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How Maintaining Prosthetic Services Can Help Prepare for the Next Fight

Navy Seaman Chris Krobath, a prosthetics patient at Naval Medical Center San Diego, reached for new heights on the hospital’s climbing wall as part of rehabilitation therapy. In this photo from September 2017, Navy Seaman Chris Krobath, a prosthetics patient at Naval Medical Center San Diego, reached for new heights on the hospital’s climbing wall as part of rehabilitation therapy.

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Despite the winding down of the conflicts in Afghanistan and Iraq, Military Health System services for our wounded warriors, particularly those who have lost limbs in these conflicts, remain steady and may well increase in scope during the coming years.

“We’ve got to be ready for the next conflict,” said John Shero, executive director of the Defense Department’s Extremity Trauma and Amputation Center of Excellence, or EACE, at Joint Base San Antonio-Fort Sam Houston in Texas.

“During the period that we’re in now, a time of reduced ground conflict, we’ve got to sustain our clinical skills in order to be able to take care of the next battlefield casualties.”

Shero pointed to the example of the suicide bombing at the international airport in Kabul, Afghanistan, in late August during the U.S. military’s evacuation from that country. Victims of that attack – both U.S. military active duty and Afghans – came through the military’s health care system. “We were absolutely prepared to care for those casualties,” Shero said. “But if we don’t sustain key clinical skills, we won’t be.”

The wars in Iraq and Afghanistan prompted major advancements in medical care available to individuals with amputations, explained Dr. Andrea Crunkhorn, the chief of clinical programs for EACE at the Defense Health Agency headquarters in Falls Church, Virginia.

“The DOD has really been at the front of that leap forward over the last 20 years,” Crunkhorn said.

Military medical leaders intend to build on that progress by continuing research and support for those with limb loss.

The DOD’s research and clinical services for wounded warriors are centered on three Advanced Rehabilitation Centers, known as ARCs: Walter Reed National Military Medical Center’s Military Advanced Training Center in Bethesda, Maryland; Brooke Army Medical Center’s Center for the Intrepid in San Antonio, Texas; and Naval Medical Center San Diego’s Comprehensive Combat and Complex Casualty Care (“C5”) Program in San Diego.

Those three centers, along with the EACE, form the DOD Amputation Care Network, with a primary mission to fully restore normal human function to patients who have sustained severe trauma or amputation.

These MHS facilities lead the nation in developing new technology and support for people with amputations.

“What has been so fabulous about the last 20 years has been the level of collaboration at the national level,” including civilian and academic medical institutions, Crunkhorn said.

Expanded Care

The ARC at Walter Reed recently made a contractual change with how it provides prosthetic services which Shero said he hopes "will increase the capacity and the amount of prosthetic care that is able to be delivered at Walter Reed.”

That change, however, did lead to some misinformation that services were being reduced, which was "absolutely not correct,” Shero said.

The staff at Walter Reed always remained at the ready to provide care. 

“The capability has never changed," she added. "Capacity has waxed and waned with COVID, and that’s fair across all health care systems. But we absolutely want to keep all of [our] capabilities well-rehearsed and well-practiced at all of our sites. In order to do that, we have to have patients flow through the doors.”

That means expanded opportunity for other Military Health System beneficiaries who may have lost a limb, she added.

Game-changers

The EACE aims to drive a cycle of improved care and innovative research by embedding clinically focused researchers within the ARCs.

“Our research team works right alongside the clinicians who are delivering extremity trauma and amputation care,” Shero explained. “From that, we identify the clinical gaps, address those gaps through relevant research, and then use those research findings to improve the overall process of care.”

That care includes sophisticated new procedures and products for those with missing or disfigured and painful limbs.

“What we’re seeing as a follow-on is some really nice evolution in surgical procedures and techniques,” Crunkhorn said. “We’re also seeing some progression with orthoses, and that’s important because a lot of young men and women didn’t come back with an amputation from the war, but they came back with mangled limbs.”

Orthotics differ from prosthetic devices in that they are supportive of a limb instead of a replacement for one. An example cited by both Shero and Crunkhorn is what’s known as the “IDEO,” or Intrepid Dynamic Exoskeletal Orthosis. The IDEO is a customized foot-and-ankle brace made of carbon fiber that transfers energy and relieves pain that can become so acute that many patients would rather have their foot amputated than endure it.

“It’s a life-changing orthotic,” Shero said. “Before, many of our active duty and veterans that had very severe extremity trauma saw their only choice as living with pain and disability or having an amputation. But the IDEO and other advanced orthotic devices that we have helped develop and implement are really changing that.”

Patients who were barely able to walk before “are back to running, jumping, and their full complement of requirements to remain on active duty,” he added. “It truly is a game-changer.”

The IDEO is available at all three ARCs, and some civilian organizations are using the same technology as well, Shero said.

Cutting-edge procedures

Crunkhorn said that prosthetics and orthotics are by no means the only answers for grievously wounded warriors. She cited four other ground-breaking surgical procedures for those with lost or dysfunctional limbs.

They include osseointegration, when a limb prosthesis is permanently, surgically anchored into a patient’s own bone; agonist-antagonist myoneural interface (AAMI), a modified amputation surgery that retains muscle and limb control; targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), both of which help with managing nerve input and pain in the residual limb. All of these sophisticated care options are under continual development, even as they are being implemented for those wounded warriors and others who need them.

Crunkhorn said the new procedures dovetail with two of the DHA’s key priorities – supporting a medically ready force and a ready medical force. Following up with men and women injured in combat years ago, and working with retirees and others from across the age ranges for all beneficiaries, she said this “evolving standard of care” gives ARC surgeons and other specialists the opportunity to work together to optimize outcomes.

“These are really changing the face of amputation surgery, and creating the potential for more functional outcomes following amputation,” she said.

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