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Surgeons using BMP-2 to treat personnel injured in Iraq
The BMP is allowing surgeons to save some limbs that might have been amputated a decade ago.
Editor's note: Orthopedics Today is aware that the author's actions have been called into question, but has chosen not to remove this article from Healio.com/Orthopedics at this time. http://www.nytimes.com/2009/05/13/business/13surgeon.html?pagewanted=all.
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COURTESY OF TIMOTHY R. KUKLO |
It is an irony of history that war has been the proving ground for many of the advances in medicine. During World War II, it was penicillin. In Vietnam, it was revascularization of extremity injuries. The ongoing conflicts in Iraq and Afghanistan are no different. Surgeons at Walter Reed Army Medical Center have been having good results using bone morphogenetic protein to treat injured soldiers.
Lt. Col. Timothy R. Kuklo, MD, said that more than 400 military personnel have been treated for major extremity fractures or open fractures. Approximately 60 of them have been treated with the Infuse Bone Graft, a collagen sponge impregnated with bone morphogenetic protein-2 (BMP-2), in conjunction with other tools.
“There are some patients for whom, as little as 10 or 15 years ago, we might have opted to have gone on to a primary amputation without this,” Kuklo told Orthopedics Today.
“[BMP-2 is] not widely accepted as the standard of care, but I think that certainly in extreme cases, it allows us to treat wounds that would not have been so easy to treat. It perhaps speeds the healing process and it certainly reduces the need for iliac crest bone graft.” Kuklo added that Infuse was also used to treat about 30 patients with spinal injuries.
Recently approved
Infuse, which is made by Medtronic Sofamor Danek (Memphis, Tenn.) was approved by the Food and Drug Administration two years ago for use in lumbar spinal fusion with metal cages and has been implanted in thousands of patients. Three months ago, the FDA approved its use for acute, open fractures of the tibial shaft based on a multicenter, randomized study of 450 patients.
Kuklo said the use of Infuse was familiar to him due to his spine background: “I’m the director of spine surgery, and I’ve got a lot of experience with BMPs. Then we got all these trauma patients in, so it was just a natural evolution that was occurring.” Kuklo said the team relied heavily on the other members of the orthopedic service at Walter Reed, including trauma chief Lt. Col. Richard Islinger, MD.
Kuklo said Infuse studies led him to believe that it would work well because it appeared to reduce infection, increased healing and greatly reduced the number of operative procedures needed. Those were key qualities, he said, because personnel were coming in with extremity injuries from gunshot wounds, rocket propelled grenades and landmines. In many cases, that meant filling defects ranging in size from 2 cm to 10 cm. Even though some personnel arrived at Walter Reed as little as 15 hours after being injured, about two-thirds of them had wounds that were infected due to dirt and dust in the field.
Extended with allograft
Fractures were set using intramedullary nails or various external fixators, and then defects were filled with Infuse that was usually extended with allograft bone. Kuklo said the team did not use ceramic bone graft substitutes because they were concerned that in patients with infection rates that were already high, such a foreign body might cause more problems.
Another tool that assisted in fracture healing was vacuum assisted closure (VAC), which uses controlled levels of negative pressure to accelerate wound debridement and promote healing. “With constant suction, this provides the ability to take the extra edema out of the wound,” Kuklo said. VAC was used in conjunction with other advanced wound-care techniques, including the use of free or pedicle muscle flaps.
Kuklo said there are a “fair amount” of radiographs and CT data available, so some studies are already being put together and other follow-up studies are planned to track success or failure rates in this unique patient population.