Long Term Follow Up After Type III Open Tibia Fracture: a DoD/VA Collaboration MAJ Jessica C Rivera, MD

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Brandon Leonard
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1 Long Term Follow Up After Type III Open Tibia Fracture: a DoD/VA Collaboration MAJ Jessica C Rivera, MD US Army Institute of Surgical Research And San Antonio Military Medical Center Department of Orthopaedic Surgery

2 The author have no disclosures to report related to this work. The author acknowledges Mrs. Pam Foltz for data collection and regulatory support for this project and Drs. Mary Jo Pugh, Laurel Copeland, and Joe Hsu for fostering this collaboration.

3 The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

4 We Recognize the Burden Injury Incidence Primary Admission Diagnosis 29% 54% Extremity Thorax Abdomen 9% 23% Head 63% Extremity Thorax Abdomen Head 11% 6% 5% Owens BD, Kragh JF, Macaitis J, Svoboda SJ, Wenke JC. Characterization of Extremity Wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma, : Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR. Resource Utilization and Disability outcome Assessment of Combat Casualties From Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma, :

5 But This is Limited to the DoD Unfitting Conditions Extremity 10% 3% 1% 16% 70% Thorax Abdomen Head Psych Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. Battlefield orthopaedic injuries cause the majority of long term disabilities. J Am Acad Orthop Surg, 2011; 19: S1-S7.

$tibia fracture enrolled on respective DoD and VA retrospective protocols longitudinal follow up linking DoD and VA$

6 Objective Pilot a DoD/VA collaboration for the study of extremity trauma a small cohort of subjects with Type III open tibia fracture enrolled on respective DoD and VA retrospective protocols longitudinal follow up linking DoD and VA data

7 Methods DoD EMR Data DoD Subject List 21 subjects with 24 limbs Transfer by secure identifiers VA EMR Data VA Corporate Data Warehouse Transfer by secure identifiers Linked Data for Analysis ü VA protocol through local VA IRB and VA R&D ü DoD protocol through local IRB ü Data Sharing Agreement ü Security Plan for data transfer ü Compilation of DoD and VA data on small pilot cohort

8 Amputees Six early amputations infection, soft tissue coverage failure, vascular compromise. Four late amputations two for infection and two for pain initially fixed with an intramedullary nail performed prior to the patients transition to VA care Only two additional procedure to the residual limb at the VA one for heterotopic ossification and one for wound infection

9 Retained Limbs 14 retained limbs who entered the VA Five limbs were treated for orally for infection Five limbs experienced symptomatic heterotopic ossification Four limbs experienced symptomatic nerve injury or muscle injury Five subjects required no further limb treatment

10 Power of Follow Up This small cohort experienced 78% limb retention > 90 days from injury with no additional late amputations performed once transitioned to the VA. Average follow up combing the DoD and VA records was 111 months (range months) following injury.

A Word about DoD/VA Collaboration Compliance with both DoD and VA regulations on human subjects protection including the DoD (32 CFR 219) and the VA (38 CFR 16) codified versions of the Common Rule

11 A Word about DoD/VA Collaboration Compliance with both DoD and VA regulations on human subjects protection including the DoD (32 CFR 219) and the VA (38 CFR 16) codified versions of the Common Rule (45 CFR 46) Research protocols approved by both the DoD and VA IRBs of record Data Sharing Agreement and/or Memorandum of Understanding to formalize collaboration vetted through both DoD and VA legal, scientific, and security authorities DoD and VA approval informed consent document and HIPAA authorization for prospective studies va-dod/ Slide 11 of

12 Conclusion So far today, I haven t told you anything that you don t already know. Specialty specific registries are powerful Long term follow up is key

13 Conclusion So far today, I haven t told you anything that you don t already know. Specialty specific registries are powerful Long term follow up is key This DoD/VA pilot demonstrates the potential of tracking long term care in terms of on going symptoms and care utilization.

14 Conclusion So far today, I haven t told you anything that you don t already know. Specialty specific registries are powerful Long term follow up is key This DoD/VA pilot demonstrates the potential of tracking long term care in terms of on going symptoms and care utilization. Larger scale DoD/VA research on our current generation of veterans with limb trauma must be supported.

15 Questions?

Update on War Zone Injuries Stan Breuer, OTD, OTR/L, CHT Colonel, United States Army

Update on War Zone Injuries Stan Breuer, OTD, OTR/L, CHT Colonel, United States Army Disclaimer: The opinions or assertions contained herein are the private view of the author and are not to be construed