Rábago, 

Elizabeth Russell Esposito, Erik Wolf, Alison L. Pruziner, Christopher L. Dearth, Marilynn Wyatt, Steven P. Cohen, 

Jack W. Tsao, Paul F. Pasquina



Improving Outcomes Following Extremity Trauma: The Need for a Multidisciplinary Approach 

26

Daniel J. Stinner



The Prevalence of Gait Deviations in Individuals With Transtibial Amputation 

30

Christopher A. Rábago, Jason M. Wilken



A Narrative Review of the Prevalence and Risk Factors Associated With Development of Knee 

Osteoarthritis After Traumatic Unilateral Lower Limb Amputation 

38

Shawn Farrokhi, Brittney Mazzone, Adam Yoder, Kristina Grant, Marilynn Wyatt



Differences in Military Obstacle Course Performance Between Three Energy-Storing and 

Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, 

Randomized Control Trial 

45

M. Jason Highsmith, Jason T. Kahle, Rebecca M. Miro, Derek J. Lura, Stephanie L. Carey, Matthew M. Wernke, 

Seok Hun Kim, William S. Quillen

Functional Outcomes of Service Members With Bilateral Transfemoral and Knee 

Disarticulation Amputations Resulting From Trauma 

55

Barri L. Schnall, Yin-Ting Chen, Elizabeth M. Bell, Erik J. Wolf, Jason M. Wilken



Core Temperature in Service Members With and Without Traumatic Amputations During a 

Prolonged Endurance Event 

61

Anne M. Andrews, Christina Deehl, Reva L. Rogers, Alison L. Pruziner



A Review of Unique Considerations for Female Veterans With Amputation 

66

Billie J. Randolph, Leif M. Nelson, M. Jason Highsmith



Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis (IDEO): A Systematic 

Review of the Literature 

69

M. Jason Highsmith, Leif M. Nelson, Neil T. Carbone, Tyler D. Klenow, Jason T. Kahle, Owen T. Hill, SP USA, 

Jason T. Maikos, Mike S. Kartel, Billie J. Randolph

Descriptive Characteristics and Amputation Rates With Use of Intrepid Dynamic Exoskeleton 

Orthosis 

77

Owen Hill, Lakmini Bulathsinhala, Susan L. Eskridge, Kimberly Quinn, Daniel J. Stinner

VOLUME 181 

NOVEMBER/DECEMBER 2016 

SUPPLEMENT

M

ILITARY

 M

EDICINE

AMSUS - The Society of Federal Health Professionals should not be held responsible for statements made in its publication by contributors or advertisers. 

Therefore, the articles reported in this supplement to MILITARY MEDICINE do not necessarily refl ect the endorsement, offi cial attitude, or position of AMSUS or

the Editorial Board.



The Thought Leadership Institute, BADER Consortium, the Center for Rehabilitation Sciences Research 

(CRSR), and the Extremity Trauma and Amputation Center of Excellence (EACE) wish to acknowledge 

the efforts of the following people in the coordination of this supplement: 

Kelly Bothum

 

Elizabeth Russell Esposito



Jeremy G. Johnson

Michelle Mattera Keon

Maria Pellicone

Christopher A. Rabago

Rachel A. Strickland



MILITARY MEDICINE, 181, 11/12:1, 2016

“Raising the Bar” in Extremity Trauma Care:

A Story of Collaboration and Innovation

Fred A. Cecere, MD; Bill W. Oldham, MBA

Today

’s military health system is working in remarkable



ways to provide complex extremity trauma care that helps

injured service members reach their highest level of function.

The difference in outcomes as a result is staggering. In the

1980s, only 2% of soldiers remained on active duty following

limb loss, despite relatively minor injuries such as a partial

hand amputation.

1

By 2010, 19% of service members



remained on active duty after suffering limb loss caused by

major extremity trauma. About 25% of this group actually

returned to theater, even though their injuries were much

more devastating than those suffered during previous con

flicts.

2

Wounded soldiers now have access to cutting-edge tech-



nologies, multidisciplinary care, and research efforts aimed

at realizing optimal outcomes for a population already used

to performing at high levels. The approach is holistic and

family centered, focusing more on the patient

’s ability than

disability. Best of all, advances in the care of these patients

offer bene

fits to other injured service members as well as the

civilian population.

This work is possible because of the synergies that exist

between programs operating through the Department of

Defense (DoD) and the U.S. Department of Veterans Affairs

(VA) across the patient care spectrum. The result is comple-

mentary rather than competing care that begins at the point

of injury and continues for the rest of a patient

’s life.


Efforts to cultivate this collaborative approach to ortho-

pedic rehabilitation care have been bolstered by three sepa-

rate but interconnected programs that have identi

fied and


developed critical research capabilities and infrastructures

that translate research advances into clinical care for patients

with traumatic extremity injuries.

The Extremity Trauma and Amputation Center of Excel-

lence (EACE) was created by Congressional mandate as a

joint enterprise between the DoD and the VA to develop a

comprehensive strategy to help service members with trau-

matic injuries optimize their quality of life.

The Center for Rehabilitation Sciences Research (CRSR)

was established to advance the rehabilitative care for service

members with combat-related injuries while also educating

the next generation of military medicine professionals.

The Bridging Advanced Developments for Exceptional

Rehabilitation (BADER) Consortium was developed as

a research capacity building program to further establish

research infrastructures and investigators at DoD and VA sites

and to launch a series of multiteam clinical research initiatives.

These programs operate independently, but they are

designed to be interdisciplinary and collaborative in nature.

This complementary approach is re

flective of the efforts by

the DoD to address the complex health needs of the combat

wounded before they reach the VA, which has already had

an established amputee and rehabilitation science program.

Together, they provide a unique opportunity to strengthen

DoD/VA research programs and in

fluence the long-term

direction of care for this unique patient population.

It is an approach that is working, as evidenced by a 2015

report by the Defense Health Board on the sustainment and

advancement of amputee care.

3

It found that the DoD is



“leading the Nation and the world in extremity trauma and

amputee science and care through its infrastructure, systems

and approach.

” That same report also reiterated the need

for collaborations between institutions, practitioners, and

researchers across disciplines and organizations in order to

sustain these advancements.

Whether it is team members from the EACE and the

BADER Consortium embedding at military treatment facilities

(MTFs) to help answer clinically relevant questions and support

research in high-priority areas or CRSR staff working to

de

fine and validate rehabilitation strategies for injured service



members,

the focus

remains

constant


—to help these

wounded warriors get back to the life they were living

before their traumatic injuries.

By working collaboratively, researchers do not have to

give up their autonomy. Indeed, each domain of rehabilita-

tion care can and should be able to work independently.

The resultant creativity and energy is evidenced by the

myriad of research projects already underway at MTFs and

VA centers around the country. These researchers are not

constrained by working toward the same goal

—helping

patients regain their highest functional levels

—but rather,

they are empowered to meet those goals in different ways.

One project funded by the Defense Medical Research and

Development Program and supported by the EACE and

BADER focused on preventing falls in service members

with amputations through the use of advanced rehabilitation

training.

4

At CRSR, they are



finding improvements in pain

management strategies that can improve the quality of life

for patients with severe combat injuries. The BADER Con-

sortium supports the goal of optimal outcomes by providing

needed administrative assistance and infrastructure support

to help address important gaps in clinical orthopedic rehabil-

itation research and patient care.

Thought Leadership and Innovation Foundation, 16775 Whirlaway

Court, Leesburg, VA 20176.

doi: 10.7205/MILMED-D-16-00314

MILITARY MEDICINE, Vol. 181, November/December Supplement 2016

1





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